HomeMy WebLinkAboutApp-Permit-Compliancew. xari4a7 t / i.�33�P' 1 3 y 'k. (1; ..g U'
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No..E,l._:3G: South Yarmouth, ,MA 02664 FE$...i�.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................................._......OF ...........................................................................
Appliration for Ilhoposal Works. Towitrudion Vomit
Application is hereby made for a Permit to Construct (--") or Repair ( ) an Individual Sewage Disposal
System at: �
iz-
.. - ..................... ___.. ..----•-•. .------..... --- -- _ ¢ .......
Location -Address `- or Lot No. j
.................... --.._-...................................................................... --...----------•-•-•----------•--•----........------_...........----_...........'�-- (F
Owner -- Address
---•-----•-------------------------- ----- --- ---------------- ,-----------------•---.....-.._.._---____--____
Installer Address /
Type of Building _ Size Lot G_�.:R.�. �._Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
Other — Type of Building
a' � . ---------------------------- -- No... of- persons
---•-• -------- -------------Showers ( ) —Cafeteria ( )
Other fixt re ________________________________
Design Flow________________ ________________ ________gallons per person per day. Total daily flow ........... �.�.._ ................. gallons.
Septic Tank — Liquid capacit'e/ gallons Length______________ Width_5,,-____..... Diameter:________:______ Depth..,...........
Disposal Trench — No . .......:............ Width _________r_____... Total Length .................... Total leaching area .................... sq. ft.
-----
Seepage Pit No.._.___ _. Diameter__.�r.,S_.___. Depth below inlet___,.5r�... Total leaching area.. -'-'-..sq. � P� >�-•------ •- P -. g ... ------ ft.
Z Other Distribution box ( �� Dosing tank ( X
Percolation 'Test Results Performed by._.___�� __ ! �' ��a Date_... v __..
--------- -----
Test Pit No. 1 ___._______mutes per Inch Depth o Test Pit/_ /______ Depth to groundwat r________________________
W Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
------------------------------------------------------------•----•------------------• --------•---•-----•--------•••----.........••--=•------•---
O Description of Soil _..y'�.............. �_ ___ ?�:�.................
U------------------------••----------------•----•--•-----------•--•------------________-_-•---------------------•------------•------•---•----------------------- . -•-------•-•--------
UW--••---••--•-----•-•----------•--••----•---•--•--•--•••--•-•••••••-------------••••----•••----•-•-•---------------------------=------...__.............................................................
Nature of Repairs or Alterations — Answer when applicable ...............................................................................................
------•----------------------------------------•-•-----------------•---..------------......-----------------...._..-----•-----------------....._..-------------._...::.•••---. --------------•--
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issusd y the board of health.
Si ned.....- ee
....
� ate
Application Approved BY .--• •........... ................................. .................... _ ' ....
Date
Application Disapproved for the following reasons_ _______________________________________________________________________________________________________________
...........................•--...-------------------•----•--•------------...------------------------.......----------•-......----.......-•-•-----•-••••-•-••-• •-•-•-........ _....--------• •----•--•-----
Date
Permit No ...... �!2�----------------------- Issued. ...... . e2 . 'Z ��-...........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF... ..:F......... `... ...................._._.._.........
Trrtifiratr of Tomplittnrr
THIS IS. TO CERTIFY, That the Individual Sewage Disposal System constructed (---)-or Repaired ( )
b.:5`; � ............................................................................................................................................................................
Installer
at. .-- %` =' e' l' '.7 7� rc r... Z_... ,Gf` . '_..-------------------------------------------------------- ----.._..._..._....-------•-------
... - -
has been installed in accordance. with the provisions of TIT LEP 5 of The State Sanitary Code as described in the/
application for Disposal Works Construction Permit No._4��:_��.�._____________ dated____.l' _a._��_.Z
r..........._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TI�
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ......... -_ ` ............................................................ Inspector. €s 1 - �.. �_.......... - ....:/