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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN YARMOUTH
........................................... OF ........-.....-.......--......................
Applutttion for Disposal Works Tonstrurtion Prrbtit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: int o
._---_-..220 MAIN STREET - SOUTH YARMOUTH, MA L67--,4/9 n? /4p -- qS`
ANN CHAPMAVation - Address or Lot No.
Owner
Address
F-1 Installer
Type Building
Address
of
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic
( ) Garbage Grinder ( )
P4 Other —Type of Building ............................ No. of persons........................--..
Showers ( ) — Cafeteria ( )
d Other fixtures .
Design Flow............................................gallons per person per day. Total daily
flow ...................... ...................... gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter................ Depth ................
x Disposal Trench — No ..................... Width .................... 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 ( )
aPercolation Test Results Performed by ..........................................................................
Date ........................................
Test Pit No. I................minutes per inch Depth of Test Pit....................
Depth to ground water........................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit....................
Depth to ground water........................
Descriptionof Soil --•-•----•---------------••---------............----•-............---------•--•----------------------------....-------•-----•--------------...............--•-••--......
-•---------------------------•------• •-----•----•-----•-----••-'------"------"-------••----....... •------••• •----•--•--•----.....----------•-------•-----....•-•---......."--•••'-•••----.....---...-•--
----•------------------•----------•••---"------......---•------•---------...-------------•--------------•-•----------•-----• •---•--•-----------------------•---------•---•---..........---•-•---------•-
Nature of Repairs or Alterations —Answer when applicable..1000 GLPStone/Lined
...
.. .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLs, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has begn issued by the boargl of heal
6/24/86
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to
Application Approved By ..................... -- ` . ..----------------------------------•.....----- _
..............
Date
Application Disapproved for the following red ons-------------------•--------•-----------------------•-•---•----•--•-•---•--------...............---•-"......_....
Permit No ............ .§! . _ 331
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Date
......... 'C7!WN...................OF.........................YAR.MOUTH .
.................................
Trrtifirabt of T%ntplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X)
by..... Rs —A..........................................•----------...---•-------------------------------------•-------•--•-••-----•--------....................---.......-•---•--•--•---------
Installer
at 2 tJ• iiN- ETRE) _-_ SOQUT H[. YARM+D_v. TH.
...................................------------------------------------------------
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_ ....... /241$6.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A. GUARANTEE THAT THE
SYSTEM WILL F NCTION SATISFACTORY
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DATE_f.. Inspector. "''^t t .................................
....._
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