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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fine 1,:.5._—.
, pplirtttion for Disposal Works Tonstrurtion 1rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
5-10
IP
Loc 'on - Addres`s or Lot No.
%
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Installer Address
Type of Building Size Lot .:.......................... Sq. feet
Dwelling—No. of Bedrooms.... :5 ..................................Expansion Attic ( ) Garbage Grinder ( �
Other — Type of Building ............................. No. of persons ........... ................. Showers ( ) — Cafeteria ( )
Otherfixtureg .........................•-....•----•----------------..........--------•----••---------------------------------------------.._......---•-•......------
Design Flow ........... 6.�...................... gallons per person per day. Total daily flow ....... ��_�C)......................gallons.
Septic Tank — Liquid' ca acity._..._._....gallons Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No. Width ...q............ Total Length ..�S?.......... 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. 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 ........................
---------------------------------•--•---------...---..•..---.......-----•----•----••••-•••••-•-..............---•---••--•---•--•-----------•.......••--•--•--
Description of Soil ..........................................
.................
Nature of Re airs v Alterations — Answer w en a7li i
Agreement:
The undersigned agrees to install the aforedescribed
the provisions of 'LE 5 of the State Sanitary Code —'
operation until a Certificate of Compliance hA-bEet
Application Approved 1
Application Disapprove(
................. i . . ........... .....................
Individual Sewage Disposal System in accordance with
he undersigned furtAer agrees not to place the system in
Permit No..`..��%_------••-•----••--_......
-.
Date
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Issued-......•� � �au
---'--. ......
Date
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^--^ ^---^ H ~V ~ ~u
THE COMMONWEALTH OF MASSACHUSETTS 1 j
BOARD OF HEALTH
TOWN of YARMOUTH h�
Trrtifirab of Tompthtttrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (yam
by- . C_.`. ... :5.--- t `t..: L -............................................... ...... _
�,} I Installer
•-----
at- ------------------------------------------------- ------ 34 :::: <-`.. Q.......L.1_( Nn.--...---------- � _ ���^ ..............................................
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described 'n the
application for Disposal Works Construction Permit No...._._L=. /' _
-- ------------- dated.........��J".. ..-- ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,.
DATE.......... �,�� ',--------•--------------•-----.--.-......,. Inspector. - --r�'