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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
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............... ..LHE ... S 1------------------------------ - ----------- .................. -_ _. .. a
Location - Add or t No.
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Owner
eI MI.- 1( ----------------------- ........ .... .... yketAak ...............
Installer Address
Type of Building Size. Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.... . /I .................................... Expansion Attic Garbage Grinder
Other Type of Building ............................ No. of persons................._..__.._._. Showers Cafeteria
04 Other fixtures ......................................................................................................................................................
Design Flow.. -- a_�...............................gallons per person per day. Total daily flow .......... q.% -M ...................... gallons.
Septic Tank A- Liquid* capacityt.&O...gallons Length .... 1.0 ...... Width..6 . ........ Diameter ................ Depth ................
W4
Disposal Trench — No- -------------------- Width -----------------... Total Length.............._..... Total leaching area ............._.___.sq. ft.
Seepage Pit No .... (� .......... Diameter ... /0 ----------- Depth below inlet.._. ....... Total leaching area ................. sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by-----------------------------------------•----•-
Date....----..__._...._..-----------------..
Test Pit No. I ................ minutesperinch Depth of Test Pit.._._..__ -Depth to ground water..........___._......_..
Test Pit No. 2 ................minutes per inch Depth of Test Pit ................... ;. Depth to ground water.........._._.......___.
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0 Description of Soil ........................................................................................................................................................................
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r Zf 7 .......
Nature off Repairs or Alterations —Answer when applicable. --tZIC
U ...................................
zO _51 dteE ...........................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT 1Z 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 b th of filth.
Application Approved
Application Disapproved for
following reasons: J --------
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PermitNo.-----• Issued_ ........................... ......... .............. .
Date
THE COMMONWEALTH OF MASSICHUSETTSI
I
BOARD OF HEALTH
TOWN of YARMOUTH
Tafifiratr of Toutplitturr
THIS IS Systei co
CEeTIFY, That the Individual- Sewage Disposal in nArtic . ted or Repaired (K)
by....._, ............ A V L
......................... .................................................. .............................
Installer
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has....................................... ........ L -:E...._._..
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a I sc in the
_I 'V
dat
. ..... dat ----------------
application for Disposal Works Construction Permit No.. ZfT
THE ISSUANCE OF THIS CERTIFICATE SHALL N09' -BE- MSTRUED S, UARA TE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Inspector.....
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DATE.:.::...: ................................... Inspector ......................... "'T"—.', (� -------