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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Application for Disposal Works Tonstrudion 1krmi#
Application is hereby made for a Permit to Construct ( ) or Repair (kran Individual Sewage Disposal
System at:
.1 ... Zap------------------------ _----------- --.---------------------------3t:-.AA................................ ....................
- Location - Address or Lot No.
----Cha-�r1 ----- - - ------ - _... - ' ' c� ?rc! C1.1�.1QW....& ......................... ..-.......
Owner- Address
................lam �..... P ' aha& ................. =-- ------......._......---•-.......
---------------
Installer Address
Type of Building Size Lot_
........ Sq. feet
Dwelling —No. of Bedrooms ........... �----------------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ...S14T.,r _._....... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------------------------------------------------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
ei$T�a> - Liquid ca.pacityl.(?ao-.gallons Length-: �_�_.`.`. Width._`�.'2 f. Diameter ................ Depth--..' !sic .
isposal free 1c i — No. ........ !k ......... Width .... 9 ............ Total Length ---3 ......... Total leaching area..a2`�......... 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 ........................
---•---------•------------•----------••----------------------------------------------_._.........--.........................................................
Description of Soil ............. �......
.__. -------- a.-:. ..................... � '.��-------------- - �:
• . - . : ..........
..........
.Y-----------------------------------•-..__...------..----...---..-•----..•--.._...........--------.--.
Nature of Repairs or Alterations — Answer when applicable.. ; _ L'...-. �-1`.'F'"
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLI: 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
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ApplicationApproved By .... -1 --- ------------------•--•-------.------_----...----------------.--------------- ........
Date
Application Disapproved for the flolowi4 reasons: ........................ -----------------------------------------------------------------------------------------
Permit No....... `1Q.�. 4.`- - ----------------------
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tatifirate of Tomplittnrr
THIS IS TO CERTIFY, That the Ind:
ate
( ) or Repaired (
r�q U 1 ' �jy'L— _rstall
at--------- -----•-------�----------------------- ------------------lS..Z?.--.----•---•------------•-•-------------------.------•-•- ..............
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. _.RQ_ n.19q ................. ' dated...... .' .
application ...-.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA W LL FUNCTIONSATISFACTORY.`�--�o
DATE.. ..... ... � � 0 .................... Inspector:-... ................ :....?..,'.'"i..,_. ... ......... �.