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307 Septic Application & Permit 1980 No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF F Appiiratinu far liapn.5al 3ffnrlui C>Zauntrurtiau lgermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal m Syste at: t' �,J �" ._.....r:i._:.1 LaeStlon-Address 4-i�....) ("L'. I OOwner j.Address -1 t_-NA. "'r"f` r Installer- � Address co iit U Type of Building Size Lot Sq. feet Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) p. Other—Type of Building No. of persons Showers ( ) — Cafeteria ( ) d Other fixtures • Design Flow gallons per person per day. Total daily flow ons.// W n4 Septic Tank—Liquid capacity; - gallons Length / n Width ri t Diameter Depth._. _ W x Disposal Trench--No. Width Total Length Total leaching area sq. ft. 3 Seepage Pit No Diameter Depth below inlet Total leaching area sq. h. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by Date ,'"lj Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water ra, Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water C4 O Description of Soil 0 w UNature 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 iT LI 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 hoard of health. Signed Date l Application Approved By Application Disapproved for the following reasons• Dam Date Permit No Issued . , by at has been installed in accordance with the provisions of Ti`TLI 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 YIU.L FUNCTION SATISFACTORY. DATE ` '< -_: - . ' s Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - Cnrrtifirtttr of (anniplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� (J Installer No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF 33inpnnttl Marks @tnnntrurtinn jrrmit Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No FEE Street as shown on the application for Disposal Works Construction Permit No Dated Board of Health DATE FORM 1255 HOBBS & WARR EN. INC.. PUBLISHERS