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31 Septic Application & Permit 1975 CHECK OR FILL IN WHERE APPLICABLE No Fits— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Application for Qinponal than Clonstrurtiott Permit Application is hereby made for a Permit to Construct ( ) or Repair (✓") an Individual Sewage Disposal System at: Location-Address Owner or Lot No. Address Installer Address Type of Building Size Lot Sq. feet Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons Showers ( ) — Cafeteria ( ) Other fixtures Design Flow gallons per person per day. Total daily flow gallons. Septic Tank--Liquid capacity M.—.. gallons Length Width Diameter Depth Disposal Trench— No. Width Total Length Total leaching area sq. ft. Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft. Other Distribution box Percolation Test Results Test Pit No. I Test Pit No. 2 Dosing tank ( ) Performed by Date minutes per inch Depth of Test Pit Depth to ground water minutes per inch 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:Hi: 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 Dal Date Oat ff Application Approved By Application Disapproved for the following reasons Permit No Issued_ Date by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF (Ertl- irate of (llnntplianrr 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. DATF Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF No - FEE Bispoonl Permission is hereby granted !!- I to Construct ( ) coy Repair ('gran Individual Sewage Disposal Sjirem at No sweet as shown on the application for Disposal Works Construction Permit No Dated C arks i>Innstrurtinn Permit Board of Health DATE FORM 1255 HOBBS S WARREN. INC.. PUBLISHERS