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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tons'.rnr ' n Farm#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage
.:
Di
I LVoRSyBt at
. ._.. �:_4 �...............
res.
... ..`� ... - ....................................
Installer
Type of Building
Dwelling —No. of Bedrooms.......... ..........................Expansion Attic
Other —Type of Building ............................ No. of persons .......................
Otherfixtures.._.....---•------------------•--.._._.._...----------.----•--------------------------
Grinder ( )
_____ Showers ( ) — Cafeteria
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 .................... Tot lC7 I?, ('I -�
Seepage Pit No_____________________ Diameter._______.__..__..___. Depth below inlet_____.__.........._. Tot
P
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by______________________________________________________________________ l r
Test Pit No. 1 ________________minutes per inch Depth of Test Pit .................... Depth L
Test Pit No. 2 ................ minutes per inch Depth of Test Pit .................... Depth ITJ
.................•----------_-- �_
Descriptionof Soil........................................................•-----------._..._..---------•--
........................•--------------------.._..---....---....------------•----•-------------------••--•-•-•....___....
----------------•------- --------------•-------•----------------------------•-•-------------------------
Nature of Repairs or Alterations — Aniwer when applicableA..______.
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The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLij 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of pliance has been bthe b rd o al -
Signed..... ---------------- ... ... ............................ - y
Application Approved By ....
Date
Application Disapproved or the following reasons___________________ _ _________________________________________________________________________________________
------------------------------------------•-----....--••-----------•--•--.....--•--..._..--•------........_..---•------......-----------...--•-------------------------------......----•-------........--
Permit No .....Q ....... 6---------------------. Issued _-------` -Q •---1_----47.---.. ae .....
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tanfirate of T%ntplinurr
THIS IS TO CERTIFY, That the Individual Severe Disposal System constructed ( ) or Repaired
by.......4L_ ,l A: ----- "��.: J:4:.....`�... ,r ,:, ... !... _ 'r�_
has been installed in accordance with the provisions of TITI± 5 of Tjie Atate Sanitary Code as described the
application for Disposal Works Construction Permit No ......... !T___"'._1'T_ ___L_...:___ dated ....___t
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT -BE -CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FYNCTION, SATISFACTORY.
DATE ............ ............ -.... - Inspector ............- ..... Garbage
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