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THE
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Toniirurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( L -f'a'n Individual Sewage Disposal
System at:
Z,. Q ��
-.. Lo tion- Address
.................... 1! ! �.�: k w .............................
Ow er
................. ..-- - ---------------------
Installer
Type of Building
or Lpt o.
............................ _fJC3 .... ._.._ ...............
--------- --- --
Address
.....•-^----- ..... ..�� :f.?���`..................... ................
Address
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms- ....................................Expansion Attic ( ) Garbage Grinder
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfi res .• .----------------------•.._............--•---------..
Design Flow..... _.< ............................gallons per personday. Total 4..�
aly flow.._._ ------ --..........................gallons.
Septic Tank N_ Liquid ca.pacit}D ..gallons Length-_ ..... Width_.> .......... Diameter ................ Depth ................
Disposal Trench — No- -------------------- Width .................... Total Length.._._.___ j......._. Total leaching area .................... sq. ft.
Seepage Pit No ........ I ........... Diameter --- `...._.... Depth below inlet ---Lf ............. 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 ..........................................
----------------------------•-•----•-------••---•---------------------------------------------•---------...---••--•••----•---•----- -i
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Nature of Repairs or Alterations - Answe when applicabl _ t l-c�-�.w_�_l.._.... fly. —5e." ..'t Wsi!...............
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 by the board 4f health./
Application Approved
Application Disapproved
Signed.
the following reasons:
Permit No. ----W ._....r ......................
.......... .. `..
�l...2...--------
Date
.............................................................
Dau
Issued ............ i./.:----- --- ::....
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrlifiratr of Tontlithturr
THIS IS TO CERTIFY, That the
Sewage Disposal System constructed
) or Repaired (L-rl
at....-••-•------- ................... - l4 vL . /...., _ u : -�-,.,........-- ..... �� �` : o" �....-•---------------------------------............
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No -------- ....... dated ....... ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. l
DATE..........�.j
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