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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �J J
TOWN OF YARMOUTH
Application for Disposal Works Toosirixr ' n 1irrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at
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-• O.,w,n�er/
Installer
Type of Building
Z
No.
Address C�
Size Lot_.�G./.L .._._._..Sq. fee
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder (/-)Id
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures . ..............
Design Flow ............... •.••-•---��.Q//.--------gallons per p� V aoy. Total day PPW .........................................
Septic Tank — Liquid capacity(_ gallons L;ngth_ t�... Width. _ ____ Diameter________________ Depth_______..
Disposal Trench —No. .......... j........ Width .................... Total Length ..__.�6..... Total leaching area___. ;iFl .__sq. ft.
Seepage Pit No ..................... iameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( Dosing t ( )
G✓ �J�1i/*�— 8 c�
Percolation Test Results Performed by._.____�>�s.��.__ e�� _.� ____________ _Date_____._ _____...�G___......�__..
Test Pit No. 1................minutes per inch Depth of Test Pit ____:l_�...____ Depth to ground water ......
Test Pit No. 2 ---------------- minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil ... ........... ......--------...----•---/....-----•---------- •----------•--•-----•----- •--•---- ..... P...---•
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_____________........................
Nature of Repairs or Alterations — Answer when applicable---- %!✓ ..... --......
.................................•---..--...........--------------------.........---•----------•---------------......•-----------•--•-----•--•-7 ...........................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'ITIS 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iOued by. the board of iealtl.
igned_•-.-...... --h •-----•-•--�--•- --•- •---....--•••---•--•..-__.. ---
Application
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Application Approved BY ...... .................... ...._.. -.... ........
Date
Application Disapproved f ' the f ollo ting reasons: ..............................................................................................................
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Permit No .... /� C�
---... Issued.........._/.._../._.l.....a.._......
- - - Date
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THE COMMONWEALTH OF MASSACHUSETTS \�,,
BOARD OF HEALTH 1 W (;Qjwy
J
TOWN of YARMOUTH
Trrtifirtt#r of Toutpliattrr
THIS -IS TO CERTIFY, That the Inc ividuJ Sewage Disposal System constructed ( ) or Repaired ( ,
by ------- ! ! S '2fO �= -� a c �, ..CL,..r�it .c9 '� -- ... . --- . . y......................... . . ..
has been installed in accordance with the provisions of TITLE 5 of T g State Sanitary C/de as describedi the
application for Disposal Works Construction Permit No ........ -=:J6�.__...._. dated ... ....... �% :_._<.. ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTIO SATISFACTORY.
DATE ............ Inspector r
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