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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion Prrmi#
Application is hereby made for a Permit to Construct
Systkm at
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t") --V— 4ocation Add
..Ale ...................................
Owner
................................................
---------- Cemr-
Installer
Tvnp of Building
) or Repair (,'jr'an Individual Sewage Disposal
.t .... N
A.P.P. A. ftl*raln.. (2Jt X . tadA .....Cf..,.........
A40ress
.31 ..... . ........ . _l....... . .............
Address
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............... a ....................... Expansion Attic Garbage Grinder WA)
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........ t .......... 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 Alt rations — Answer whsn ppli ...... /�.Iwv ..... :P'q-t! ...... yo
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. . ..........
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........... h)AJ A ........ WX a S.).MA.e . ...................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance
the provisions of T I T IE 5 of /the State Sanitary Code — The undersigned further agrees not to place the ystt
operation until a Certificate of. Compliance,has been issue by t e bo d of I Ith
Signe
y
S......... . ..3r- .... ........... ....... /0 Z`. .......
i e_
ApplicationApproved BY ----•' .................. .......... ............. .............................. .....
Date
Application Disapproved for
Permit
following reasons:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
77&i; --- Y
VDate
in
&rfifiratt of Tompliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ,.(-&,.)*'
by............. 01±.2 ....... eef —a .................................... installer ....... *" ...... ...... * ............ ........ ---------- —
has
------------------------ been installed in accordance with the provisions of TITLE 5 of Sanitary Code a/ describp in the
application for Disposal Works Construction Permit No ....... 1.5-=j dated ......
THE ISSUANCE OF THIS CERTIFICATE SHALL 40T BE D AS A,Q ANTE HAT THE
SYSTEM WILL F CT N SATISFACTORY.
... 7 ','-',7 7 .7 .. ..... ...................................
DATE....._.... !��2 'Co ..1.> .......... ............................... Inspector ..........
777.7"