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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Apel ration for Disposal Works Tons trurtion hermit
��}} Application is ereby made for Permit to Construct
...... at;--
---.... ------------------------------
Location - Address
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Own
rr -� Installer
) or Repair ( ) an Individual Sewage Disposal
a---/-- o Lot
- �/•� �1. P `.... .
om----------Q--- ......«......
Addre A-
.
'�H ` 'L ..
Address
Type of Building---------- -
Size Lot ---------------------------- Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ") — Cafeteria ( )
Otherfixtures----------------------------•-----•-•--------------•--•-------------------•-------------......------......----------.........----•-----•--•----------.
Design Flow ---------- //-0.........................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacit� -gallons Length ................ Width ---------------- Diameter ................ Depth ................
Disposal Trench — No ..................... Wit h-.........__._.____. Total Length ...... . -.-- . Total leaching area ................... sq. ft.
Seepage Pit No ........ I....._..... Iameter................. Depth below inlet ........ Total leaching area .................. sq. ft.
Other Distribution box �1 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.--. P't
fA�
.....---•..................•--•---.....-------•-----------------------------------•--•-------------..........------.....-•----..........-----•---------•-------------•-----•--•--••---........-----------
••---...---•-•••-•-•-----•-•••---•••----------•--•--•-••••----•-••--••••----•--------•................•-.....•--
Nature of Repirs orrAlter4ions—_Answef whenlicble-_. _.0 x!!L..P: e -1 ri��f� ►�i v� !.� /I
P-—------. J-- --------------- ........... ......... ='t-- -------- ------ t.......
Agreement:
The undersigned agrees to install the aforedescribed Individual S
the provisions of 'AI TLL 5 of the State Sanitary/lode — The under gn
operation until a Certificate of Compliance has egh hued by the��d c
Application Approved By ... --------
Application
�Application Disapproved for the following
Disposal System in accordance with
.3er agrees not to plVthnsytem in
1..._.-----•-••--.....•--• -_..a.......
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...-----•-----------------------••--•-----------•--.......--------.......----•-...........--------..........---•---•-----------•------........-••._...--............................................
Permit No. C�'. .....------------- .. Issued•-••- 4........nate......
D
77/7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH i
Trr#ifiratr of Tomplittnrr
THIS IS R Y Tha ew, a Disposal System constructed or Repaired
..... . -; a, ,�•-----P y •---•-•..................... ( ) P'
• Installer
at .............•.---•-.--••-•-----------•---.�......._..._.._.._........_.......................--•------•-----.. ..........._...............---
--
has been installed in accor ance with the provisions of TI LE 5 of The State Sanitary Cod . described in the
application for Disposal Works Construction Permit No.... -' ............. dated....�........_..._.....__-.-....
THE ISSUAN E OF THIS CERTIFICATE SHALL NOT BE CONSTRU GU RA TEE THAT THE
SYSTEM WILL C 1 �TISFACTORY.
DATE ....................... ......._........... Inspecto ......_..- `._....... .._................-•- -
`. .........