HomeMy WebLinkAboutApp-Permit-ComplianceYAR,MOUT.H HEALTH DEPT.
. g.�-�. -.: �� Town Office Building
No
"" South Yarmouth, -MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFHEALTH%J
_ .......... ..... Y1,4.................OF................-!i..ij-.-.4-..I
Fics... 115.._ ..... _
Appliratiun for Uisposai 19orks Tonstrurtiun f . mit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
--Location - ddr ss - ---
A / or Lob No "
• Installer Address
Type of Building .� ize Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( Garbage Grinder ( )
Other — Type of Building ............................ No. of persons..... -4::L .------•-----_-- Showers ( ) — Cafeteria ( )
Other fixtures . _.....
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. 1................minutes per inch Depth of Test Pit .................... Depth toground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
-----------------.---------------- ....-- ----------- • ..---7-
Description
7- ..
Description of Soil -- '0
.. — .......�i�ts!%✓.._/_b/L! L.
.............•---------------•-----•---------•••----•----------.....------------------•-----------•-------•----------•---------------------............................................................
Nature of Repairs o ter tions —Answer whe applicable.S
................................ .
G,�l/ lJ�'-•cam . . � -'�..----- �!�y ®---•- ---1 v Gam..----•- . S._D-!30�
1
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT:..i: 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 t -
of health. _
Signed_ � - C�`
.................... ........... -...................
Application Approved By..... ---------------------------------------•----•- .....tfs-•-
Date
Application Disapproved for the following reasons- .... -.........................................................................................................
-
---------------------------•----•••-•-------------•-------------•-------•--------------•-----------•-----•--------- -- ------
Permit
Permit No. - `�5� ... �1�----•-_-•-----•--....--- Issued-------i�_a.I.995.:
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
d7• ry -/
Tatifira#re of Tautphaurle
THIS IS TO CERTIFY That the Individual
` Se -wag Disal System,.constructed or Repaired
by ..:....._ 5.. - ... ..._.......( )
at ..................... ----_x... J/t% 1. I s�{r � r `tri'
•----�._._ . Z..G_.......................•--•- . -••-----•---
has been installed in accordance with the provisions of TITLE-,j.of The, -state Sanitary Code as dogrjbe# in the
application for Disposal Works Construction Permit No..�_S� ,,,.of
_`2..... ..... dated__....r_'��..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIILI F4NCT N SATISFACTORY.
DATE........ --- - Inspector_..._ `*
_.�