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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for R-4pnnttl Worko Tonntrnr#inn Famit
Application is hereby made for a Permit to Constr
System at:
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�// //'�' Owner
.....1..>....!�.-..Y_�... �..w(,.0.......................................................
Installer
net ( ) or Repair (44 an Individual Sewage Disposal
Type of Building L
Dwelling — No. of Bedrooms........1 ...............................
Other —Type of Building ............................ No. of
Other fixtures ......... - ..... •- ................------
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••-------•------•..................................
Address
......................................
Address
Size Lot ............................ Sq. feet
...Expansion Attic ( ) Garbage Grinder
persons ............................ Showers ( ) — Cafeteria ( )
Design Flow..------•---------------------- ------------gallons per person per day. Total da' flow ............. ons.
Septic Tanlc—Liquid capacit��Jftf�..gallons Length-%•--- Width4O0....... Diameter ................ Depth..............
Disposal Trench — No ..................... Width .................... Total Length..... ./............ Total leaching area. ................... sq. ft.
Seepage Pit No ... I ................ Diameter. ,�?Z.. Depth below inlet.... no ........... Total leaching area..—T .....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 Soil .......... ...........................................................
.......... ...................... ........ .................... .._.............................................................. .................................. - - w 3
Nature of Repairs or Alterations —Answer when applicable%. U !1%��... U � ...!� Y.W ...............................
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 been iss3!�44 the rd of health.
Signed -.(.W, ! 3 GjS /•
�n' �/q Date
Application Approved By.i� � �..... -............../...................... ... ? Y / - ............
Date
Application Disapproved for the following reasons:
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Date
Permit No. .S...... .......
................................. Issued -----3 /................
Date
_—-..._..__._.____.___________________________________________ ___—_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtifuttte of Tontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (,')
at............t................................
has been installed in accordance with ;h1e provisions of TI
application for Disposal Works Construction Permit No..:.
THE ISSUANCE OF THIS CERTIFICATE SHALL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................... ... .. ' _::..................................
TLE- 5 of The State Sanitary Co as described in the
............ dated... �. 5. ? ....................
NOT BE CONSTRUED AS A GUARANTEE THAT THE
s
Inspector ............. "'`^ ...... r ✓c.:.�.'.r....�.f .�:r..... , :.....