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THE COMMONWJ"-,2
TH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrur#iun 1hrmi#
Application is hereby made for a Permit to Construct ( ) or Repair V) an Individual Sewage Disposal
System at
.................. . Le.:e....L:k.�,_ ..-----------••----•------•-----• k..f .1 r.._.....ki......_a_.1...--•-•-----•-............_..
- ation - Address or Lot No.
WJA
A _ -.. Owner dress
.....................
rl!_!'kl�.✓l ♦ :�!' '�....................... . l-'1iGZl-�,........................_..
.-
Installer Ad ress
Type of Building
Dwelling —No. of Bedrooms
Other — Type of Buildil
Other fixtures _._..
Design Flow .......... LS
Septic Tank -� Liqui c:
Disposal Trench — Mo.
Seepage Pit No ....... /._...
Other Distribution box
Percolation Test Results
Test Pit No. 1...._.-.
Test Pit No. 2.........
I Size Lot ............................ Sq. feet
........................'........E ansion Attic ) Garbage Grinder
............ No, f perso s ........................... Showers ( ) — Cafeteria ( )
......... .............•---..................................... ..................................................
[tons per erso er da . Total daily flow)/. ..... ......................gallons.
Ions Le h.. .........
Width ....._.... iameter................ Depth ................
;h^d ..........
To al Len g .......... Total leaching area .................... sq. ft.
O`-....._.... pth b ow inlet ...... ........... Total leaching area..................sq. ft.
Tosing to ( )
erformedb ------------------------------------------------------------ Date ........................................
mi utes per inch Depth of Test Pit .................... Depth to ground water ........................
Ii utes per inch Depth of Test Pit .................... Depth to ground water........................
Description of Soil ............................
-----------------------------------------------------------------------------------------------•-•--------....••--------------------•----------------•---•...------------•--•--•--•------•---....
Nature of R airs or Alterations — Answer when applicable_ k'U5_T4..� --kom- _C . _` �_ �.............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z- 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isied byxhpa d of health.
Signed_
Application Approved By....
- -.------------
-
Application Disapproved for the following reasons:
4 Si.. 2 + ....�
Date
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�cc....// � C
PermitNo.- I. '!............................................. Issued .... ..................-- au._....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtifiratr of Toutphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by--------------------------------------•-rMIK.5------J_A_iiAA-V_.-----------------------•-•--•-----------.-.--------------------------- - -
I ( Installer
at ...................................... k�`�`�------``E�
-- `n---------------------------------------------------------
has been installed in accordance with the provisions of TITLE_ 5 of The Sfate Sanitary Code as described in the
application for Disposal Works Construction Permit No.___`15� i?�_�;! ................ dated.__kS.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.