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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonoirurtion Prrnti#
Application is hereby made for a Permit to Construct ( ) or Repair 014 an Individual Sewage Disposal
System at:
O T
nQ...-------•-• - � �-./�'q c,.
.._
ocation - Address -• or Lot No.
._.._ �.. ................•-..................._......._.... ..
caner Add ..................................
.-•-•...............................:.--
a- ..� .---..Q�. �A-------------------------------- -----.._?...... ""),' s
Installer Address
Type of Building Size Lot ............................Sq. ^fqe
Dwelling —No. of Bedrooms........3...............................Expansion Attic ( ) Garbage Grinder oQ
Other —Type T e of Building No. of persons ............................ Showers
a, YP g-•------•-•................. P ( ) —Cafeteria ( )
Other fixtures .................................. . .... .
- ----------------
W Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid' capacityt=.Ugallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ---------_--------- Diameter ............. _...... . Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by...............................-•-------------•------•-------------------- Date ........................................
Test Pit No. 1..............:.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 ........................
P4--------------------------------------------------------------
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.----------
•---------
•------------------
_....
0 Description of Soil -----------•--•....................•----•--------------•-----.......----------•-...•..------•-----------•--.......----•-....--------------------•---••-•-----•--•--.....
W
t, ----------------------------
---------•.--------.-.--.----------.-----------------•--•--------------•----------------------------------------•-------------------•---•-•----•-------•---------•----------
UW•----...••••--•--•----•-•---•------•--• - -•••• ----•-------
Nature of Repairs or Alterations — Answer r wintapplicable._..__c_.__.e��C�...
......
Agreement: S %CZAMC)-, > L, C. rov^J ��� c\rkZ ,
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 b issued by the Health. ` v / _
Sign ..� \ .. ----- - v ,-•� I ! C
• -••-••.....-----•-•---•--•-•----
Applica.tion Approved By ... ..'........ .................................... ---•-•-•-•• .............................. -•-•-- 3...�.�� t 5
Date
Application Disapproved for the following reasons: ..............................................................................................................
.......................................................•---...--------••--•-----------............----------•••--------••---•---•---•-•-----•-•----................---••••--•••----.................--
gJ t Date
Permit No .... • ..5 - • - ........ ........._ Issued ......
Date.. ��
......... ..............
—-----------------------.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
TrritfiraU of 09-nutpliattrr
THIS IS TO CERTIFY, That the Iqdividual Sewage Disposal System constructed ( ) or Repaired � )
by........ �. Ste.......C,r. .. CU-'�=5•-------•------------------------------------•-= -----•---------..........•............---
Installer
at ........... ...:. ,}. � 4. L(;�c - ----------------------------------
........
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod , as 4escribed in the
application for Disposal Works Construction Permit No.__`_'�'4- :.""'�)--y.....--:--. dated-_. ,> .... ..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GIJAR,NTEE THAT THE
SYSTEM WIL FUNCTION SATISFACTORY.
DATE ........... i ------ 1---------- ------------•--••-----•---------------- Inspector..14__ ,• -? c .. ..........i!`.t........:�