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477 Septic Application & Permit 1971 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF _.._ ... . . Application for Blowing i,r;nrkO (IInstr Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at: ,. .� Fee - on Permit ...................___r..., 0 L...... Address ........ usta_..—........._..._...................... Address $q. feet Type oBuild n 1i t n Size Lot - -.. V ns� e. � Garbage Grinder ( ) Type of Building Expansion Attic ( ) — Cafeteria ( ) Otheri—Type of Bedrooms No of persons Showers ( ) OthK—Tyhe of Building gallons . Other fixtures ---,,.--,..gallons per person per day. Total daily O4Diameter Depth......---..._. Design Flow._._....___.._....._. Width gallons Length Total leaching area sq. ft. Septic Tank nc Liquid capacity ga Total Length Disposal Pit No No..._._.Di meter h Total leaching area sq. ft. Seepage Pit No..._._._.._._.. Diameter.._._._..._._. Depth below inlet Dosing tank ( ) Date Other Distribution Test box u ( ) Percolation Test Results Performed by Depth th to ground water_.._._._.._.._._ Depth to ground water Nature Pit No. 1._._._-._.emotes per inch Depth of Test Pit Test Pit No. 2........_.._-.nrrnutes per inch Depth of Test Pit eP or Lot No. Address Description of Soil Nature of Repairs or Alterations—Answer when,applinhle r�• yam... '✓ ,. ................_.. .._.._.._.._.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code eued by the board of further agrees not to place the system in operation until a Certificate of Compliance h sa✓hWt ..:.......... . SigneZl'.::...::..... t _Date .._....-y.;Date Application Approved By -/I - Application Disapproved for the following reasons:...__.._._....._........._ __.._._..._.._._.__..._.._Q.._.._..._..._._. Date Permit No 1 Issued by r . at + i.. . has been installed in accordance with the provisions of Article XI of The State Sanitary dated Code as described in the 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. ( Inspector , ({ DATE "� • ^` "I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Otrrtificatt of nn pliu t n THIS IS,-TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (/7 Installer No OF iiispnsal rii nrks. (linnstrurtinn Permit Permission is hereby granted I dividbal-SCW;<Ke Disposal System to Construct ( ) or Repair, ( ' Z q at No Street as shown on the application for Disposal Works Construction Permit No i Dated i Boca of Hellth DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS