HomeMy WebLinkAboutApp-Permit-Compliance4
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Y VCUTH1 Hr--" ! T,9 C-EPT.
Re Town Office
South Yarmouth, .WA, 0," x&6,4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD: OF HEALTH
......................................:C..of ............................................................-----------------------
Appliration for Disposal Works Tonstrudion pamit
Application is hereby made for a Permit to Construct (\() or Repair ( ) an Individual Sewage Disposal
/ System at:
/
..... 4 Ir ( vvt
.Ca. . -- --•--- v---- -._._... - . ...............................••-----.......-•----•-------.....-----••---------------------•----•--•-•.••-•--
�~ L n • Address or Lot No.
.._.. ...-----
/ Owner Address
Installer Address
Type of Building Size Lot ................ Sq. feet
---------- -
�. Dwelling — No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
Other fixtures -•--•---- ----------•-•-•......•-•••----------
W Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid"ca.pacity............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ---_-_------_-- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank( )
aPercolation Test Results Performed by.............................................•---....---.................. Date ........................................
Test Pit No. 1................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 ........................
Fus.... 0... ...
Descriptionof Soil ........................................................................................................................................................................
-------------------------------------------•-----------•-------------•--•----------......--•-----•----------•-------------•--------......----•--•---•------....-------------•-•----••-•---------------•-
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 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 board of health.
Signed ---- .... ..,
D
ApplicationApproved By..... -•-•-•-•.............••-------------------------•-----•--------...._.._ .......
Date
Application Disapproved for the following reasons:.
Permit No ...... �..� ._.� 3. � ................_..
/' % Date
Issued------� f �` f ..........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ...............................................................................
Trrtifirab of Toutplittnrr
THIS TS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-••----•--•---------------------------------------•---•---•------•-•-------------- -------------•-- -.-.------------------_---_-----.-----•-----•-----------•-•--•--------.---
Installer
at---•------•-----•-------•-----------------• ----- ---•---------•------------.--------------------------------------------•-----------------------..-._.----------------------•------------------
has been installed in accordance with the provisions of TITLB 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------------------------------------- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector .................................................................................... A