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THE COMMONWEALTH OF MASSACHUSETTS '� (Q1
BOARD OF HEALTH �'j V
TOWN OF YARMOUTH FEB 1 5 1995
LTH CREPT.
Appliration for Disposal Works Cnnnsirur#ion
Application is hereby made for a Permit to Construct ( ) or Repair ( � Individual Sewage Disposal
Sy.... ... .....................
`ire e
Location - re
----------- - ........... ..... �1.�° ...............
...:2 Owner
Installer
Type of Building
Dwelling —No. of Bedrooms............ ---_------------- ----
Other —Type of Building ............................ No. of persons.......................
Other fixtures
fi
Showers ( ) — Cafeteria ( )
....................................................................•---------•-----------------......-•--------------•-------.....------•--.....•--•-
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. 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 ......................................................................
----------------------------------------•-------------------------------------------•-------------------------- .......--•-....--•--- .... -.........................
Nat R airs or Iterations — Answer when applicable.-- - = -- ...........-•---
_.... .
e.
Agreement:
The undesigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE5 of the State Sanitary Code —e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is d bVIhe board 2JUel�h,�
Signed....
Application Approved By
Application Disapproved f olthe following reasons: ............................
Date.....
Date
...................................... a a
Permit No.------- ....`f! -_.... Issued_ - � 4� ............ `
Date
--------------- — --
THE COMMONWEALTH OF MASSACHUSETTS �-•
1
�!� � 66
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#ifirate laf Toomplinurr
THI ERT , That the 14rdividual wage Disposal System constructed ( ) or Repaired
b-..... � ... _..d .._ .5.. = - e�.. - ............................................................
y... -• • ---
Install
at...... .--.... �::_...- --------- .... . .... .........................•--
has been installed in accordance with the provisions of TITLE 5 of T State Sanitary Code as escri ed 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.
DATE............ ........................................ Inspector----- -----• . ..... f/ ._ .....