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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Application for Disposal Marks Tonstrurtion ramit
Application is hereby made for a Permit o Constrlhct ( ) or Repair (t,,�'an Individual Sewage Disposal
System at: � /� loc-f ii ��"' !% /TSS=' e
.......�..7__ �_l.w:e:o!'��...1�............. ...........�.....---........._...........---......�`---lzl-:.....:'ip�
.....Z
0! :.4.��Lo..... A.ra=-1....................................................................... Lot.No.........................................
Owner Address
-- O jZ...0-a.................................................... --••--
Installer
Type of Building
Dwelling — No. of Bedr i
Other —Type of Bu' ing
Other fixt es ....
Design Flow---------------•- --------......
Septic Tank — Liqui capacity
Disposal Trench — . .........
Seepage Pit No ..................
............... :'... Di
Other Distribution box ( )
Percolation Test Results I
Test Pit No. 1 ................m.
Test Pit No. 2................mi
Attic
No. of persons ............................
Address
Size Lot ............................ Sq. feet
Garbage Grinder (�
Showers ( ) — Cafeteria ( )
------------------•-•------••-----••------................-•---............----•••---•---------------------•---........-•------------•----•
ga Ions per person per day. Total daily flow............................................gallons.
... Ions„ Length ................ Width ................ Diameter................ Depth ................
idth...................... Total Length .................... Total leaching area ................... sq. ft.
ter .................. Depth below inlet.................... Total leaching area .................. sq. ft.
Do ing tank ( )
firmedby......................................................................... Date ........................................
°s per inch Depth of Test Pit .................... Depth to ground water ........................
is per inch Depth of Test Pit .................... Depth to ground water........................
.........:::..........................•----•-•--...............................-•---........_....---------•-----.........---...............
Description of Soil ..........................................
...--•-•---••----•----------------------------------------..;-•---.......---•.........-------••-•---------------.......... •-:-------------------•-------•--------------.
Nature of Repairs or Alterations &swer when applicable _-4.tr.�' .. _J.%....�/...l v ,l?..1 �%1..............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu;dby the b rd of health.
Signed_ L �.. `3..
Dat /
Application Approved By...... ..... ...... . ............................................................... ....................
......... L .......
Date
Application Disapproved f ollowin easo:..........................................................................................................
Permit No.......� .......I- ..........................
Date
Issued........ .`_.I .. L.,C ............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMQVTH
( rdifirtar of (aout littntr
THIS IS TO CE� IFY, That thendividual Sewage Disposal System constructed ( ) or Repaired QA
by..............................I.........---•--••-------•--......----...----........................---.....................................................
Installer
at.... L -2----...0 1 . to ..... <!. .... - n-•----------•-- -0--....... ..: `I- A.(. 3 ............................ ........................
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as d • 'bed in the
application for Disposal Works Construction Permit No......_ �-'���..:........... dated........ 6.:a/ ..................
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ........... ................. .._ ......
. .
....... ...... .............. Inspector ... .. ..... ..... ..... /