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579 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Application for Disposal Hr; FEE orks (lIonstrurtion permit Application is hereby made for a Permit to Construct ( ) or Repair (75 an Individual Sewage Disposal System at: Location,Address or Lot No. Ow er Address Installer Address 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 futures Design Flow gallons per person per day. Total daily flow gallons. Septic Tank—Liquid capacity gallons Length Width Diameter Depth Disposal Trench—No. Width Total Length Total leaching area sq. ft. Seepage Pit No 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 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 %I 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._ Date Application Approved By Date Application Disapproved for the following reasons Permit No - 1 Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ohl-filtrate of Citampliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (/5 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 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 — No FEE itisponal arkn entotrurtinn ihrtnit Permission is hereby granted to Construct ( ) or pair it ( i an Individual Sewage Disposal System at N Street as shown on the application for Disposal Works Construction Permit No ....------------ Dated DATE FORM 1255 HOBBS a WARREN. INC.. PUBLISHERS Board of Health