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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
for Disposal Works Tonstrudion lirrmit
Application is hereby made for a Permit to Construct ( PI' -or Repair an Individual Sewage Disposal
system at:
. .............. . . . -e .... . . .............................................
Location -Address
Owner
..................................................................................................
Installer
Type of Building
......................... . �-o .......................................... . ......
or Lot'
�.X�jr / eC_&2Y,.1,V ...........................
ess
Address
Size Lot ... feet
Dwelling —No. of Bedrooms......... o.........................Expansion Attic (,mp) Garbage Grinder (A -f->)
Other — Type of Building No. of persons ....... 5 . ................ Showers (.2.) — Cafeteria
Otherfixtures ........ Z.,. .............. .................................................................
Design Flow ............ ZZQ ......................gallons per person per day. Total daily flow......... ................... gallons.
Septic Tank—Liquid capacity./CW .. gallons Length..: ............. Width................ Diameter................ Depth................
Disposal Trench — No...... Width.... ............. Total Length .................... Total leaching area...... .............. sq. ft.
Seepage Pit No...... 0 ......... Diameter ...... 6 ............ Depth below inlet ...... 6 ......... Total leaching area.�_YfZ ..sq. ft.
Other Distribution box (k -j Dosing tank( Date .... ZZe".. �,�'......_..
. .......
.....minutes per inch Depth of Test Depth to ground wat.... eO ..........
Percolation Test Results Performed by ..........
Test Pit No. 1.._..- . Pit%/,
Test Pit No. 2 .... r. -.....minutes per inch Depth of Test ...... Depth to ground water...._ -V62 ... o .......
-------------------- ** -------------- " ........ * ....... * .. ...................... * ......... W* ....... ; . ....
Description of Soil ........... 321.� .......... ...... . ..... ........... .... . .......... .......
....... ...... .......... . ..... ................... 1-4? ...... V...4.2ne ...... ...........................................
........................................................................................................................................................................................................
Nature of Repairs or Alterations — Answer when applicable ...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'LIT IS 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issyed by the board of health. — I
Application Approved By...
Application Disapproved for
"Ig
follo -wing reasons: .................
.... t;t ...
Date
ft
......................... 4,
.................................................................................................................................................................................................
Date
51)
Permit No ......... IssuedL ......... ...
.......................................
Dae
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irrfifiratr of Toutpliaurt
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ellor Repaired.,(
by..................................................................................................................... : ........ .... . ........................................ ---------
Installer
at......... Z: .... . ................................ Xa ...... . . a ..........................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
41)-
application for Disposal Works Construction Permit No....... ...... 1%.1. ............ dated ........ ------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............... ?.-..Z4 ............................... Inspector