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App-Permit-Compliance
No.. .�... � �o ®v_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF YARMOUTH Appl ration for Disposal Works Tonstrnrtion P.rrmi# Application is hereby made for a Permit to Construct ( ) or Repair (✓j an Individual Sewage Disposal System at: / .... .. ! ..._ �sr..iso..:�Q .._ Y_ '.sl._._,Sa...sr.QB o✓ . . LOT— U�l 14 ............._.'.,��..�.... Location - Address or Lot No. ..................................... ----•--...................................................... .................................. ..._..... Owner Add re `.' ;?c°�-.a /yl �04+1.aJ.. rtct�4� 1�V�'.A1° Iu, f Installer Address Type of Building Size Lot ............................ Sq. feet Dwelling— No. of Bedrooms ............ &J__Q---------------------Expansion Attic ( ) Garbage Grinder ( ) Other Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ----------------------------------------------•---........--------------------------------................----...-•----------•----------------- Design Flow ............... /_/10 .........-------..gallons per person per day. Total daily flow ............. 2_:;Lo ..................gallons. Septic Tank — Liquid capacity --- A0t2.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. I ................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 ................................... ----------------------------•----....................-----------•----------...--•-•------------------------------------------------•---...-----•----...--•---------------------......------------------. Nature of Repairs or Alterations — Answer when appli ble....�J u�J. S TIG----S.c 37 eS�i�j...../11A.�2._.Cs.7 ..... iAI.Q... .¢..1'k9.fc!>Q1 L`ilScrP.S ........ . ..... . ........-•----------------------------------------............--•----- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITAIL 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�Ihlth. Signed..--- �- _-- -.................... ? ZZ %/- D ApplicationApproved By---------- .. --- .•---------.............................................. -- •-----. ��/...... • ate Application Disapproved for the following r ons:---•--------------------------------•------....................------------------------------................... ..--------•------------------------••---------...-----...-----........------------....-----•-------------.-------------------....-----.....------.......•---•---_... .............. ------.........-- � ate Permit No.......^ .. / ©-----------------•---. Issued --- -- --. ...... Date - THE COMMONWEALTH OF MASSACHUSETTS `Q 7--) � BOARD OF HEALTH TOWN of YARMOUTH (In ifirair of f UMplinurr THIS IS TO CERTIFY, T t the Individual Sewage Disposal System constructed ( ) or Repaired (V -f by.....................•-----.......-•-----------•----... .l�..t,4W ..._ �.. t. : �1- ----•----------•-----.................. Installer ........................................................._c.y................. .... ..y....... . ....r......y........................... has been installed in accordance with the provisions of TI 5� T)ie State Sanitary Cod . as c scribed in the application for Disposal Works Construction Permit No...................................... . t d...... 7 r 1__................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE SONSTqUE4 14S A R N EE THAT THE SYSTEM WILL FUNC I SATISFACTORY. �� DATE............. ---------!r1R)11_11* ......................... Inspector---•-- --------------------------------------------------