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s C Town Office Building
No•9� South Yarmouth, MA 02,664 F $.._ ...._..._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appluration for Disposal Works Tonstrnrtion Permit
Application is hereby made for a Permit to Construct(" or Repair ( ) an Individual Sewage Disposal
System at: /
m
............... ............ - ............._
Location - Q dres or Lot No. ".
rus
7 --------- -
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nOwncr / / f iY —0-2 /766" /CECIL d ess �p
a ...... ........ ... [.1�.._V........—...........A..1...—.............._
..».......................................—.. 5.%1.111..........._.—..........
w q Installer Addrms pp/,%
6 Type of Building ��-ll Size Lot.... C].4t.',e.DO_'Sq. feet
aDwelling — No. of Bedrooms.....r4 ...... ¢ .......Expansion Attic ( ) Garbage Grinder (v)•
POther — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ...................................
Design Flow...............1>. ...................gallons per gevsorr per day. Total daily flow ............. -----.............gallons.
Septic Tank—Liquid caPacityZ~llons Length._�.....
Width..6....`.....-Diameterl��. P. "Depth ................
Disposal Trench — No ..................... Width .................... Total
Length ........... r...__.. Total leaching area. .... ............... sq. ft.
Seepage Pit No.......A-''......... .. Diameter ..... ,/...�?`�....... Depth below inlet--- ��....... Total leaching area.C' 22....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by..... `�.�-��1? �'- 41 ....JK �kC Date......'. 2.®..........
a G j .............. .
a Test Pit No. 1................minutes per inch Depth of Test Pit........_.. Depth to ground water...... ............
W Test Pit No. 2...f a -....minutes per inch Depth of Test Pit..... . /.3 ........ Depth to ground water.....' .................
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Nature of Repairs or Alterations —Answer when applicable...............................................................................................
Agreement:
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 beetyigsued by the boprd of health.
V.
Application Approved By............
Application Disapproved for the following reasons:
Permit No ........ Q2 _�JQ
..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#ifiratr of Tomplittnrr
Date 11
Date
TH(C -I O C , TIF That the Individual Swage Disposal System constructed ( ) or Repaired ( )
by..........k +-- -• .................... .........
has been installed in acc rdance — �m� Installer
�t
at ............ : .... r . _ ........... .... -ff .c -----............................... - with the provisions of TITLE 5 of The State Sanitary Code s des�ribed in the
application for Disposal Works Construction Per No.� ?ii ......... dateci......�� W . Q.%............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE-CONSTRUED)AS-A, GUA ANTEE THAT THE
SYSTEM jWI FU TT�ION SATISFACTORY.
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