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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
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Appliratiun for Disposal urks Con �rixr�tun �rrntt�
Application is hereby made for a Permit to Construct ( ) or Repair (V� an IndiviU Se aL.LD's osal
dr s
T uI o = . q. fee
Dwelling — No. of Bedrooms............................................Expansion Attic ( Garbage ander ( ) Al�
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 .................... I 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 ........................
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Description of
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tum of Remi-s_or kItA tions — Qnswer when_avi)licab
Agreement: i
The undersigned agre sto install the aforedescribed
the provisions of TITA 1E 5 of the State Sanitary Code
operation until a Certificate of Compliance has been i.5
d ;
Application Approved ByV....... A_
Application Disapproved for the following reasons:
Permit No .............. �-
----•---........
----------------------------•-----......--------
3ividual Sewage Disposal System in accordance with
undersigned further agrees not to place the system in
:e board oflth
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'1 __Xlaje Oy (>
......... ............. .................................
Date
------------•-•-•---------•-•------•---•-•--•----•-----•......................•-----.....--
Date
Issued ............. 7.-.2:5 .......
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tnrtifirair of Toutplinurr
TH CERT, That the Idual Sege Disposal System constructed ( ) or Repaired
by .......... ........ . ,.. < 1,.�--....
----- -- -- ---- --
—7------ .. Installer a / C' / /p -A
has been installed in accordance with the provisions of TITLE of he State Sanitar Code as describ dein the
application for Disposal Works Construction Permit No .......... __.= 7t ___.:... date __...._._�._- .,%'__.. ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
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DATE....... u .............................................. Inspector.. - --- L .: ...............