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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (tan Individual Sewage Disposal
Systm at:
----•--.... .. A ► .. T.-.-... �.....................•---•--... K f ----- rn :.� t ..........._.._..�..-----
Al
ion - A dress Jtr .ZPk N0•
.......�. M .... _�.fa.c ... ................•---------- --•- ..... ..-�'�.-.:`.. -. a (--......... .................................
Owner Address
HAI
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms---
......................................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building..................... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures --- ...•••••----------•-----......----•---------------------------•-------......-•---....•---..._............---•------•-•.....
Design Flow ------------------.
Septic Tank — Liquid ' ,
Disposal Trench — No.
Seepage Pit No ---_--------
Other Distribution box
Percolation Test Result
Test Pit No. 1 ------
Test Pit No. 2------.
!r person per day. Total daily flow............................................gallons.
Length ................ Width ................ Diameter................ Depth ................
........... Total Length .................... Total leaching area ...................sq. ft.
.... Depth below inlet .................... Total leaching area .................. sq. ft.
tank ( )
by ---------
Date........................................
per inch Depth of Test Pit .................... Depth to ground water........................
per inch Depth of Test Pit .................... Depth to- ground water........................
Descriptionof Soil -----------------------------------------------------------------------------------------------------------------------------•----------------------------.-------------
-----•----•-------------•-----------•--.....--------•--•---------.....------------•..--
Nature of Repairs or Alterations — Answer when
....................
..............
...................................................................................... —----- ,.--------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT12 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i sued byt!�q board Agfealth.
Application Approved By.---.--. V ....._ -------
Application
-. ---
Application Disapproved for the followitfg reasons:
Permit No ........
- .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trruf irate of Toutplittnrr
THIS IS TO CERTIF hat he I ivid Sewage Disposal System constructed ( ) or Repaired
..... ......................
by - ........11% --- -•• .....- • - --
.......................•...----......----................•--••--•--..._......
�- /e ' GT�
at....._.. .. �4'�................................. "t- �----------.....---•-------•-•----...---•-
has been installed in accordance with the provisions of TIT 5 f e State Sanitary CO
desc m the
application for Disposal Works Construction Permit l�To.__...- "_ ••--- dated ........ ?...,_ . ----0 -......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AA A GUARANTEE THAT THE
SYSTEMA WILL tUNCID
N SATISFACTORY.DATE.... --....- Inspector.....•.