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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTHC
/,
TOWN OF YARMOUTH �I�`�
Appliration for 31isposal 10orkri Tanstrnrtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (Xj an Individual Sewage Disposal
-Ltsr...PS`s.................:.......m n(�0
or Lot No.
Dwelling —No. of Bedrooms...... a .............................Expansion Attic
Other —Type of Building ............................ No, of persons.......................
Otherfixtures--------------------------------------.....----..........................-----......
Address
Address
Size Lot ............................ Sq. feet
Garbage Grinder
Showers ( ) — Cafeteria ( )
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 arm ................... 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......._...
SIV,
—Answer when
. , 1 , r ..
Agreement: ', ,1� C�\ s- (I rS V
The undersigned agrees to install the aforedescribed Individual Sewag 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 by the board gNicalth.
Application Approved
Application Disapproved for the following reasons:
Permit No.......7.:.I.....................................
a
Date
Date
Issued ......... ._......-. ........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
f9rrtifirate of f<totnplittnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (o' )
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9 �- $. "
at
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Co le as described in the
application for Disposal Works Construction Permit No...... t s�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE_ THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.)
DATE............................................................................ Inspector ...:.................................................