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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tontrurtion Prrmit
Application is hereby made for a Permit to Construct
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Owner. .....
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Installer
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) or Repair (V an Individual Sewage. Disposal
Type of Building
Dwelling —No. of Bedrooms.......... ..........................Expansion Attic
Other — Type of Building ............................ No. of persons............................
Otherfixtures ------------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ca.pacity............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........................
................................................................................................•----•-•...................-•-------...--•--.................
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Address NN
Size Lot ............................ Sq. eet
Garbage Grinder (1/r
Showers ( ) — Cafeteria ( )
Description of Soil............
---•-•-•-•-----------------------------•-----......-------_-------------------------------•-----.......----------.....--... .... -------------_.....
Nature of a a>rs oy-%Mterations Answer when applicable ....�c ^ ........ ..... ...........................
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Agreement:
The undersigned agrees to install the aforedescribed Sewage Disposal System in accordance with
the provisions of TITIEj 5 of the State Sanitary Code — Tindividual
e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i bthe board of health.
Signed....
Application Approved By...f./.
Application Disapproved f o the following reasons:
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Permit No ........... I.L)
Date
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ISS11ed.....
_-r....... Date ......
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irdifutt#r of Tuntviittnrr
THIS IS TO. ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b..... .................................. -:................................. .......... ..
has been installed in "accordance Ili thl provisions of TIT6E. 5S
application for Disposal Works Construction Permit No.-------- ^ E
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE
SYSTEM WILL FU10 T FACTORY.
DATE ....................... �J..�.....4............................
Inspector.
State Sa- iitary Code hs described in the
dated...... ---4.1 ... .E j...---....--
"UAFJANTEf THAT THE