App-Permit-ComplianceNo. .....�� FICs _ / S .:. O Z�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrwtion rumit
Application is hereby made for a Permit to Construct ( ) or Repair (Vraan Individual Sewage Disposal
System at:
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w r ddress
a.........CW�r......�.��.�. �� :..Gr.- ... .....� ....���/.:.
PA Installer
Type of Building Size Lot ...........................!Sq: feet
Dwelling —No. of Bedrooms............ 3........................Expansion Attic ( ) Garbage Grinder ( )
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 .................... 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 ........................
......................• •-__. •-----...__.___...._.......----........-••-•----_....................._....._...._.......--•-•-------............_._...----•-----
Descriptionof Soil...............••-----•---•-----........................------------------•-•----._..__...._..............
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Nat re of Repairs or Alterations Answer when'applicable_.__ .(Q_C�L?_..__- ........
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beenl i d the b, ki-d of i t_h. j
.D
- Date
Application Approved BY -- -• -............ -•--------------- - ��..: ? _...
Date
Application Disapproved for the following reasons_ __________ _ _
...........•-••.........................C._�___--•-•-�--...______...._._... ........ •--•--.•-•-----------•----•-•--...............__.-•-•........ _.. ....... -... .......................
Date
Permit No ...... !.....'0.• ................. Issued...... �... . �••- ..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTHr
TOWN of YARMOUTH
(Inrtiftrate of Toutpliaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..............' %�.�.�:1 ...... ._....................--------._........._.............------......._........._........---.................................
• Installer
at------•----•-- - �• -- ( u -t :........ - - ,.. _ _�_____________
has been installed in_accordance with the provisions of TIT 5 of T State Sanitaar C d . as c� ' ribed in the
c� ..............
application for Disposal Works Construction Permit No ..... r. "._.-._..... dated....
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOYB14—COSTRUED AS A,, GUARANT TAT THE
SYSTEM WT..
ION,,. SATISFACTORY.��
DATE.......... fE. :. r ..................•-•- -•- Inspector. ...- . .�1.... .... ..........---...--