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Lot 149 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE No 4,/i I Fna 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6 Apptiratinn far Tinpnnal hurls Cimuirnrtinn 1ermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -7) ,c11La.`.✓!'S1^-"-6`E- L1?11:t 'uce . Ile Type of Building Dwelling—No. of Bedrooms Other—Type of Building Other fixtures Design Flow Septic Tank—Liquid capacity Disposal Trench—No. Address Addrets Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) Showers ( ) — Cafeteria ( ) No. of persons gallons per person per day. Total daily now gallons. gallons Length Width Diameter Depth Width Total Length Total leaching area s..ICI.Q.sq. ft. Total leaching area sq. ft. Seepage Pit No Diameter Depth below inlet Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by Test Pit No. I minutes per inch Depth of Test Pit Test Pit No. 2 minutes per inch Depth of Test Pit Date Depth to ground water 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 b issued b the board of health. L/i r/"�j/ Application Approved By Signed Application Disapproved for the following reasons• Date Permit No l k f Issued..i"-1�% E t'='I 1 1 971 Date by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Certificate of Toniplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) 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 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f et L Vet ati.tr yf FEE/S; Malmo ul�or�ks k`io/nsfrnrtito�n Permit Permission i ereby granted i . .. . a.:.,l :+.xn-:x.-.L.e?Io=t t to Construcct( )kr Repair ( an Individ h Sewage Disposal System at No iTgst snore' as shown on the application for Disposal Works Construction Pe t No. $.) DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Roe l of