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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works (foustrurtivit 1hrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at
......... .-p --
7 6�.1.. pq.-
----- — -------- '
.. VA_& ... . ...............
j / Logation-Addresa or Lot No. 7
Installer Address
Type of Building Size Lot ............................ Sq. feet
�-4 Dwelling —No. of Bedrooms ..... I ................................. Expansion Attic Garbage Grinder
P4 Other — Type of Building ............................ No. of persons ............................ Showers Cafeteria
P4Other 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.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation 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...._............_......
--------------- 7 ................................................................................. .........................................................
0 Description of Soil ........................................................................................................................................................................
--------------------- * -------------------- * ------- * ---------------------------- * --------------- * ---------- * ------------------------------------------------ ------------------- ** --------------
.................................................................................................................... ....
Nature of Repairs or Alterations —Answer Answer when applicable ...........4g
U applicable_._..__._.._. ..... V....................................................
............................................................................................................................................................................ ...........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLI171E 5 of the State Sanitary Code — The undersigned further agrees not to place the syste n
operation until a Certificate of Compliance: has b ssu.e by t e board health.
le
Sig. ......... ................... ... ... ......... .. .....
D
ApplicationApproved By-- ----- ---------------- ------------------------ -- --------------------------------- .... �/Dte ........
Application Disapproved for the following reasons . .......................................................................................................... . .. -
...................................................................................................................................................... . ............. ----- * ------------
cr Date
PermitNo .•••• .......................................... . . . Issued ....... ) ..........
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrfifirate of Tomptiattrr
TRIS IS TQ CERTIFY ha he ln.4,vidu ve age Disp3o S_ s con tr u C t Repaired
by... ..... ..... . .. .................. . ............ ... . ..... .
In tel
at...... ..... ................... .........................................
has been installed in accordance with the provisions of ITLE 5- of It Sta e Sanitary Coh as de - ribed iw the
d, 0(
ate
e
d...
application for Disposal Works Construction Permit No.._`7 ----------- — -- -- --- ---- ----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BEC STRUE S ARA TEE HAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... .... .............................................. Inspector . .... ..... A ............ 4-- ....... .....................
.....