App-Permit-ComplianceFicin ....�'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Disposal Works Tonsiru•rtiun Frrmi#
Application is hereby made for a Permit to Construcl
System at:
.........7 .... �A C14.......... J_tj = •- ---•-------•..............
•ocation - Address
x~........
Owne
--------------------------------------------------
Installer
Type of Building
Dwelling — No.
) or Repair (-p-ylan Individual Sewage Disposal
or Lot No. -W Pre-( S
Address / y •---•�•�-•--
-------------------
Address
Size Lot ............................ Sq. feet
of Bedrooms ... 3.....................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................. Showers ( ) — Cafeteria ( )
Otherfixtures--------------------------------------------------------------------------------------------------------------------------------•-•-------------------
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 arm ................... 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 ..........................
---------------------------------------------------------------------------- -a....----------------- --- ... ----...........LD.... ..-_.
ature of Repairs �r Alterations Answe when plicabl •.•._ !Glc' r�' 7 �'"!` ....•....--. ` - R! -y ....
b.._..�._.----••-------...-- j ------- -i �a�•�'Q-*---------------- -----------------------------------------------------------------------------------
Agreement : A
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z- 5 of the State Sanitary Code — The un a igned further agrees not to place the system in
operation until a Certificate of Compliance haseen pFd by the hoajd of health.
Signed. _.....
Application Approved By.....oeollorwin
..... .........
Application Disapproved for reasons:
..........................................
......
� ....................... `..----------.....-•----------................................ : ��-------
'Z..........
�Date
PermitNo ................................ •.................. Issued_. - ............
1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
j -':�0°-cam?'�'
---Date: `. .._.
Date
TOWN of YARMOUTH
Trrtifirtt#r of 09umplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( v7
by- ...... 4 9t.B -. CA:2C.0............................................................................----------------
........
........................
- ......_......
Installer
at........7....... �.R.lr,-H..T-...... L -k: ,...--...a.,h„e-:..... �- . ---------------•----•-------•--...................--•--.....-------•--•---••-----•------
has been installed in accordance with the provisions of TITLE 5 of a State Sanitary Code as described in the
application for Disposal Works Construction Permit No ...... ._.._ .1 ............ dated ..... .% ...:. .. ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUED AS A GUARANTEE TH THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.... , ..... ............ ---------.......... Inspector ........
J :...