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THE COMMONWEALTH OF MASSACHUSETTS 1 ��,.,�✓
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Diopo,4al Works Tomitrnrtion remit
Application is hereby made for a Permit to Construct ( ) or Repair ((/ an Individual Sewage Disposal
System at:
J2.5 5........ .. - ' ' 1 !i 3 C a
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Locati�Address \_ (/�/ or Lot No,
..................... `ULULL:.:.. . rmllr.j?..-\.j.`P.�.S::1 ai4. ... ................ (�Al :'�`�-/............................................................
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/^� lrl� OwnE�4 _ Addr� /J /
:14Ini ........ -(&Yt:d ? ......./.tic .........................
aa«s.
Type of Building VV Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms...._................................Expansion Attic ( ) Garbage Grinder (
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Othert�s ..... --- ----------------------.................................................•---....------............................
Design Flow. . ......................gallons per person pe_r day. Total�aily flow..... 0 .......................... gallons.
Septic Tank Liquid capacity.f.O.O. .gallons Length.............. Width...s>_....... Diameter ................ Depth................
Disposal Trench — No ..................... Width .................... Total Length.................... Total leaching area..... ............... sq. ft.
Seepage Pit No ....... J. ............ Diameter....�..1� .._:. Depth below inlet.....A.i........... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ....................... __......_......._.............................. Date........................................
Test Pit No. 1 ...... ___ .... minutesperinch 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 .................................. .................................. _:..
Nature of Repairsor AI erations — ns er when
A,)—re� .��e ntT
Agreement 7 J_
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State Sanitary Code — The undersigned furth r agre not to place the system in
operation until a Certificate of Compliance has been' d -by e b -h tN.
Sig. ... .................. = 7.1 .....
ate
Application Approved By..... ..................._................. `..--r ......-•--............ . �� t - -��-
Date
Application Disapproved for the following reasons:.----.......... •• ----------------------------------------------------------------------------------
Permit No ..... ?I.I........1..(...!�.........................
�..I- — _
ssued--------f_::.......//............
Date
-_________ ________
______________________
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
farriifirair of Toutphanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
_ v
has been installed to accordance with the provisions of TIT 5 of T;he State Sanitary Code as describe to the
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application for Disposal Works Construction Permit No_ {[.' ._, f .............. dated......1 .:: 1 :.1 7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. r,
DATE............:...:.. ........................................ Inspector...:.. s C " rr...... ...............,