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15 Septic Application & Permit 1968 y7 7 5 ft /5 1, h Na is 5 h No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH FEB OF . 'rrr Appliratiuo for Dii pomit Gc nrks @innstrurtion 'Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ton Address or Lot No. Address ow-er 1..1 3ti r Installer Address Sq. feet Type of Building Size Lot q Garbage Grinder ( ) Other—Type Dwelling Type No.— of Building p of Bedrooms Expansion Attic ( ) of persons Showers ( ) — Cafeteria ( ) Other fixtures gallons Design Flow gallons per person per day. Total daily flow Septic Tank—Liquid capacity gallons Length Width Diameter Depth Disposal Trench—No. Width Total Length TTtalal leaching area reaa sq. ft. Seepage Pit No Diameter Depth below inlet g Other Distribution box ( ) Dosing tank ( ) Date Percolation Test Results Performed by De th to ground water Test Pit No. 1 minutes per inch Depth of Test Pit P g Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water Description of Soil Nature of Repairs or Alterations—Answer when applicable „r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 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 beery issued by the board of health. 1 .a ' Signed. /- • fr Date .. _ . . t d� Application Approved By • f1 •+ Date Application Disapproved for the following reasons' Permit No Issued. Date Date by has been installed in accordance with the provisions of Article XI of The State Sanitary dated Code as described in the application for Disposal Works Construction Permit No 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 OF .. . . . . . .... . . . _ .. . fertifiratr of Qinmpliattre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installer No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF A'- .?. Einpnnal nrk2HQtnnutrttr'tina j rrmit Fae Permission is hereby granted,.. to Construct ( ) or. Repair (Y) an Individual Sewage Disposal System at No 't -� r Street as shown on the application for Disposal Works Construction Permit No - ' Dated DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Board of Health