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Lot 4 Septic Appication & permit 1976 CHECK OR FILL IN WHERE APPLICABLE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Peratyri Appliratintt fn finpuSttl Wurk5 Tottatrurtion llrrutit Application is hereby made for a Permit to Construct (V) or Repair ( ) System at: 01.4347-0rl RJ:K an Indio:dual Sewage Disposal or Lot No. Addreha Astrist hQ-Ip.CA: Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) No. of person Showers ( ) — Cafeteria ( ) Type of Building Dwelling—No. of Bedrooms Other—Type of Building Other fixtures Design Flow gallons pc Septic Tank—Liquid capacit 4_grillons Disposal Trench—No. Width Total Length Seepage Pit No Diameter Depth below inlet Other Distribution box ( ) Dosing tank ( ) JQ✓0, Percolation Test Results Performed by Test Pit No. 1 minutes per inch Test Pit No. 2 n:mutes per inch person per day. Total daily flow gallon.. nth Width I)i:uneter Deed•.____.._... Total leaching area sg_ ft. Total leaching trea sq- it 041 tiets d .4...a Date Depth of Test 1'it Depth to ground water Depth of Tex Pit Depth to ground water Description of Soil Nature of Repairs or Alterations—Answer when applicable Agreement: . The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with the provisions of Article NI 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. Signed �7 p � `Yf"" (/ // Dmc Application Approved By Application Disapproved for the following reasons' Permit No. 7o 9 Issued art-ICE 46 Date by at.. has hcen In;tallcd in accordance with the provisions of Article SL of The State Sanitary Code as described in the application for Disposal Works Construction Permit No - dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Trriifiraie of klomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired meaner No7O f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Y�_ U - h ptioa • U orka fron�f_rurtion 1rrmit Permission is rchy granted -O! M HO�j- •to Constru`cp(t t) oeRepajr ) an Individu: coewage Disposal System p> at No O(.c�'� '�d f4 }t;19:>" ..).._ -iiff.L' s�:e.� �j / }/y,��i �J !/..'6 70( Dated. - ; as shown on the application for Disposal Works Construction rn No._ FEE DATE FORM 1235 HOBBS Be WARREN. INC.. PUBLISHERS