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Lot 16 Septic Application & Permit 1971 CHECK OR FILL IN WHERE APPLICABLE No A FER.AS G 0 THE COMMONWEALTH OF MASSACHUSETTS ,( BOARD OF HEALTH ea, OF j,4-1 fa-nrC:n Application for §inpnnal rr;nrki Cllnnstrurtinn remit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: L /114:17 ssalec Own Address Installer Address Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) No. of persons Showers ( ) -- Cafeteria ( ) Type of Building Dwelling—No. of Bedrooms Other—Type of Building Other fixtures Design Flow //�� �gallons per person per day. Total daily flow gallons. Septic Tank—Liquid capacityh ,ugallons Length Width Diameter De th Disposal Trench--No Width Total Length Total leaching arc e 3T11k..sq. ft. Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by Date Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water 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 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 been issued by thfi board of health. Signed;a (ray'tx'- f.:k`' ... �.- Application Approved By ;. 1.�4H t:.l� :;I t-ec' _( _/ 7/ Application Disapproved for the following reasons' JJ Permit No Issued "' l• I 4 ..7/ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Trrtifiratr of Tnmplianrr 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 dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector CHECK OR FILL IN WHERE APPLICABLE No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (, ,:... OF Applirntinn for ainpnnnl nrkni(knnntrurtinn Vrrmit r:r; Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: tir' Installer 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 in _ gallons per person per day. Total daily flow gallons. Septic Tank—Liquid capacitypr—ltigallons Length Width Diameter Depth Disposal Trench—No. Width Total Length Total leaching area 6iLL.sq. ft. Diameter 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 / or Lot No. Address Address Seepage Pit No Other Distribution box ( Percolation Test Results Test Pit No. 1 Test Pit No. 2 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 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 issued by the board of health. Signed elf Application Approved By Application Disapproved for the following reasons Date Permit No ' Date Issued 412 t. 1 f LI 2/ Date