App-Permit-ComplianceNp ,- -1►2 ! Fss_....Zs...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
, ppliration for Disposal Marks Tanstrurtion 11amit
Application is hereby made for a Permit to Construct ( ) or Repair (>�) an Individual Sewage Disposal
System at
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....--- ---•-•••-j--'L-»�`Location - Address 2O�lr-•N...............X .....». - C .. ./---
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Owz ddress
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.........--- - » ... •-c..h�L.G.S...---......
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................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..__..... e�....... Width....:.. '___._.. Total Length..... l ..... Total leaching arm...................sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet .........4.2!. Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
PercolationTest 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
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UNatur f Repairs or Alterations — Answer when applicable _...__�(✓Ct.`Irf_.Y...I. �—
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'LIT 1Z 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i d by the b rd.9f health.
Sig_...... .. ........ ............ ...................
ApplicationApproved By.... • .. .. ............ ..... ........... .............................................. ......»l� - 7 ' Z.�•--....
Date
Application Disapproved for e f ollowing r ons: .. ......................................................................................................... .
..................................... . ...... . 1 ..... ....Date .--•...-••---
Permit No.... _ .. .............•--........ ......... Issued ....» ..J . _ ....L .... Date.....»
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Totifirate of Tanwitanrr
THIS IS TO CERTIFY, That t4 Individual Sewage Disposal System constructed ( ) or Repaired
by............................................................ )167 w�_ .... r' !.::�T� /s!N........••-••••...........•-•.................
.: 4L ................• ---...._•-•--•............................d . — — — —-.Jr..:.�._a..cc... _.
_..... ...........................................................••..
has been installed in accordance with the provisions of TI 5 of The State Sanitary Code a desc i ed in the
.application for Disposal Works Construction Permit No.__.-�-E- Z . ...... dated......... 1;\ ... ... ... .�....,..........
THE ISS A E OF THIS CERTIFICATE. SHALL NOT BE CONSTRIJ A GUAR NIE THAT THE
SYSTEM WIL F NCTION SATISFACTORY. --�"
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DATE........ 1,--......:A. ................................•--.......... Inspector-- ...-- ...... »�1.. ............