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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
r.
Appliration for Ili4pontt1 Works Tonstrurtion Wrui t f
Application is hereby made for a Permit to Construct ( ) or Repair (-1 an Individual Sewage Disposal
System at:
................bc.rzerek�-_
Location - Address or Lot No.
Owner Address
� ........ f' C!yJ 1F+ , v'..
----- •••.
Installer Address
Type of BuildingSize Lot ............................ Sq. feet
Dwelling — No. of Bedrooms.................�� ...........................Ex ttic ( ) Garbage Grinder
Other — Type of Building ............................ No. of p ons .............. ............ Showers ( ) — Cafeteria ( )
Otherfixtures-----------------•-------------------------•----........ ;-............ •---.......... .............................................................
Design Flow ---------_--_--------------
Septic Tank — Liquid capacity
Disposal Trench — No- ------------,
...._.gallons per perso per
.....gallons Lengt.........
. Width .................... Total
Seepage Pit No ..................... Diameter .........._..__..__. De th beld�
Other Distribution box ( ) Dosing tank 11
Percolation Test Results Performed by------- ------ ------------
Test Pit No. I................minutes per inch eptl of est
Test Pit No. 2................minutes per inch epth of est
Description of
Total daily flow ----- --------------------------------------dons.
lidth ............... Diameter ................ Depth ................
i .................. Total leaching area .................... sq. ft.
t ................... Total leaching area .................. sq. ft.
................................. Date.-----.................-----------------
................... Depth to ground water ........................
.................. Depth to ground water ........................
.-•---•-------------------------------••------------••---•--------..................-- -------------------------------•••-•------------....---...------------------------------------------------------
Nature of Repairs or Alterations — Answer w en a pIicable..VIA- ?:.S ........-------- V -6-('4^Q.'. ...... �is`��._.. E �'� K
31 _9G
Agreement :
The undersigned agrees to install the aforede ribed Individual Sewage Disposal System in accordance with
the provisions of iIT11j, 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.
Signe..-••-•-- ........... .................................... ---•------•- --- '=
Dat f
Application Approved BY• ........... .. •------------......................... -•----' } Y ate --- ----•-----
Application Disapproved for the following reasons: .............................................................................................................. -
----------------•-----------.
......................................................................................................................................................... ;;
y Date
Permit No.....7 ...................................... Issued ....... -- / .. (- - -
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trdifiratr of Tang haurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (/W)
by........ ........ �-S ......................•---------.....----•--•-------•---•-------------•--.......------------------......-•-------------•------•----•----••--•---
Installer
at --•---1 s........_ L� `..*`..fZ'---....!t' � . ----------•----------------------------•---•---------------•------------
has been installed in accordance with the provisions of TITLE5 of he State Sanitary Co e as djerjgd in the
application for Disposal Works Construction Permit No ..... 9 S ................ dated__ 3 _ `. C/....,5...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................•-•--..................................--•-•--•--•---------•---. Inspector.