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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion rrrutit
Application is hereby made for a Permit to Construct
System at:
....................
.-..IQ Nw Location Address ......................................................
.•.........................
..t�:.u.4.c1_ .K
...............................................
Installer ..
) or Repair ( V/ an Individual Sewage Disposal
�_crr A ®H l 0 "A'P (n Q
or Lot No.
--. . Address ..•..--..........
i�!.r..........
1 ..............
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms .............. !ate.- ......................... Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures.........•-•••-•••-••••-•.................•--------•.............-•--•••-••••••-•-••••••-••-••-•-•-............------.........-----•--------.......•..
Design Flow ............... //",,-..................... gallons per person per day. Total daily flow ......... �3t7......................... gallons.
Septic Tank — Liquid capacity../ 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. l ................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...................•-•---...............-----•..................
.....................................................................................................................................I............................................................... .
Nature of Repairs or Alterations—Answer when applicable .... 1,,,,s°i`•Q4T_.._�Plr..,e4.._E!..._?............
_._e.)r_l1PFoej...___..a:........... MA wA... W. -4m ......_czfAp...._.� �c-..._xx �c.�.c.__x:.r ...... F..,u :...:.. ..............................................
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 furtlier agrees not to place the system in
operation until a Certificate of Compli a has been issued by the board o health.
Sie .............................R.
a
Application Approved B -• . ... . • • ..... ....... ....... ........1 � ... �...........---
ate
Application Disapproved or the following reasons: ............................................................................................................ . . .�_ Date .............
PermitNo ........... ............ C1/ ....•.•.......----. Issued......... - --------.-...
ate
THE COMMONWEALTH OF MASSACHUSETTS A
BOARD OF HEALTH
TOWN of YARMOUTH
Trriifiratr of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (L,-�
by......................................................................&k .... r..... .....................................................................
Installer /
at........................................................... 2!%... �4r.Jl. ----------- So .... y.�3..Q►dto.I. ..............................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described,in the
application for Disposal Works Construction Permit No ...... �.��„lr---- _----. dated ------- �=�.7.-.J...........
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION cSSATTISFACTORY
DATE..................0 -Z?fl .L��,'...........•... ................................ Inspector_ ..... ......��r�. ................
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