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No.�.. 2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Elisposal Works Tonstrurtion f rrntit
Application is hereby made for a Permit to Construct
System at:
.........,1 _� :.......... �.�...........................
Location - Address
......�' ........2iZ.-................
owner
,... ..............................
Installer
Type of Building
Dwelling — No
Other - Type
Other
) or Repair (Individual Sewage Disposal
or Lot No.
--.....--.•---s de .......................................................... ........
Address
........... eC2 k1 - -----.r? .... .................... *..............
Address
Size Lot............................SI feet
of Bedrooms ............-�� ----------------------------Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
fixtures......................................................................................................................................................
Design Flow --------------------------------------------gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank Liquid' capacity/dot?_-.gallons Length---------------- Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .....6........... Total Length... ...... Total leaching area ...................sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... 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 ........................
---------------
Descriptionof Soil .. -----...,1 r5- . ....--....-•------------•-----------------•----------•--•------•-----•----..------------------•--------------.-
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.........................................................................................................................................................................................
.................. .................................................................................................. .............................................. .t ....................................
Nature of Repairs or Alterations — Answer when applicable ------.. ........................
-------------------------------- �..........._r
Agreement: �S N
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
eSigned ........ ... .. ..... � ---- ---
Application
- Application Approved By ................. ... ...•---....---•--------....----•-..............--••-•• ...............�--1.--............
Date
Application Disapproved for thng eason.......................................................... ..................................................
...........................................-----------•......------.............--------...----------............................................. .............. .....................................
41,2
Permit No ....... k : �-------------------------------- Issued ... �.......Date ......
D e
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN-of"YARMOUTH
(arrtifiratr of Tontpltatta
7 IS T p CERTIFY. That the Individu wage Disposal System constructed
1"_I t�l�l� l"ilA� T1`
)� or Repaired
at......... !_. -----. P—......._.ar.:..-.:::...e.:.-.:.....................•.......-•----•--------------•--•----•....._................-------•--•------•.-_-.-.. ..
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a desc bed in the
application for Disposal Works Construction Permit No. -.-.l 2_ ----------- dated ....... ... .._7�.-•.---.--
THE ISS UA CE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUAR NTE THAT THE
SYSTEM WILL UNC ION SATISFACTORY.
r
DATE ....... ............................ Inspectors •-� ..............................
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