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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
.1 pplirtttion for Disposal 30orks Tons rur#iou llermi#
Application is hereby made for a Permit to Construct ( ) or Repair (k) an Individual Sewage Disposal
System at:
Itg CLEFr/�' c32o6 ,eDa-."Ol/Ta(
Location -Address N�;
4_4-46—/-7-,5- -•---•-------------------- -•---- ......-- -E-------•-------..... .......-•------•- .....--•--..............
Owner d r ss
LE �s�c._...-•----•-------•-•------------ -- �'.v, 43 lox ....
� �. �� c�
.. -.... • �- -- -....1 -• ..._ ...... ...... . ..�
Installer Address -
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ................ ......................:Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons.-, .......................... Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow ......... J 5. ......................... gallons per person per day. Total daily flow .....--_ � d .....................gallons.
Septic Tank— Liquid' capacity/OPP.-gallons Length.'__ __. Width ---•6' `... Diameter ................ Depth ......
Disposal Trench — No . .................... Width•.....:............. Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No...__..1_..._.__.� Diameter. ---.40.`...... Depth below inlet ------- &......... Total leaching area..,tt--4._....... Zfc C Pb
Other Distribution box (f Q 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 ........................
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Descriptionof Soil ...........................................................................................................
----------------••-----••---•----------------........---------------••--•----------••-----------•-----------------------•------------......------.......------...........::-------•••-•----•-----.......
Nature of Repairs jor Alterations —Answer when applicable--/!v..i �' I. ..... . .-... .t.J'.:......................
._._X._C.- h._..... ... Il.. .... .'.{3.. \IP__ r.... f,�i_! __.�.....%::_.. . 1_.. L.7 i_F!_ .A ..................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL S 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 h alth.
Signed. A (s Z
------ --.
ApplicationApproved By --- .--• ..... .................................................................... ........- ---- L
Date
Application Disapproved f r t follo ng re ons:--•.....................•--------•--------•-------------....---•---••---------•-------•--••---.....•-----..._...
_ � - Date
Permit No......�.. Z�...... ........ Issued-- - �`� -�-----......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF ''HEALTH
TOWN of YARMOUTH
C9rdifirtt#r of T-amplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal_System constructed ( ) or Repaired (pC)
by.......... � ..--•--.4.....?.4.0 A.......--••--•-•....................•---.........----........----.....-•-----•-------••-•-------.............................._...---...-----
Installer '
at �'.... -- - --L. ft 2 • 2 Q 1; 4 A �.----0-1----Y (l�'!.Q__t�. ................................................
has been installed in accordance with the provisions of TIT of The tate Sanitary Code as described in the
application for Disposal Works Construction Permit No.__.._:��...�:I_�.._. dated._ 6....✓' ".�'1`. .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCT ?N SATISFACTORY
DATE... : l.:.0 �9 'L Inspector....-- ....... ............................... ......