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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratinn for Disposal Works Tonstrurtian f rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (L,)/an Individual Sewage, Disposal
System at ..30
Z.�.n� l......--•...................
.......................X19.. - .
T Location - Address
......._.�'�.� ...(.)Al. »----------------------------------------------------
oLot
........... L?.l lP �.:il.�s.��r.................»........
Owner Address
...^------.. �. . .
........................................................... - ?Pwd!i......fir..........................................
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms........... �•-------------------•--Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building
No. of ersons._.. Showers — Cafeteria
(l) ( )
....Z.WZ�
gyp_...
p...................
Otherfixtures...-------•----•--•-•---....--•----•------------------.---------...•-•••••----......----...•...•.........•..•............--•--.....-•-........-----...
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank— Liquid capacity/s�O.gallons
Length../.o......... Width._., ........ Diameter ..............•. Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No ......... /......... Diameter ........ 6....... Depth below inlet ..... C.... ....... Total leaching area.X,5hf::.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....... 4 ----- "minutes per inch
Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil ............................ .............---------....................................----...---------------------------•-•----..................-•-•--...........J.....
Papplicable. ......�... ... ...... A<A
t
Nature of Repairs Alteratio s —Answer hen _ 'Y�........_....
Agreement: q
The undersi ed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 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 byAe board of health.
Application Approved By.:....r ..r- %..... �...V.
Application Disapproved for the following reasons: ............
Permit No..............G .r....
Dat
.... _---- Date .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtif iratr of Tompliattrr
THIS TO C) .RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (i
by............ �1�� .. ......................... ..............Installer..............................................................................................
has been installed in accordance with the provisions of TIT 50
f
application for Disposal Works Construction Permit No.. t.. =24
�.
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE C
SYSTEM WILL FU CT N SATISFACTORY.
DATE........... ..........------ ..................... Inspector....
1
State Sanitary Code as
........""dated ............ '
rRUE"S A GUARAI
io the
THE