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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Bispooal Works Tonsirar#iun rami#
Application is hereby made for a Permit to Construct
System at:
,(� y ( � tio--,A,ddress o
---......._.C—'�fa(r.4 --- 4 �.M__ .� fLU ............ _...
Owner
..------.aAk (?:i:_l.e /0 __40-s:
.r��- .'0.,..� ..................
Installer
) or Repair (%�an Individual Sewage Disposal
Af 104C
--------- -----or Lot No. .... .........__••_.-----....
:.........................................................................
Addres
----....--_.'�. 4._.(... ��-.4..............
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms_._._ ................................. Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------._..__........_...._........------------...---......_.......-------....-----------------•------
Design Flow ......... �.IC5 ..................gallons per person per day. Total daily flow__ —Z..,�.'. _,D_.........____.....__..gallons.
Septic Tank — Liquid ' ca.pacity.._____..._.gallons Length ---------------- Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width ------ .............. Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No ----- %.............. Diameter --- 1.-Q_.r_..... Depth below inlet___! r_._.._..__. 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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Descriptionof Soil ..................................................................................
.-----------------------------------•-----•------...----------------•------•-------...---------------------------..
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Nature of ,
or Alterations — Answer when
The unde'rs`igned agrees to install the aforedescribe
the provisions of TITIZ 5 of the State Sanitary Code —
operation until a Certificate of Compliance has been issued
Application Approved By,
.--•------------------------------------------•--------------......_....---•-----------------------
.LLA
d Individual Sewage Disposal SysteQiccordance with
The undersigned further agrees not to place the system in
bv, the board of healA.
Application Disapproved for thoollowing reasons_____ __________
Permit No ..........--------•---
e
S ` Dat 2
........................................
Date
-------------------------------------•--.........----•-----...-----
Issued ... _ ..... ac.......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifirab of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by_ ................................. �!_ ,4, 10 �---._f:I`................................... ........_
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Installer
at------=-• ............... !�' f. (�f L 1 ` �A-�t? \}•r.(- '�.m- . G-.tl lh!lo...:Y '-------....._.._..----
has been installed in accordance with tale provisions of TITLE 5 of Theltate Sanitary Code as les i in the
application for Disposal Works Construction Permit No.._.���_-'__�.t��,....... dated ------- .: r� ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S G�A A�TEE THAT THE
SYSTEM WILL FUNC�TIO SATISFACTORY. , \ i\�