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THE COMMONWEALTH OF MASSACHUSETTS!U
BOARD OF HEALTH
TOWN OF YARMOUTH
Ap liration for Disposal Work, Cfunsirnr#inn Errant
Application is hereby made for a Permit to Construct ( ) or Repair R<� an Individual Sewage Disposal
System.1..-..---••-----•-- _................................ ..1-.. --•-..Aicr-
�"`. v4 �• / O �.....-
/• Lo�cjation Address f� �> w ,�
Lot N�
....5.11 :. I was...... Y. _..-.-.-...................................... _.......__..._................
l�wngr_� ' _ * e Address
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling—No. of Bedrooms-------------- ;) - Attic ( ) Garbage Grinder-+--)-
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .•-----•----•.................•---...-•••.........•-•--••--••----------•••--------• ...
Design Flow ............. ... ......................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ca.pacityZA40... gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width ...... i............. Total Length .............r.---- Total leaching area _................... sq. ft.
Seepage Pit No......./.......... Diameter....,/O ........ Depth below inlet ...... 6._........ Total leaching area..................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 --------------_---•--.----
------------------------------------------------•-••---•---------•---------••------------------.._...........•-----•-•----•------•-•--•---•--•----•----•----•-••----------•--•--•--......-•••--...._.
Nature of Repairs or Alterations — Answer when applicable____----- 4b -O.._____ ' _.___._t.U_OQ.. __.._.1.2 ......
VV' 11-14
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been hued by thenar f health.
Application Approved By.. -•-•--- -.lam
Application Disapproved for the following reasons:
PermitNo ...... .............. ....................... ...._
Da
............................ ate '-�•^
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Issued_ ............
// .......Date......
D
�E
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irrlifirate of Tout pliattrr
THIS IS TO CERTIFY, ThatIndividual Sewage Disposal System constructed ( ) or Repaired
by .................. j,:2 �_ �:...��.'7-.......----•----. J�!`?�4�_��/�:�I...........................................
........----••---•......................
nstaller
at • ------
f �N `sr' c/-/ Cry- ? ...
has been installed in accordance with the provisions of TI 5 off he State Sanitary Code a desc ib in the
application for Disposal Works Construction Permit No -. J�-"................ dated .......... Z. ...... .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA AN EE THAT THE
SYSTEM WILL FUNCTION SATI FACTORY. r
DATE...................... IF.................... ---•----••••--•------------- .. Inspector - .._::::.....Z` -=-......