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830 Septic Applications W d Type of Building U Dwelling---No. of Bedrooms No Application THE COMMONWEALTH OF MASSACHUSETTS BOARD OFU�{.,�.•EALTH OF Fee nr 33inpnnal i lnrkn Construction lrrmit Application is hereby made for a Permit to Construct (X) or Repair ovmuer an Inditidual Sewage Disposal "I. Other—Type of Building a■ Other fixtures Address p Size Lot_p 4t 4 Sq. feet Expansion Attic ( ) Garbage Grinder ( ) No. of persons Showers ( ) — Cafeteria ( ) • Design Flow • Septic Tank—Liquid capacity gallons e7 Disposal Trench--No. Width allons per person per day. Total daily flow gallons. Length Width Diameter Depth Total Length Total leaching area sq. ft. pth belpw it et 'Iota) leaching area sq. ft. • Seepage Pit No Diameter _ z Other Distribution box ( ) Do. ng 4� ( ) Percolation Test Results Performed b . . �,( 1-410--' .-1 Test Pit No. 1 minutes per inch I epth of Tesf Pit Test Pit No. 2 minutes per inch Depth of Test Pit NW ' Date % L f 19 7 S367° th to ground wat „n ecnl2_.... O Description of Soil. ti..-.ret-A.?b-e. ▪ U .c�,_�.�:P,.s... -ty, '7 A.R tell,, .. Depth to ground water Nature of Repairs or Alterations—Answer when applicable 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-- 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 Date Date Date Permit No Issued Application Approved By Application Disapproved for the following reaso Date THE COMMONWEALTH OF MASSACHUSETTS CHECK OR FILL IN WHERE APPLICABLE 91 .No...... ._ FEB Fua. THE COMMONWEALTH OF MASSACHUSETTS ,t . $$-BOARD OF HEALTH OF �?ry.(�rPn Appliratinn fur 3inpnnnl works Ulnnntrurtinn lrrmit Application is hereby made for a Permit to Construct (V)--or Repair Installer Type of Building Dwelling—No. of Bedrooms Other—Type of Building No. of persons Other fixtures Design Flow _J,Q-n gallons per person per day. Total daily Septic Tank—Liquid capacity/nkfgallons Length Width Disposal Trench—No Width..old t Total Length._._S✓ Seepage Pit No Diameter Depth below inlet Other Distribution box (X) Dosing tank ( ) Percolation Test Results i Performed by Test Pit No. 1 ..5 minutes per inch Test Pit No. 2 minutes per inch an Individual Sewage Disposal or Lot No. Address Address Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) Showers ( ) - Cafeteria ( ) flow 59 0 gallons. Diameter Depth Total leaching area. //1.d...Q..sq. ft. Total leaching area sq. ft. Date Depth of Test Pit Depth to ground water Depth of Test Pit Depth to ground water Description of Soil Nature of Repairs or Alterations—Answer when applicable 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—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. d; Application Approved By 2/t C 't�iLLD /y?/ Date Application Disapproved for the following reasons'