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24 Septic Application & Permit 1980 CHECK OR FILL IN WHERE APPLICABLE No_..yt...�-3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF % t"MThe ttli'en/ Application for Uispanal Works Cans trnrtinn lrrmit FEB S cc Application is hereby made for a Permit to Construct System at: ay pie ati&1-Address mr.:mr Type of Building Dwelling— No. of Bedrooms Other—Type of Building Other fixtures Design Flow gallons Septic Tank—Liquid capacity gallons Disposal Trench— No. Width Seepage Pit No Diameter or Repair an India idual Sewage Disposal or tot No. Address Address Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) No. of persons Showers ( ) — Cafeteria ( ) Other Distribution box Percolation Test Results Test Pit No. I Test Pit No. 2 Description of Soil per person per day. Total daily flow gallons. Length Width Diameter Depth Total Length Total leaching area sq. ft. Depth below inlet Total leaching area sq. ft. 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 Nature of Repairs or Alterations—An when applicable ateli Y ' 30 e f r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions oI 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 gy the ear of he Application Approved By 't ef-t ik Application Disapproved for the folio reasons. Date Permit No Issued. n q Da[ _ly..._/-1..r(. by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF L)e_ rrtifiratr of Tomplianrr THIS IS Tp CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (k ) at : % tc4cr ! - has been installed in accordance with the provisions of TIT ff. 5 of The State Sanitary code as described in the application for Disposal Works Construction Permit No k dated y< t ft THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION (ISATISFACTORY. DATE �; : t 7 Lib Inspector_..;_:rz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF. Disposal rQ inks tbonntrnrtion tirrmit Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Sewage Disposal System FEE . . at No y._-..__n_ sdrect as shown on the application for Disposal Works Construction Permit No Dated Board of health- DATE FORM 1255 HOBBS & WARREN. INC., FUELISHERS