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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Dispas tl MurksC�,an #rixr inn �ertni
Application is hereby made for a Permit to Construct
System at:
-Location - Address
-I C VS!� .............................
Owner
...._. . a: .....-. C 8 ►� .? t3 ---------------------------
Installer
( ) or Repair (tan Individual
T... ............................
- or Lot No.
Address
Type of Building Size Lot..
Dwelling —No. of Bedrooms..•._2 .. ................................. Expansion Attic ( )
Other Type of Building ---------------•-•------•--- No. of persons ............................ Showers (
Otherfixtures --------------------•-------------..............___....------•---
Design Flow............................................gallons per person per day. Total daily flow
.------------
_..
Septic Tank — Liquid' capacity.. --..._.._.gallons Length ................ Width ................ Diameter._ .
Disposal Trench — No . .................... Width .................... Total Length .................... Total lelate..
g
Seepage Pit No --------------------- Diameter .............. ...... Depth below inlet .................... Total ln
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..........................................................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth tound
ound water ........................
Test Pit No. 2................ minutes per inch Depth of Test Pit...._._.__...___._.. Depth water•.•---.----------------.
-----------------------------•-------.......--•--------------•--------•-----•---.
Descriptionof Soil ............................................................................................
Nature of Repamb or Alterations — Answer, when a licablg 1'
Agreement:
The undersigned agrees to install the aforedescribed Individual Se
the provisions of iITI.L 5 of the State Sa de —The ut rslgne
operation until a Certificate of Compliance h bee i -jed by theo rd of
Application Approved By,
Application Disapproved for the -
Permit No..-- =•- L --'�_o- -�- = - ------------- - -----
age Grinder ( )
— Cafeteria ( )
--------- Depth ................
area ...................sq. ft.
area .................sq• ft.
Disposal System in accordance with
leer agrees not to place the system in
Date
.-------------------------------•--- ...-•--•••.. ..................................
Issued.............eZ
ate
_7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
/ Trr#ifutttr of 09-i plittnrr
THIS IS ' TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (✓f
f� .r- E ......zrf 1 .� --...-•....................•-----•----....------.....................---....--------......-•-----•-•--...---.......-----....................----
by_....-"•"'- .-.. Install r
at.... �S '
has been instal. ed in accordance with the provisions of TIT 5 of The State Sanitary Cede as c�scribed in the
application for Disposal Works Construction Permit No. -I-).' �?- .............•--. dated......_...r .cc1.. ?-:
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE A GUAR TEE THAT THE
s r: irw WILL FUN TI N SATISFACTORY.
L
Inspector... DATE.. .._...� _� .-- --.... :.:.. ...............................
..,.,.�... __....