HomeMy WebLinkAboutApp-Permit-ComplianceYAR:M O U T,�i KE I;' Lill b'tr' T.
Town Office auiWipg
South Yarmouth, MA Q
THE COMMONWEALTH OF MASSA MIETTS
BOARD OF HEALTH '
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Appliration for Dhopoul Worka Tonotrudiun 11trutit
Application is hereby made for a Permit to Construct (rX) or Repair ( ) an Individual Sewage Disposal
System at:
._.._---.----•• ---- ------ - ------Tt .................. _.._.....
- Locatioi - Addres or Lo 'No. ��•
1C.�.. a .........................•.... _..•..... `� ,
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(� O er ress .......................
._....-. tK.. f -----•-- ----•-.All .-%.. ��-'1� ........ --•---•-Z .E Ma�?L:.�fi� ............
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Installer A ress
Type of Building -2— Size Lot./..+. -----. ---------Sq. feet
►-� Dwelling —No. of Bedrooms....--------------------------------
Other—Type
.......................................Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building ............... No. of ersons._._......_.._....._._...... Showers
a YP g ------------- P ( ) —Cafeteria ( )
d Other fixtures .
WW Design Flow ................��........._._....gallons per person per day. Total daily flow ......... z Zt?---------- ............. gallons.
C� Septic Tank — Liquid ' capacityl).O Ai?..gallons Length .... ci :....... Width.... ! Diameter ................ Depth..,/ -
Disposal Trench — No. .....1 ........:..... Width..__ .......... Total Length.....z.5�. �....- Total leaching area ___--l_ ¢ d'... -_•sq. ft,i ZYa cPC
Seepage Pit No ..................... Diameter.................... Depth below inlet..--................ Total leaching area ................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ) /
a Percolation Test Results Performed by. ...........:...Y:}-____....._____. Date_:_ `./._ ...........................
�3
Test Pit No. 1------: y:'_ ---minutes per inch Depth of Test Pit .................... Depth to ground water .........................
f3. Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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O Description of Soil......._.. .........
.. o xl L� t P 12�..
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U Nature of Repairs or Alterations — Answer when applicable...............................................................................................
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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 heajth.
r
Signed_. .... _ .. _ ------ -- - -- -------------------------------•---
�D to
Application Approved By.. ............................... --•--
Date
Application Disapproved for the fol owing reasons-------------•-•--•----•-------..•....------------.......----------------...-------•--------•-------------------.
Permit No....__..�........
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Date
Issued. ........... 1._2 - s�:- ..-.2_.2. ...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
(9rdif atr of (Euut litturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructedby (, or Repaired ( )
.. •---
nstaller
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permita_._� ............ dated-:.._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS.,A,GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. '..
DATE........ �::. ` :v . ..._... 7?--•-----------------•---.--..-.--.--. Inspector - �� ;, :.: _ -