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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
I D ! h
(C4 k. 4
Appliration for 11isposal lVarks Toustrnr#iun• rrrnti#
S Application is hereby made for a Permit to Construct ( ) or Repair (t,-� an Individual Sewage Disposal
System at:
. ........... ...... Vis. �:.. -- - p..............................._..._..---•-•----•
Location - Address or Lot No.
----- G..QG A. 5=. ! .__... -----------------•--------------------•---•• -
..
•-----.........-- ......................
Owner Address
W is -i C �a,►_a C� 2 b Ii�q ` 1- ........ to�2
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ..-:3 .................................... Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures ...........................................----------.-------------------------------------------------------------•------------
••-------------
W Design Flow ............................................ gallons per person per day. Total daily flow ............................................
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 ( )
6.4 Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit--,----------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil ...........................................................................................................
.......................................................... . _...- •...•----•---•••......•------•--••........_. �._....- ............
............................................................ RR � Nk & ► � L� A
Nature of Rgprs or Alterations - A saver when app 'cable_- x�,xCA�[r!�c. .._,..
....
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Agreement: J
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code — The u dersigned further agrees not to place the system in
operation until a Certificate of Compliance ha bee issued by th bo rd of health.
Signed_. - ......... .---•---------------•-....................................... Io : 24 - 24
y� D ate ��
Application Approved By-, •. _ ...... .. .......... ....................................................... •-•--•• ? .. _/
Application Disapproved for the f olk6vAng reasGns: [..
....................................................... ---•••............................................................... � ... Date - ....
Permit No.. - - - --- - V.. .. Isc>�cl-..-•- . ----...1--------------------
Date'.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH'
f9rdifirat a Of f911ntplitture
THIS IS TO CERTIFY, That the Individual Sewage Disposal Sygtem constructed ( ) or Repaired ( y'
J
by ........ "+ ...._ .R.N Q.-•-•------•--•-----••-•---•-•....................:..............................................................•..........................--.--
trt Installer
-- ----------------------------------------------------------------------------------------
•----------•----------•-----••••--------••--•-----
has been installed in accordance with the provisions of TITLE o ,T Sanitary Code as described ed in the
application for Disposal Works Construction Permit No ............. _-. -._. dated ...... ��a:_: ��� .................
THE ISS NCE OF THIS CERTIFICATE SHALL NOT BlE~GO STRUED S R N EE THAT THE
SYSTEM WILL FUN T SATISFACTORY.lei
DATE... , r —------------------------------------------Inspector .... ........... .. .--:........_.......---................
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