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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratton for Disposal Works Tonstrurtion Jrrutit
Application is herebv made for a Permit to Construct
System at:
. ........................
Location •Address
P't� a 1Z__
............
.... . .... . . .............. . ..............................
Owner
... n!!:.. I>-
..................................................
Installer
) or Repair ( �an Individual Sewage Disposal
........I�QT-- C4
...... ................ . .....
or Lot No. P—
.......................................... ......................... ..................
c.r. L4,Pp, U!r.............
Address
Type of Building Size Lot ............................Sq.
feet
Dwelling —No. of Bedrooms.--. f...................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ........................................................................................... - --•--•-----•--•---_-*.........._---_.._...
----------------- * ...... * ------------
.... " ........... *
Design Flow ............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid 'capacity ............ 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.
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............._..._......
Descriptionof Soil ........................................................................................................................................................................
.........................................................................................................................................................................................................
.......................................................................................................... ........ ... .......................... . ........... . ...... . ... . .
A
Nature of Repairs or Alterat nssV n1wer when appli'Fable ... ... .... ......
CIA
. . .. ......... .....
* .............. t� .... .... . . ..... .... 04 .........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T LE 5 of the State Sanitade
'Ne — The unfkrsigned further agrees not to place the system in
operation until a Certificate of Compliance has ee Id by the rd of health.
Application Approved
Application Disapproved fo`r–VfeJoUowing reasons:
...........................................................................................
Permit No.... a. ...................
-------------
......................... ... ..
D e
................................................................................ . ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrfif#atr of ToutOattrt
6 / IZI 19-2 Date
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired, (W;f
by---.... H.!*�a ...... C43 -P. -CO ............ ... ...... ................................................................................................................ I .........
Installer
at...... aa .... 1 L. .IF .. ?ft.......... sa .. ! ................. ..................................... il ....................
has been installed in accordanct1with the provisions of TITLE 5 of The State Sanitary Code 4s d9s i, ed in the
application for Disposal Works Construction Pbrmit dated ....... . ...........
MARA I TIN4ATT 1E
THE ISSUA C HIS CERTIFICATE SHALL NOT BE COCONSTRIJ�D A�.S AC
W U� FT
7PI, - - - - ............................. ;�' ............. ...... ...... 1-1
SYSTEM �1 ION SATISFACTORY.
t L > ...... .... .
..........
DATE ................ ... Inspector........................----...-- . ..