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- U7141
No .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Bioposal Work,5 Tintotrnrtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (✓) an Individual Sewage Disposal
System at tion. Address.... ..... '......... ...............� .... ......r Let No. �`...
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Installer Address
Type of Building Size Lot..... ....................... Sq. feet
Dwelling — No. of Bedrooms ...... ...............................Expansion Attic ( ) Garbage Grinder J)
Other — Type of Building ............................ No, of persons ............. ......... ...... Showers ( ) — Cafeteria )
Otherfixtures ............... ................................................. ............................-.................... .........
Design Flow............................................gallons per person per flay. Total daily flow........... j.. U....................gallons.
Septic Tank—Liquid capacity/ ...gallons Length........... Width..... _/f) .. Diameter ................ Depth ..... ....... _
Disposal Trench — No ..................... Width....... °� ........ Total Length.... /.0_/ ...... . 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........................
Description of Soil------------------------------------------........................---.
�gr ccu,cta
The undersigned o install t aforedescribed Individual Sewage Disposal System in accordance with
the provisi L . Lis 5 of the tate , nit€-- Code — The uci rsigned in ther agrees not to place the system in
operafi'otnnl ' a Certifi e of Com lian • as bee is by the ar of lieu th.
Sg e 1 ! ' - - ...........:....-----------.......... .fU. f � t� ......---
Application Approved ........................ •............... .. ... ............. e
Dae
Application Disapproved, he following reasons:------....................................................................i................................._
Permit
Date
Date
___._________________________________________________________"
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Grtifutttr of Tomplittnrr
THIS IS TO CERTIFY, That the,Individual Sewage Disposal System constructed ( ) or Repaired
Imtaller
at
.................... .....
r
has been installed in accordance with the provisions of TITLE j 5 o_f Th State Sanitary Code escri t i the
application for Disposal Works Construction Permit No.......:.�1`j.:..:...14 ...._... dated..........1.�...)��....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN EE I THE
SYSTEM WILL FUNCTION SATISFACTORY. /
DATE...............f ...................................... Inspector...- --�----r...... ..Y .r.,. .4. ,.......