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Itck �%k9THE COMMONW ALTHSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appltration for Btsposal Works Tonstrur#tun ranttt
Application is hereby made for a Permit to Construe
System at:
• Location - Address
4 owne
-----------------------------------•---•--
Installer"
Type of Building
Dwelling —No. of Bedrooms .........................
Other —Type of Building ...........
Other fixtures .... a ..........................
Construct
( ) or Repair ( ) an Individual Sewage Disposal
M Oct�- v/ i--
C ... - or Lot No. ------------------
-----........... ....................
............... '---.._-- ... _--••----------------------------..._._._------
dress ,
......._:�:�.. �� pA .le-_ ......... > .....
Address
1 Size Lot ............................ Sq. feet
--------------
0.
------------ o. of Derso ..............
Design Flow . ................•------. gal s per pe)
Septic Tank — �iquid capacity ....._.____gall s Leng
Disposal Trench No ................... Widt-----.._----.____
Seepage Pit No ______________ iameter....... .......... Di
Other Distribution x ( ) D g tank
Percolation Test Res Its Performed b -------
N _'_____
Test Pit No. I_..._ ......_' inutes per inc Dept]
Test Pit No. 2--------- ------n inutes per inch e
Descriptionof Soil •••••••••••••••..••••• .........................•-----
................. •---•-----• ....................
)n per da Tota daily flow..
................ Vidth.............. Di
Total Len th.................. Tot,
th below i let ......... ......... Tot
i
Garbage Grinder ( )
( ) — Cafeteria ( )
....................................................
.. •-------•------------•---------------dons.
Teter---------------- Depth ................
leaching area ...................sq. ft.
leaching area..................sq. ft.
------•.-•--•----• - ......... Date. ......................................
.
of Test Pit .................... Depth to ground water ........................
of Test Pit .................... Depth to ground water ........................
..................................................... ----.._..._......._._......_......---•--. •. ---••--•-----•----•-----•---•--•-•••---
....-•-------------------------------•--------------------------------------- f
--------- -------------- --- ----
Nature of Repairs or Alterations — Answer wh n applicable. �/- ------------�--....."r'. 5izv
............................................... f1 d �c .... ?� .�'
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITii� 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ie y e oa of health.
?S`
to
Application Approved B'-.-. ------•---•--- . • .......................................... 'Z '- ,--......
Date
Application Disapproved for the following reasons------------------•-----......•••------------•-•---------------•----------------•--------._......-----•--........
................................................... ............................. .........................................................................................................
�- � , Date
Permit No.. y ....................... Issued. ........ 7 ..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(En#gfiratr of Toutplitturr
T IS IS TO–CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by...._.E,)......... 3..0461k 5.••......---•--------•----•---•-•-------------••-••-•-•--••••-------•---_--..........---.........----•----
11 r a Installer
a�.._......--"'_---F... ..... .......-=r---. ................. -_........................ 'C ........................................ -........................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Codr. as described in the
application for Disposal Works Construction Permit No.._.�.�-�.��.'77............. dated ----- �---- —9j ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.