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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Disposal Warks Tonstrurtion jhrmi#
Application is hereby made for a Permit to Construct ( ) or Repair �an Individual Sewage Disposal
System at iN
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caner ddress
a - _... :c•� -... ...... .........
--- -- ........... ............... �� ..........-----•--................
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Installer Address
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms..... '-...` :........................Expansion Attic ( ) Garbage Grinder ( )
py Other — Type of Building ................... .... No. of persons ............................ Showers ( ) — Cafeteria ( )
p' Other fixtures ---------------- ------- -------
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WW Design Flow -------------------------------------- ----gall ns person per day. Total daily flow ........._.........._.........._............gallons.
WSeptic Tank — Liquid' capacity --- --------gall Length---------------- Width ................ Diameter ................ Depth ................
rJ x
Disposal Trench — No . .............. ..... Wid 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 ( )
Percolation Test Results Performed by------•--------------------•---•••-----------........------•-----....... Date ........................................
,aa 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 ........................
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0 Description of Soil ........................................................................................................................................................................
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U Nature of Repairs or Alterations — Answer when applicable4q'T.... '_ _.... � ..........
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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 b he bo d of health.
Signed.. ! ... ...................................................... ..................... ... `p
Date
ApplicationApproved By ....... .......................... -- ............ ---•---•----•----------.---•- � p ._............
Date
Application Disapproved for the following reasons: ................................................................................................................
....---••-•----------•-----•-•--•...........................•------•--•---•--.....-----.....---------•---.---•-•--....--•••-•---........•---•----•••-•......-•-•----------..•---•••----...•-••-••--•-•-•-
U/
L Date
Permit No .... .- ` 1 L/ ................. Issued.....................................................o ..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifiratr of T%m plinnrr
THIS IS TO CERTIE That the Indivi al Sewage Disposal System constructed ( ) or Repaired
by....................................••.- :.l............--------•--•--.....................-----.....-•---....................-- ..........
at........ .... _
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ................................. �- �.`..`�................. dated......��-1 d'y y Z
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE. C07" UE S GUAR N EE THA HE
SYSTEM WILL FU CTWN SATISFACTORY. � �
DATE................. J...� `` .LZ............................. Inspector ..... -.a j. ... . ��.......:'. .......................•----...