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46 application and permit • CHECK OR FILL IN WHERE APPLICABLE Faa.crL..._...— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OE_..,\&? ft Ali rir +O.1"I. ration fur flinpnnal a nrks Qlnnntrnrtinn f rrmit Application is hereby made for a Permit to Construct System at: 3_ ? �Zf2 A&tlr's Altai Owner Installer Type of Building Dwelling—No. of Bedrooms i Other—Type of Building lth'3@�x. 1�A11.... No. Other fixtures ( to an Individual Sewage Disposal C 46 I/L, or rot Nn. a�iA.. / Address Address Size Lot_it' Sq. feet Expansion Attic ( ) Garbage Grinder (✓p of persons V Showers ( ) — Cafeteria ( ) Design Flow h?. Septic Tank—Liquid capacity Disposal Trench—No Seepage Pit No Other Distribution box Percolation Test Results Test Pit No. I Test Pit No. 2 Description of Soil gallons per person per day. Total daily flow "a1 gallons. gallons Length Width Diameter Depth Width -4 - Total Length.. ,:3'b ' Total leaching area.._/i 5t._i2.sq. ft. Diameter Depth below inlet Total leaching area sq. ft. Dosing tank ( ) 0 ,tt1 1 Performed by ' iti•--"*�f"1-'%:"` '� Date %Y'� yft T minutes per inch Depth of 'ICS Pc-1/0 1. Depth to ground water__.idI,l4 minutes per inch Depth of Test Pit Depth to ground water Cay ,u 9 , . Nature of Repairs or Alterati ns—Answer when applicable.. xli7(-.IC.l= HRl=�1 Q1v.b.y Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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. Si Application Approved By r'//' 3' 4'/ Application Disapproved for the following reasons' Permit No Date Issued. by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF «trditiratr of (itomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installer at has been installed in accordance with the provisions of TITLE 5 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 No 3o- `1N THE COMMONWEALTH OF MASSACHUSETTS %1 BOARD OF HEALTH Disposal riinks fdnnoir n/Permit .Permission is hereby granted.. &t6L.d to Construct,4 or Repair (X an Individual Sewage Dispo ystem at No ...C _,r:..rt It r as shown on the application for Disposa DATE a_ ei5 FORM 1255 A. M. iULKIN. BOSTON St nstruction Per '/.) I /i4 Board of Health