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No.3..`�... �:: South Yarmouth, MAA 026.64
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .. .......................OF............ ..
Application for Dispo larks C vnotrur#iott jhrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
tai....
.................--1---x-7- --ve----.Y.�'LY ��(� .--- •---........ -
or Lot No.
1 ype or uunaing
Dwelling —No. of Bedrooms.
------...---•.............................................•----...----.............---
Address
.............Expansion Attic
Other — Type of Building -------------------_------ No. of persons.
Other fixtures
Address
Size Lot ............................ Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
•-------•---•----•------•------•-------•--------------.--••----•--•--------•-------•-------------------•-------•--------......-----•----•--••---•-----
Design Flow............................................gallons per person per day. Total. daily flow ------------------------------------- :...... gallons.
Septic Tank — Liquid ca.pacity............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. I................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........................
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Descriptionof Soil....................................................•--------------- --------------------------------------------------------....-••---------
.--•----------------------------------------------------------------------------------------•---------------•-------------------...----------------------------..............
----------------------------•---........................................ ------------------------• '-
Nature of Repairs or Alterations — Answer when applica.ble.... � �%..gat/ .--------
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been' ued by the h alth.
Signed. ...
te
Application Approved By... . - �0,�--................. ........................... ..... 1 Zqa
Date
Application Disapproved for the following reasons--------------------------------•---•-------------....---------•-•-----------•---•----------•----•-•----•--•-----
-------------------•---------------------------------..................................----Date ......
Permit No ...... �.... 3.��2------------•----------• Issued--------2(Z�.t�aE-..........................
Date
THIS IS T
THE COMMONWEALTH OF MASSACHUSETTS P .:
BOARD J OF HEALTH
........._OF ..... ..,i ., :7.I. ° 1 :.....................................
Trrtifir* of Toutpluturr
RTIFY, That �tke Individual Sewage Disposal System constructed ( ) or Repaired ( �'
l stiller ------------•------•---. --- ---
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has been installed in accordance with the provisions/of TITIZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit .................. da.ted..._ Q4J. V 5....--....._...._......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... ;`i_. Inspector.....t t ----------------------•---