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SO. YARMOUTH MA 02664 Fim$_.��„�'�_„_.... .....,,
THE COMMONWEALTH O MASSACHUSETTS
BpARD HEA VYH
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Appliratiun for Diup 1 orks Tomitrurtiun "pamit
Application is hereby made for
System at: s ,
( ) or Repair ( V'7 an Individual Sewage Disposal
Installer
Type of Building
Dwelling —No. of Bedrooms............................................Expansion Attic
Other — Type of Building ............................ No. of persons .......................
Other fixtures
Address
Size Lot... ......................... Sq. feet
Garbage 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 .------............. 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. 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 ........................
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Descriptionof Soil ......................................................................................................................................
. .
.....-•-•-------------------•--•-----.....------...................----------------........-----•-------------------- ....• -•---- •--- ---------------
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Nature of Repair or rations — swer when applicable.__....._ ... y ..._......- ='- 7 � ..................
..........................................••----•-.....
Agreement:
The undersigned agrees to install the aforedescribed I 'vidual Sewage Disposal System in accordance with
the provisions of TITly, 5 of the State Sanitary Code — ersig her ees o place the system in
operation until a Certificate of Compliance has beeq is - e b- o alt
Application Approved By
Application Disapproved for the following
L
Permit No.._.. --..
I --- :.....---
R
........................ ..........................................
Issued_ ..........%��� Date ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
A, >- BOARD ,/HEALT
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-°-�(�='....... OF...,..,...� .......................
Tntifir4b of Tomplinurr
T aTO CERTT, ,,� jth Injit'uL� wage Disposal System constructed ( ) or Repaired (�-)
.
by ... _{ rt���'r.,' �� :•�r'.a'..
Insat. L'�c s'' :.. .� Y G .✓'' -� ` -lam ------------•-----. ----•---. ..-----.
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.____':................................. dated ......... .......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL)FUN¢TION SATISFACTORY.
DATE........ . j.. r"_'.�-------------------------------------------•--- Inspector.. •� ._'��� � % <