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�> YRR;MOUT.H H,EL.�-E-9 C'E,PT. G„�
Town Office Building
No......g ..s...... South Yarmouth, ,M,A, 0.2,6&,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .......... .............. ----.-......--....O F......................................------.....---..............._............._...-----
Appliration for Disposal Works Tonstrurtiun Frrmit
Application is hereby made for a Permit to Construe
,,.,..System at:
Location - Address
..........................i.�...... �' �--+ 01 er........ .................
- ---- ---------
....
Installer
Type of Building
Dwelling — No
Other — Type
or Repair ( ) an Individual Sewage Disposal
C or Lot No. ?
dres
���........................bs,�dg„ /✓Aih�'�✓
...... ---•-.. . ..(............ ._..._.........................
- Address
Size Lot ............................ Sq. feet
. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-------------•---------•----•-•----------•------------......----......----...---------------•-----•-.----- -
...... ---------------------------------
Design
------------- -- -----
Design Flow......_.... -......................gallons per person per day. Total da}1 flow ....... :73-5 19ns....
Septic Tank — Liquid capacit3K�?!2cS.gallons Length---,�F_..... Width.. .._........ Diameter ................ Depth--- ------..
Disposal Trench — No—/ ....... Width_, _....- Total Length---lr�•� ---- Total leaching area.._,,,
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area ................. f .
Other Distribution box ( z, •' Dosing tank
Z
Percolation Test Results Performed b .�._.. Date.....
`GP-
? .........
Test Pit No. 1.:-::!!�.minutes per inch Depth of Test Pitg*--sE�------------ Depth to grow d wa r....�_ ....,_..
Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water...---..................
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Description of Soil..... ....... -----------------------------------
------------------------................................................................................................................................................................................
Nature of Repairs or Alterations — Answer when applicable................................................................................................
---------------------------------------------------••---------------•--••---...••------•-------•-•---------------------------------....-------------------------------•--•------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate .of Compliance ha bee • s e by he board health.
Signe--_.... J9'_........_..
D r..
Application Approved By....
Date
Application Disapproved for the following reasons: ---------•--------------•------•-----------------•--•--------------------------•------------------•---•.------_
PermitNo.-----�---------------------------............ ---
THE COMMONWEALTH OF MASSAC4USETTS
�!/• /�� � Date
OARD O HEALTH
........:........ off,`::°:... f,!'D..v.7".........................................
Trrtifutttae of Tomptla trr
THIS IS TO CEIi'TIFY, That the Ind vidual Sewage Disposal System constructed (4-1 or Repaired ( )
,by -- /� . y f� --------------- .............
at....._..�- ..... t' !__ E feS iFt' -.--Install ;....................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as escribed in the
application for Di. osal Works Construction Permit No.._.� __ _c --__--._. dated.. 41-V !` ,. .................
THE It CE OF THIS. `CER'.1FICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE;
SYSTEW WILL FUNCTION' SATISFACTORY Ins ector f
r
DATE ...... _...1 % ..' ......... P.Ze�.. �/
-- ` ------ ... ------------------•-