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435 Septic Application & Permit No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF FEE 1pplirntian for iflispasul Works Cnanstrurtian Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal System at: Location-Address Owner aInstaller d Type of Building V Expansion Attic ( Dwelling— No. of Bedrooms No p. Other—Type of Building 6 W Design Flow e4 Septic Tank—Liquid capaci4- zDisposal Trench No Seepage Pit No z Other Distribution box Percolation Test Results '.7 Test Pit No. 1 u, Test Pit No. 2 or Lot No. Address Address Size Lot Sq. feet Garbage Grinder ( ) of persons Showers ( ) — Cafeteria ( ) gallons. Other fixtures gallons per person per day. Total daily flow Depth Width Total Length leaching gallons Length Width Diameter _ P Total leachin area�i ' Diameter Depth below inlet Total leaching area ) Dosing tank ( ) Date Performed by minutes per inch Depth of Test Pit Depth to ground water minutes per inch Depth of Test Pit Depth to ground water a 0 Description of Soil V U sq. ft. sq. ft. o � .a1. ,. Nature of Re p errs r Alterations Answer when applicable... , L �+ -lt .,. A if Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal-System in accordance with the provisions of:rI° 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 Signed Application Approved By Application Disapproved for the folio.:ng reasons' Date Date Permit No Issued Date Dam by at — of The State Sanitary Cede as described in the has been instilled in accordance with the provisions of TITLE dated application for Disposal Works Construction Permit No THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF _. . . __. . (4rrtifirttte of Qlnmplittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) m.<aIIer DATF No Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF . ... .. .. . .... . . . . . . . Disposal Works ((Construction Permit Permission is hereby granted, to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No Street a as shown on the application for Disposal Works Construction Permit No Dated DATE FORM 1253 HOBBS & WARREN. INC.. PUBLISHERS Board of Health