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THE COMMONWEALTH OF MASSACHUSETTS p•^ Jia, -(JJ
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratinn for %ripoottl Works Tonotrur#inn rtrmit
Application is hereby made for a Permit to Construct
System at:
�, ��`�_
...-.. �.-...-...................... ......................................
p eea en -Address
*`ow cr t�.
'-'
Installer
or Repair (°'°'fan Individual Sewage Disposal
Li j
/:.... or Lot No.
............... ...............
G+.,J g1A: t.'.! U .......................... ....
..-.-.---.
- ----- A� ress f
Address
Type of Building Size Lot............................Sq. feet
Dwelling — No. of Bedrooms. --. -:-----------------------------------Expansion Attic ( ) Garbage Grinder (Y )
Other —Type of Building ............................ No. of persons ................. ........... Showers ( ) — Cafeteria ( )
OtherfZxWres ............................ .... ---.... --..................................... ----........................ ...........................................
Design Flow ............ ------------------------gallons per person per day. Total daily fiow-.`-..:r`.'............................. gallons.
Septic Tank — Liquid capacity ............ gallons Length ............ __ Width ................ Diameter................ Depth .... ............
Disposal Trench —Talo- -------------------- Width .... ................ Total Length .............. ...... Total leaching area .................... sq. ft.
Seepage Pit No ...... Diameter..Aa ............. Depth below inlet--''ra......-..----. 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..........----.-.--...-.
Description of
Agreement:
The undersigned agrees to install the aforedescribed
the provisions of TITLE 5 of the State Sanitary Code —'
operation until a Certificate of Compliance has been issued 1
Application Approved P
Application Disapproved
reasons:
Individual Sewage Disposal System in accordance with
he undersigned furthgr agrees not to place the system in
ate
Date
-----------
�' L -nate
PermitNo.....-.. �..................._.... Issued ---------1- - 1- ... ............
Date
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THE COMMONWEALTH OF MASSACHUSETTS
THIS IS TO
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#ifiratt of Tou pliaurt
hat the Individual Sewage Disposal System constructed ( ) or Repaired (.-)
application licat on foreen installed
Disl osalaccordance
Constru tion Permit No
S ,� e State Sanitary Code as described in the
L r
PPP ... - -----.-...-. dated............ ............. ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. .......7 -------------------------------- Inspetor-
.. s.....................................
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