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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Dha-pnoal Works Tonntrur#ion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (� an Individual Sewage Disposal
,yst at : -................................. ................. ............•-----------------------•--•--^a,-------••----•----
------------
Location - Address or Lot No.
....14C- E S N----------•---------------------------------------------------------•. _----------------------------__
Own ddre s �
LU^:�`'`-------•----•-----..... ck---f> C CZc' --� _. ....�
Installer Address
Type of Buildingn Size Lot____________________________ Sq. feet
Dwelling— No. of Bedrooms ......... o__[__ ............................ Expansion Attic ( ) Garbage Grinder 4)0
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------•----------.-••••---------••-----•------•-•-------•-•-•----••--•---
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.
Other Distribution box ( ) Dosing tank ( )
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 ........................
Description of Soil__
.................................••-------•---••-_.....
---------------------------------------------------------------------------- •-•-•--•---•----•-•-.-.--- •-- -------------------------------------------------------:._....------------••-•--
Nature of Repairs or Alterations — Answer when appl' able.-L�G.�. ___:_.�SS jL �.-9�-____.�( U l
- i s ._.r... 6 _ a.�c_.�_... 1 `-� s- Fc,�-S ........... ^ r/
Agreement: POL �C Gtr -0( t C d
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1 � 5 of the State Sanitary Code — The . agrees not to place the system in
operation until a Certificate of Compliance has b issued by the boar alth.
Signed- --------• .........................................
Application Approved By ...... . ___ _______________ 3 Date
�r�Da
Application Disapproved for the following reasons_ ___________________ l ............ 1___________.__-_-____-___________________________-____-------------________--
---•----------------•--------•--•------------......._.....--•----•----------------------------•-----......--•--• --..._..._..--------------------------------------1-------------------------•-----------
�` Date
Permit No.................................................. Issued_._..---}
.......... � ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irrtifiratr of Toutphatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
by--------------- T-.'\ C^ S"C"' C�'`-•------ CU!� ----•-------•---------------------•--------------•----•----------•----...------.._..------....--•---.....-•--
Installer
at - -C a. C�e.�..--------
as een installed in accor ance with the provisions of TITLE of The State Sanitary Code as described in the
--••_.
h � '
application for Disposal Works Construction Permit No.__`......�_�_`.f?_____________ dated_--��.�cl f r____._______.._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.