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* No...r........... 3) �... FEB....../ S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Applirttiion for Disposal Works Tons rurtiun f rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( 4-y an Individual Sewage Disposal
System at:
-- -..
-- Location . Address MAP—
-701
Lot No.
.....:_ �.e. --- •-:.... • --................................ Owner Address
.A 11.10 .......................................................... ---•--•-----•-•••...............•--•----•--.......•-•-•-•-----------......•--........_..
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ........ 1,3 .............................Expansion Attic ( ) Garbage Grinder (A10
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures..---••••---------------------------------------------•----••--•-•--------------------------..............----•------.......-•---••---•-------•-------
Design Flow............................................gallons per person per day. Total daily flow ............................................ 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.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. I................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 .................................................................................................................................
----------------------------------------------- ------ •••••. ....... ..,�.-------•--•-.
of Repairs r erations — Answer when applicable-./- rri_ � ......._...._...�!
! • .1�: �vx--.....p......:.1-41.e X.4sS f!.`1....... _f� l•v v. t?._....
Agreement: l '
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 has been issued b th bo of health. _
Si -••-••--- -- . �. J
Application Approved By ................................................
•..... Date
Application Disapproved for the following reasons:................•----------------------------------._......-----•--------•-•--••---___...
............................•-•-----•---------...----•-•----•------•--......•-----.........-----..........--•--------------------------.............---•-----------------------......---•----•-......----
04 16 (?
PermitNo..... �!...SP..............................••...... Issued........................................................
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#ifiralr of Tomplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (✓
by .................... ._..._.......: .---- ...__..
-------------•---------•-•• -- •- -... .�
//''�� /� { / II staller� • .-
......i�:.a ........ ? �': c----------•---- rte' i rsrf-Y-� ............. � =
at G c I
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. r-_ 1 0 ................. dated ---.3...... .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL//FUNCTION SATISFACTORY. '_
DATE...................:..:: .....•......................................... Inspector .... ..................... ..`l4 ` -/�...--------•-
J
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