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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �L
TOWN OF YARMOUTH
Appl ration for Dispasal Works Tonstrurtinn ]Jrrmi#
Application is hereby made for a Permit to Construct
System at
�! C L � O d�, r�
Owner
Installer
Type of Building
Dwelling — No
Other — Type
) or Repair t,-<an Individual Sewage Disposal
.................... = -1 -• ..........................•---
or Lot No.
Address
Address
Size Lot ............................Sq. feet
. of Bedrooms. 2..................................Expansion Attic ( ) Garbage Grinder
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures---------------------------•--.......--........---..........-----------------------•------------..........---......---•-•-----•-••---._._..__.........
Design Flow ............................................ gallons per person per day. Total dail flow ............. _.............................. Ions.
Septic Tank �l — Liquid capacit...gallons Length__ G'�.. Width .... 6.. Diameter ................ ...................
Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No ... I ............... Diameter.`Y.x. i-Z Depth below inlet ----- q.._...__.. Total leaching area .................. sq. ft.
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 .................................................................................................................
-----.ure..o--f -- Ree.....---------------------------------------------------------------------------------------------------------------------�--.....-----� I-_J- --- �� --- --- ._ .. j
Nature pairs or Alterations — Answer when applicable.---___. ............
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 e bo d of health.
Signed.. ----- .... --------......................................... �5 -
�� Dates
Application Approved By ......... ... ... ......... ......... .
............. •-------••- ....... .�--------------------
Date
Application Disapproved f o e following reasons: --- . ----•- ----------------..................
•............................................
-
Permit No.•--��-'-���-----------------•-v
Date
Issued...........� ......
Date
--------------------------�--------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tn tifirn#r of Toutpliatta
THIS IS TO,/�TIFY, That t� Individual Sewage Disposal System constructed ( ) or Repaired
b.....- �...._ .--•--•••--.-_... .
I istaller /
at---..._:��.--„-�:�;�. 5. L� .::P._- i !_.�� �....1..
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod as described in the
,Twapplication for Disposal Works Construction Permit No ---------- —._---..... dated....._... :;--- r����----------•---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
{ _, w .... Inspector....
DATE...-• --- -................................ ---- .-- _G ......---