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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Application for Disposal Works Totts1rnriion "prrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (/an Individual Sewage Disposal
System at -
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Installer Address
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Type of Building Size Lot ..........:.................Sq. feet
Dwelling —No. of Bedrooms ............ ...........................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 ..........................................................................................................
-•------...-•--•.........•--•-••....-----•--•--------••------•---------•••-•-•.....--- •---
Nature of Repairs or Altera s — nswer when applicable l � ,� i .:.......... . c ?t .._... �.: ......_.
...... - fes?..................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu he boar of � alth. a
Signe.. ---A= -'s �................................ .......................... ..
Application Approved B�� �'�. —��
PP PP By ........ `
.......... .......... ----- ---.............-------•---• .......---^-• .....----- ............................Date
Applieation Disapproved for the following re ns:............................................................................•___..............................
/, v............................................
1 �,r Date
PermitNo... ......--• ................................... Issued...----- --•......---•._.........._..............••--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH T
Gr#ifutt#r of Tontplinurr
THIS -IS -TO CERTIFY, That the Indiv;dual ewage Disposal System constructed ( ) or Repaired
by......... .:.. .. Inst ............................................ 'a .................................................
at .. �i 7L iG lit ...... ----- - ®-� :-- ,1
has been installed in accordance with the provisions of TIT 5 ,'he S�Sa.nitary, Code asfdespribed: in.#e
application for Disposal Works Construction Permit No -------- ..................... dated ........ :............. '._....`:; . .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 13_CONSTRUED AS A -GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �'
DATE............... ..:.... .. .....-..........- .. Inspector...........'` ........ .. ......... ......... ............
.. .....