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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrixr#ion thrum#
Application is hereby made for a Permit to Construct ( ) or Repair ( vJ an Individual Sewage Disposal
System at
1.x111.» ... •�4
:o ...
........ d - Addre or No.
.............................. ......................11_m.... ..
J..7:1�...._.
..- -
..�[ O er ..... - ........ Address
.1-:_ ......................................................•..........................
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ........... D ..........................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' 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. 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..............................•--.......-•----------...............----------•-----------...------•-----••-•-----------......................
----....--••--•..............•-------......------------..........-•-------------•-----------•.....---------••-•--•----•-------...............--•----••--••---.......----•• .. ........ ---
Nature of Repairs or Alterations — Answer when applicable... ...._......L - .9,!`l!^....... r�.. 8...
...................................................................•--•----......--•--................----------......_...........---•------......-----•--------...----•-•••--....................---...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Com liance has b s de and of health. /
Signed.......
Application Approved B ........ •... .......... . .•---•--.................... .----- ..� . ...---
PP PP Y i�D.te
Application Disapproved for the following reasons: ............... .............................................. .......................
.................................•----.......---••-......-----------...-•--•-••••-----•--•...
PermitNo............ 1W ........................
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#ifiratr of Toun dtaurr �%
THIS A CER ;Wgr ,That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
at.......! `�''.�. .� ���`..'�--'.4�' ...�•....n-�._:...... - i = ......_
......-•...........................•---• •••---
has been installed in accordance with the provisions of TITLE 5 f T}ae State Sanitary Co d •cr' the
application for Disposal Works Construction Permit No ..... ....�.`.............. dated....... ..4...... .......
THE ISSUANCE OF THIS CERTIFICATE. SHALL [SOT BE CONST ASA GUA ANTE THAT THE
SYSTEM W.�F
.......U T SATISFACTORY.
DATE.........
�-. ._�..............................•--............. Inspector. ...............................................