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471 Septic Application Permit & Plans 1994 CHECK OR FILL IN WHERE APPLICABLE N THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF ( I 1 ppliratiun fur flinpunal Iii arks «Innstrnrtinn Prrm Application is hereby made for a Permit to Construct ( ) or Repair (`) an Individual Sewage Disposal System at: Location-Address or Lot No. c s Ox1nir Address Installer � Address Type of Building Size Lot Sq. feet Dwelling—No. of Bedrooms Expansion Attic (-5i) Garbage Grinder (r ) Other—Type of Building x No. of persons Showers ( ) — Cafeteria ( ) Other fixtures Design Flow Septic Tank—Liquid capacity Disposal Trench—No. Seepage Pit No Diamete Other Distribution box ( ' ) Dosing tank ('" ) Percolation Test Results Performed by ' Test Pit No. 1 - minutes per inch Test Pit No. 2 minutes per inch gallons per person per day. Total daily flow - ' gallons. gallons Length - Width Diameter Depth Width Total Length Total leaching area . sq. ft. Depth below inlet 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 r ' Nature of Repairs or Alterations—Answer when applicable - - Agreement: The undersigned agrees to install the aforedescribed the provisions of TITLE 5 of the State Environment system in operation until a Certificate of Compliant Application Approved By Application Disapproved for the following rea Individual Sewage Disposal System in accordance with de—The un.- '_ned further agrees not to place the aid of health. gtaddkavt•Nf Leder 01. 13-‘34 G°').l -95/ Permit No. Fe Issued _ Date Dor THIS by at has been installed in accordance with the provisions of TITLE 5 o The 4,4teenvironmental C the application for Disposal Works Construction Permit No. 014— dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UA NTEE THAT THE _ CER THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tiL OF Qlertifirati of Compliant sal System constructed ( ) or Repaired ( the ual Sewage e es,dcesscribeelfy SYSTEM WILL Fyg1CTION SAT ISF SCJDRy. DATE . ��� '� No* '% Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEATH A OF Bumps t Work Tapia, n permit Permission is hereby gran ed to Contra;�j�((�.'j ) pp(((��_RyQee 7�, ( an dividual a Disposal System at No sti as shown on the application for Disposal Works Construction Perm o. �t Dated "a jY fr F -45 in F DATE Form 1255 CHnW Hoses&WARRENM Publishers of Health OIA tkIn fq c- 47 912C h 67E/0/ 3110 55 Li .. • - JO • arV7LP / i.c