HomeMy WebLinkAboutApp-Permit-Compliancej r%1 VIT7 V V 1 1.7 - 1. nu I— . . t -..r —
}� Town Office Buiiding
No...� Y..-2: c South Yarmouth, MA 02-664 FnS..... �f")_........ .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
at,1iY1...................... OF ... ( ...........................................................
Appliration for Disposal Works Tonstrudiun Firntit
Application is hereby made for a Permit to Construct
System at
.....�R .� .. .P �.G SIration _Id
zLoction7Address
........... .Owner
Installer
Type of Building
) or Repair (*) an Individual Sewage Disposal
LOT` V5(o Y h aP :-?.-3---------- --------------
. or Lot No.
Zs..14.YlRl��t� i]1P�. �tf£ft:�. ftl:JjlQ ..................
1 Address
Address
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.............3 .,..........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures.....---•---------------------------------------------....----...---------.........:..-----------------------------...........------------............
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ' capacity............gallons Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water........................
Descriptionof Soil ................................................................................................................................................
----------------------------------------------•-•••-•------•-..._..._..._..---...•----------------••-•-.......--•--•--•------•-------•-----------•...--•...----------•----••---•-•-------------------.
Nature -
Repairs or Alterations — Answer when applicable.. � n.atd-----ioC?�?_.�'� __.i'4,aA.. Ft (�-�- gj................
� Q n - 1rer .ir s=------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boardpf health.
....... - ....
Application Approved
Application Disapproved for the following reasonf---------------------------------------------------------------------------------------------------------.
---------------------------------------------------------------------------------------------------------.---........------.......--------------------.......---------------------...------------•
�i 7'/ q - Date
PermitNo.....--- .................. ----------- Issued....... _ /..l- -.{ ..... .---•----
/// D
THE COMMONWEALTH OF MASSACHUSETTS
Oft"',
BOARD OF HEALTH
�j I o cv�xO F:.... ` .CAT i?� e [t#it "....:....................................: ......
.................. 2... ..... .
(Irrfifirittr of Inutplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (J'_)
by............. 12� �Y4°Q---------------------------•-------------....-----------•--......------.......------..............---------..................---------
'nstaller
i
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for. Disposal Works Construction Permit No ---- r.��s.:._ i ::........... dated.__.- < ____...___......:.___...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _::�
DATE ._.___... 66 = CSP=-- ............... Inspector.....