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THE COMMONWEALTH OF MASSACHUSETTS
M BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ratilan for 11isposal Warks Tonstrudiun 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (I an Individual Sewage Disposal
System at:
...�.�......__ Cf cv �:.....FV .....4 W .................. A-.! ------------•... ...._......------....- ---• •.........------.....------ --- -..........
-Location - Address T or Lot No -
................ _.... __7 r"7. saF'nT..................................... ..... .._ �^ t�4' ( LL -� Q x------T :.....`r
Owner Address
-------------------------------------- ..•.�.�� __.. Q Q.C.P e!?..._C/4 ...4q&U ui.A Z7
Installer Address
Type of Building Size Lot ---------------------------- Sq. feet
aDwelling —No. of Bedrooms ............... ........................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures ..............................................
W Design Flow .............'.' --------------------- gallons per person per day. Total daily flow --------------33.0................... gallons.
w Septic Tank — Liquid' capacity............gallons Length ---------------- Width ................ Diameter ................ Depth ................
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.....------------------ ................
aTest 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 ........................
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0 Description of Soil ........................................................................................................................................................................
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U Nature of Repairs or Alterations — Answer when applicable__.2E� C.4.......... ..i.E CSC t S?', cS TIC �IfC�
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R.a2 X>..... o... 0_!FFs ... ..........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beT issued by the bo�ard of h lth.
Sign --... ..s- 4-�u- � ,F f
Application Approved B =.................................
Dl
Application Disapproved f r the lowing reasons: ...............................................................................................................
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.� Gr:.. - .. �C /Date
Permit No......... /� .._._...... Issued... ... f/ I/ ......
Daft
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifirate of Tamplinurr
THI IS TO CERTIFY, hat the Individual tSewngt Disposal System constructed ( ) or Repaired )
by
has been installed in accordance with the provisions of TI �5 f �
State Sanitary a escr in the
application for Disposal Works Construction Permit No...." .�--...---- dated----� ''.-- •..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ............................................................. .......................