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No. :.4 �.� / Fps .............�... .
THE COMMONWEALTH OF MASSACHUSETTS /
s �A BOARD OF HEALTH '-17,067
Jo TOWN OF YARMOUTH
Appl ration for Disposal Works Tonstruriion rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ((,)'an Individual Sewage Disposal
System at: �- M a GHQ So, yac . lu al, M6? 3 3�3ttZ
Location - Address or Lot No-
................. .�C.fa. .�%... �`..!+q:v t :�...........- --............... - L -��-j-.--- ��=�. 4 _.1.........................
Owner Add ss - ---•-
......•---�..lA...i...,P�.. y?.'._�.i ......................
-• ....---• - -- .... (Yl r C k----•-•----.....
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling — No. of Bedrooms... 3.....................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures.••••••--•.........-•••......................•-•-............•-----•••.....................-••••••-----......................._............._•--.._...
Design Flow.......:.. �..........................gallons per person per day. Total daily flow...... z3.0_........................gallons.
Septic Tank — Liquid ca.pacity............gallons Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .........jr....... Total leaching area .................... sq. ft.
Seepage Pit No ...... I............ Diameter....-: ........ Depth below inlet..... e........... 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........................
.....
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Descriptionof Soil ................................................................................
•------•........................................•---•----•----•--••-•--------•--........................-•--•-•...--------------••-•_....
Nature of Repairs or Alterations — Answer when applicable....; X.(I ....°
Agreement:—
The undersigned agrees to install the aforedescribed Individual S wage Disposal System in accordance with
the provisions of TIT1Z 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
p p Si d.
operation until a Certificate of Compliance has been issued by he board of li th.
... . ..................... J :
D t
�...�
Application Approved BY- -.. ............ • ... .... .......... ...................................... at
... ..:.��
D
Application Disapproved for the following reasons: .......................................................................... ..................................
_
..------•----.....---•....................•-............---------..__.._...--•••-•-•---.........................-•----....._.............••--•-•--.................,...................................
r C..l.`1..... t_ . . Date
Permit No...,..... . ............ Issued...... �...�� ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irr firate of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by.... ................�'�..OiVj ...L. sr1 � fie. ....----............................................... ............................
Instally�
at :f............................. ... .........._ C r T ..`�! _.Sr.'�t:!^U !............... ...........
, .
has been!- installed in accordance with the provisions of TIT 5 of The State Sanitary Coe as scrib in the
application for Disposal Works Construction Permit No........... dated_
THE ISSUA CE OF THIS CERTIFICATE. SMALL NOT BE CONSTRU A A GUARAN EE T AT THE
SYSTEM WIL�'j F NCTI Nf; SATISFACTORY. `\
DAT............... 1�................................ Inspectors.._.. - :Ll..`'.........