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601 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE No � V -2 1 THE COMMONWEALTH OF MASSACHUSETTS „BOARD O F HEALTH OF 21Qi-i.:foL/lt Applirntian far 33inpanal 511 nrkn (fIanntrnrtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Indic idual Sewage Disposal System at: y_ 6o1_, :LC'1 'x+ .91 Lorallon Addscy�{� or Lot No. lit I, Address Address Type of Building Size Lot Sq. feet Dwelling—No. of Bedrooms Fxpansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons Showers ( ) — Cafeteria ( ) Other fixtures Design Flow gallons per person per day. Total daily flow gallons. Septic Tank—Liquid capacity gallons Length Width Diameter Depth Trench—No. Width Total Length Total leaching area 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, `Y 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 Application Approved By Application Disapproved for the following reasons by Permit No..(. T.7 Issued...s62-e ` F..�.9J( Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF (firrtifirate of ainmplianre 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 dat r' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Tertifiratr of M ntplianre 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 OF FEE,! • Uispnnttl, i9 arks Otonstrnrtian jrrntit Permission is hereby granted grantedyr to Construct ( ) or Repair (/ ) an Individual Sewage Disposal ystem at No tn)-I f ( . '• Street as shown on the application for Disposal Works Construction Permit No: DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Board of H