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No. ... r1. 1:_42�-Z South Yarmouth, MA 0,26,64
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....------ •............................OF.......................................
ApPl ration for 14spasal Works Tonutrudinn Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
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................__ ... .- ---��-----....... .. - ......_..-• - --- ... .. -•- ..._...._....
Locatio, Address or Lot No.
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_,,,_,.Owner Address
Address
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Installer Address
Type of Building Size Lot ---------------------------- Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ' capacity......._....gallons Length ................ Width ................ Diameter ................ Depth ................
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 ............. .............
Description of Soil ...........................
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Nature of Repairs or Alterations — Answer when applica.ble.../1>1���.�� ...�.fi� ` ` F/w� ,—.4
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL: 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 the board of health.
Application Approved By
Application Disapproved for the
Permit No ...... !E�! .......—
reasons:
� xo_ j ....................................................... --------
` Date
.. ............................. = S ......
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S
Date
Date
Issued_.--A'�' -= ...............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................OF....elalf
Trriuttflu utpltttnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4�'O'r Repaired
by------ A!! 5'.�12................................................................ -------•----....--•-------.....-----•-------•---------•--------•-----............------••--•---------•--
Installer
at.... 4 G ....
has been installed in accordance with the provisions of TITLE 5 of he State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ ,`l ` _l� Z_._._. datedh ,_5.....e..I<..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.