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86 Sepic Application & Permit 1971 7 No.. -<-../.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . � ci y. /11/,`Y/ Application f Thnpnnnl 'li oxlip &nnstnirtinn 33Pxinif Application is hereby made for a Permit to Construct ( ) or Repair an an Individual Sewage Disposal System at: ,,.. T installer-- / G Type of Building H Dwelling—No. of Bedrooms a Other—Type of Building Other fixtures - -- --_gallons per person per day. Total daily flow Design Flow_.._.._..............._.... g Diameter gallons Length....._---_.-.-Width Total leach Z Septic Tank Trench capantY Total Length Disposal Trench—No..................... Width Diameter................. Depth below role or Lot No. Address Address Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) Showers ( ) — Cafeteria ( ) No. of persons gallons. Depth leaching area sq.ft. Total leaching area sq. it Seepage Pit No Dosing z Other Distribution box ( ) "" Percolation Test Results Performed by aTest Pit No. 1.__._.._..minutes per inch G4 Test Pit No. 2....... ... . minutes per inch tank ( ) Date. Depth of Test Pit Depth to ground water Depth of Test Pit Depth to ground water �U Description of Soil eC ` Nature of Repairs or Alterations—Answer when applitable_ !j U The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with rt 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/ssued by the board of health. Signed—,.,1.`� f.X -t ta...... rti Application Approved By .!! Application Disapproved for the following reasons Permit No_:f 'i„ Di". Datd Issued rt Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... . . OF Ott-Ott& of Taittplfattat THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.. . Installer at .. .... has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.................................. date&... .................. .... ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector........................ ......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No "1,3 1 . .. ..C.1, C.4 OF jitt !. k4. ,, ta;:.CII.;...................... 0 li ilisposat arks Tonstrurtinat Iltrittit Permission is hereby grantecl........1/4.444.:......-Ls....—:.... 4..‘„,...(...., ............................................................ to Construct (,.. ) or Repair 17) an/Individual Sewage DisPo(sal Systern at No . ................................ ....................................................................... Street as shown on the application for Disposal Works Construction PermitN0..4...i. I -I f- k A 137;;;4d of;‘elartfh.. '‘ DATE................................................................................ FORM 1255 HOBE s & WARREN. INC- PUBLISHERS