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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... TOWN_ ................O F...................YARMOUTI3........................................
Appl ration for Dispuuttl Works Tonstrudion Frrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
,,,,,,-,,,_55 Howes, Road,_ South, Yarmouth, MA_ _ _-„_, ,,,_ „P 3K21,ac,_ Assessors .Map,28„,,,•„•,
Location _ Address or Lot No.
-------••- Daniel F. _Doxle... .......... ........................... ...... -... - -.... ...................................................
Owner Address
a Brian Ki.........................................................
Installer Address
Type of Building Size Lot ... t2l,acres,_,,,-Sq. feet
aDwelling —No. of Bedrooms ................. 2........................ Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
dOther fixtures.---.._..-•--•................•---........-----........-•-----•-----------•----..._..-•--••-•-------......---.........._....-------...............----
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ' capacity........._..gallons Length ................ Width; ............... Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length ..................... Total leaching area .................... sq. ft.
3 Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by ............................... ... Date ........................................
0.4
1.4 Test Pit No. I................minutes per inch Depth of Test Pit .................... Depth to ground water........................
1� Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
a--•........................................................................
0 Description of Soil ........................................................................................................................................................................
x
W____ -i.••----•---•---------------------•-----•--------------•-•---------------•----••--••--•-----•----------•---•----------••-----•••--••----•••••-•---•---.---------- ..:...._...
------•---- __-----�----•-•-•••-•---•-----•- -----------------
UNature of Repairs or Alterations —Answer when applica.ble.__.���.�_._._t�c�.:_1........-fi....�.?...��.1%1.-�%...................
1. t=ll sc-------------------------------------------------- -------------- .._......_...-------------•-----------------------------.............---•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of. TITLE 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 by the board of health.
Application Approved B}
Application Disapproved for the following reasons: ............................
J
Permit No .... ...:`-_���......................
Date
Date
THECOMMONWEALTHOF MASSACHUSETTS
BOARD OF HEALTH
............W:. OF............YARMOUTH .. ... ...........................
... . ....
`� - (rr#ifutte of &rntrlitnr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or 'Repaired ( 91)` '
by........................................... Brian- Kisslin• ..-..........................................................-__. • _..
. Installer
at... ......................... __55 Howes Roads South; Yarmouth, MA.._ .....
.. .......... .... ........................................................
has been installed in accordance with the provisions of TITS 5 of The State Sanitary Code s escribed to the
application for Disposal Works Construction Permit No.._..... ....__. �,�,�� `? r- ..... dated 7 . _..� ..................
F.
._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GnIJA ANTEE THAT THE
SYSTEM `. WILL` FU CTION 'SATISFACTORY.
DATE.. �� ., K Inspector 1•' - t._`'...... t