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No.._J.P _Zf?i.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Toustrudion trrmit
Application is hereby made for a Permit to Construct ( ) or Repair (t4/an Individual Sewage Disposal
•
Dwelling No. of Bedrooms ............ ... ........................ .Expansion Attic ( ) Garbage Grinder ( ) /VV
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----------------------------------------------------------------------------------------_...._..-----...---...---------------------------------------
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. I................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 ........................
Descriptionof Soil ..............................................................................................
Nature of Repairs or Alteratio , s — Answer when applicable -_-_�`�... 5 :................
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'1E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been d by-Jhe board of lWalth.._�,
........... .... -- e •: !-
Date
Application Approved By..... -. �(.
Application Disapproved f o the following reasons:...
Date
Permit No. ... • .. ....... Issued. ............. Jam..: I^al....
Date ....... _..
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr if irate tit Tompliattu
TIIIS CERT Y, That the Individual-5ewagg„Disposal System constructed ( ) or Repaired ( �
C----sem✓
by........ / .. 1 �' J._....t -r> ......................................... S .......... ----........-•----------------------••---.......--••--
--�� �� �iIna alleg ��
at..... _.... .....:�f%!1... �°� j-�'...---."/f�' f 2 f .---......................................
has been installed in accordance with the provisions of TITLE�,�s of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...__.._J`�`L__` %6 dated ............ '__...' .`."-..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
,r f`f
DATE............. ....----- ..j ........................................ Inspector------