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THE COMMONWEALTH OF MASSACHUSETTS
LU BOARD OF HEALTH
bag
TOWN OF YARMOUTH
Application for Dhipoal Works Tonstrnrtion ' llamit
Application is hereby made for a Permit to Construct ( ) or Repair (VI an Individual Sewage Disposal
System at:
ion o t
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O
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ad as
a-----------•--------••------- ..._.....AJC--... L.-• �J :--•----•--•••-----..
p� Installer Address
6 Type of Building Size Lot............................Sq. feet
aDwelling —No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
p' Other fixtures -------------------------------------------
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W Design Flow ............................................ gallons per person per day. Total daily flow ............................................
WSeptic Tank —Liquid capacity ............ gallons Length ---------------- Width ................ Diameter ................ Depth .............._.
xDisposal Trench — No . .................... Width ...... :............. Total Length .................... Total leaching area _... :............... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by .......................................................................... Date ........................................
Test Pit No. 1 ................ minutes per inch Depth of Test Pit .................... Depth to ground water ........................
(x, Test Pit No. 2 ----------------minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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.O Description of Soil ........................................................................................................................................................................
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Nature of Repairs or Alterations — Answer when
Agreement:
The undersigned agrees to install the aforedescribe
the provisions of iITIE 5 of the State Sanitary Code —
operation until a Certificate of Compliance as b n issued
Application Approved
Application Disapproved for the following reasons: ............
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Permit No.....� ... � ...... ..............
by
d Individual Sewd�e Disposal System in accordance with
The undersigned further agrees not to place the system in
of health.
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Date
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Issued.-- .. -a........ Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifiratr of Tomplittnrr
THIa TO ERT �r.gjkaat the jnd:vikal Sewage Disposal System constructed ( ) or Repaired (t/r
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cogle as; described in the
application for Disposal Works Construction Permit No.....` .�i. _.._ `.af............ dated ..... -- ---------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY./'� �
DATE... �. 2 ....:... ........................ Inspector..' , Y` ......... ._..