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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
. ppliration for Disposal Works Tons#rurtion 1rruti#
Application is hereby made for a Permit to Construct ( ) or Repair (' 4/an Individual Sewage Disposal
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`e 3 Lo ion- A -- or Lot
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pq Installer Address Ay?�
6 Type of Building Size Lot ............................Sq. feet
aDwelling —No. of Bedrooms ......... S............................Expansion Attic ( ) Garbage Grinder ( )
44 Other —Type of Building ............................ No. of persons.., .......................... Showers ( ) — Cafeteria ( )
a Other fixtures ...................................•-------_...
W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank —Liquid capacity............ gallons 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.
Z Other Distribution box ( ) Dosing tank ( )
`4 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 .........................
0 Description of Soil ........................................................................................................................................................................
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V Nature of Repairs or Alterations — Answer when applicable.... .-� .. .........
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT!Z- 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue b the board of health.
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Signed---- ---- ---- -- ------ .......4.._... .................. �`.... ..
Application Approved By ... ..... ............. . . ..................................................... .............................
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-------------•-- Date ._......---
APPlica.tion Disapproved for the f ollo ' g reaso s:----••-•---......••--•-•-•--------------------•..._..--•------....._.............._.........Da ------•-----...
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Permit No. .......! ............... Issued..----_............................_ 7..........e
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tnr#ifirat e of Toutpliam
., ' .4
TH�� IS �`TO CERTIFY, Tat the Individual Sewage Disposal System constructed ( ) or Repaired
................
..............................................................................................
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has been installed in accordance with the provisions of TITLE 5 ef he State Sanitary Code as c escr' ed in the
application for Disposal Works Construction Permit No ...... __............. dated__..___��!'.%--�w_..__._.._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTI5AkN SATISFACTORY.
DATE...:.... v ........................................... Inspector....... ...•••----.. . �.. %..