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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Disposal Warks Tonstrudiun rrrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
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&ationi Address o.--....._._.:�� .1. �_..•r.�.-'---....... _._.. (,-.�.._..----- �Address....-`_-'• ................................................. ...............................................................................
ype Installer Address 11 q
T of Building'� Size Lot-.--i�.t•_ ....._.....S .feet
Dwelling —No. of Bedrooms ...................• ------------------------ Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ......... -------------------------•-----------.._..--.-.-..-.---------------------------- .---------------------------------
Design Flow...................rte-�._.... _..... gallons per person per day. Total daily floes___..___.... t'} G .................. gallons. N
Septic Tank — Liquid -"capacity .�0QQ.gallons Length_Z 1.._� q Width 4 t-.iQ.__ Diameter ..... '..... Depth_.
Disposal Trench — No ..................... Width..... j_.............. Total Length .................... Total leaching area ..................... sq. ft.
Seepage Pit No....._...V........... Diameter ...... t.0........ Depth below inlet........ _..._. Total leaching area ------- ft.
Other Distribution box) Dosinf, tank
Percolation Test Results by. --L�-., ----- �.-�.UJ_W_
�? Date------- - ------ _tai_
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Test Pit No. 1 ...... (.!.___minutes per inch Depth of Test Pit________ ? ��. Depth to ground wat r_.....hl�a_t.4�`4_..
Test Pit No. 2.------. minutes per inch Depth of Test Pit...._.._ �' Depth to ground water...---
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Nature of Repairs or Alterations — Answer when applicable .........................
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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 i u d by the boar f ,kealth.
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Application Approved B ... .... ...... -- ---- •. 1.... ... ..... ..�i�.......
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Application Disapproved for the following reasons-------------------•-----•---------------------•----•--............................-----......--•--••••..........
Permit No...........! z -91
Date
_ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifirate of Toutplittntr
THI O ER Y T t the Individual Sewage Disposal System constructed or Repaired ( )
by........ - 11 !L -------------- i .. - ----------------•--........................- -• • ............................
at ............. f .U. ............ ��i� -5--�= .4 ` '
has been installed in accordance with the provisions of TIT 01
application for Disposal Works Construction Permit No------------ - - ----
THE 1SSUANC OF HIS CERTIFICATE SHALL NO .4
SYSTEM WILL DIN 10 SATISFACTORY
DATE.... •.--•--. _......
. --.................................... Inspector..`
'h State Sanitary Code s desc ibed ' the
Cjdated..... &---- ... ........
TRUE S GI%AN�T�E�'T HAT THE