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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion jhrmit
Application is hereby made for a Permit to Construct
System at:
W-17 ......
.a ... 6eA.-W–g
L cation - Address
........................................
Owner
Installer
Type of Building
Dwelling — No.
) or Repair (1,,) an Individual Sewage Disposal
.......... ..... 1.. �-4� ......... . .............
or Lot No.
T—� 7 �.4400d ....... .............
A d g;/
...
. ..........
. 7:2 .... T&AAAt ... A� .....................
Address
Size Lot ............................ So. feet
of Bedrooms..........: ..........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ..... L4.76z4 ........ No. of persons .......... ................. Showers ( ) — Cafeteria ( )
Otherfixtures ......................................................................................................................................................
Design Flow ............... //-Q .................... gallons per person per day. Total daily flow ............ 3.da .................... gallons.
Septic Tank— Liquid ' capacity./.Q -.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........................
Descriptionof Soil ------------------------------------------------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
Nature of Repairs or Alterations — Answer when applicable -------
/P.0.0 ..... Com..., - .........................................................................
.e - 0
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board o health.
Application Approved By
Application Disapproved fof the following reasons:..........
...................................................................................................
4)p —
Permit No ..........------------- - -- -
ae
pate
...........................................................................
D
Issued........._. !? 7 .... ..... ate
......
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THE COMMONWEALTH OF MASSACHUSETTS 1Z
BOARD OF HEALTH Z
TOWN of YARMOUTH
(9trfifiratr of Toundiattrr
THIS IS TO CERTIFY, That the Individual Sewag Disposal System constructed or Repaired (4,,)-
. ..........................
by ---------------------------------------------------------------------- ----- A M, ................................................ . ........ .
In tal Lcir
at................................................. '_4 ..... . ..................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a described ia 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. .....- -- 6- nspector .....
................. Z -t .................................. I .....