App-Permit-ComplianceNo ....1 V' c Fps
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Dispnott1 Iforks Tonstrnrtion 1rrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at -
...._.. ................ ..........................._....._..... ....---- - ._..._.....----
Location - Address ° r Lot No.
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Odrco
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Installer A dress
Type of Building Size Lot ............................Sq. feet
Dwelling — No. of Bedrooms............................................Expansion Attic' Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-------------------------------------------------------------------------------------------------------------------------------------•--.._...--------
Design Flow ---- -------- 0...........................gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid' ca.pacit} ?_...gallons Length ---------------- Width ................ Diameter ................ Depth ................
Disposal Trench — No ................... Width....:............. Total Length ----... �........_. Total leaching area .................... sq. ft.
Seepage Pit No ----- I--------------- Diameter ---- 6__............ Depth below inlet...._..._.._..- 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 ........................
Description of
..--------•--------•-•-----------------••----------------...-----•------...........-•-------........---------•-----------------•-----------------•-------------------...---------------------------•-----
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re of Re rs or Alteration __AWwer//when- licable._�..0 __.. t.....t_l--l__
W.
Agreement:
The undersigned agrees to install the aforedescribed Individual Se age Di sal System in accordance with
the provisions of TITLE 5 of the State Sanitary e — The unders furtl r grees not to place the syste in
operation until a Certificate of Compliance has b e iss d b he bo f heal
g --
Si ned C. �? ...._
t 9
Application Approved By
- /
•----
Date
Application Disapproved for the f olrwing rons:---•----------•-----------•----------------------------------------•---•--------------...---•-•-------•---......
..................................-------------------•----....--••--•--•- 1...................................................................•--------...........
.1(.q...........
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C-, — JG t q w Date
PermitNo..----- ......--•----------------• Issued.......... ---. .......-- -------
ate �
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tatifxrtttr of Gantplittnrr
THIS IS'T' TIFY Th thWew a Dis osal S- stem constructed ( ) or Repaired)
C�p y
Installer
has been installed in accordance with the provisions of TI
application for Disposal Works Construction Permit No. ---
THE ISSUAN E O THIS. CERTIFICATE SHALL
SYSTEM WILL F NCT1 ,fi. SATISFACTORY.
DATE.............. LO.. �' t....................................
... Vhe State Sanitary Code as
dated--------I..Q...
BE CONSTRUED Ate► GWAI