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28 Applications & Permits CHECK OR FILL IN WHERE APPLICABLE No c THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (-It it, OFA^'�-.^)nT^. FEE Application for 11ispnsul 111 arks Tonotruction jrrmit Application is hereby made for a Permit to Construct ( ) or Repair (14 an Individual Sewage Disposal System at: �-- ,ti its c, f w i , Lh VDIL Dwner Inshllc: Address Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) No. of persons Showers ( ) — Cafeteria ( ) or Lot No. Arld?c s 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—1.iquid capacit gallons Length Width Diameter Depth Disposal Trench—No. Width tr ' Total Length 2 O Total leaching area O O 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 the provisions of Article XI of the State Sanitary Cod The undersig d furth r agrees not to operation until a Certificate of Compliance has been is ed by thpbgrtrd V„eats Application Approved By Sijaedst .tr tt,. is Application Disapproved for the following reasons' in accordance with place the system in r, 3Dat Date g / Permit No `X 1 G Date 5 Issued Date THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF -HEALTH Olnttftratr of Qlamplianrr THIS I T . . O C1 R f14 h The 4J e�is al System constructed ( ) or Repaired ( ) by , q at has been installed in accordance with the provisions of Article XI of The State Sanitary C,pde s described in the application for Disposal Works Construction Permit No dated CY THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL,FU�SON SATISFACTORY. J�� fy. DATE Inspector 6�.�LN No OG THE COMMONWEALTH OF MASSACHUSETTS BOARS OF r EALTIit-1. OF Uts}mnatn>ks Permission is hereby grantrt to Construct ( ) or Re¢mt � ) an dividu&l Sewage Disposal System at No - CJt'�^ nurftrortian Vrrntit FEE so-rc` A- C as shown on the application for Disposal Works Construction Permit No ... Dated -4( At/ dattIal Board of nedIBt DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS CHECK OR FILL IN WHERE APPLICABLE No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF FEE--- Appli ration far Elispnsai iflurks Tanntrurtinn lrrmit Application is hereby made for a Permit to Construct ( ) or Repair (; ) an Individual Sewage Disposal System at: Location.Address Owner or Lot No. 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 fixtures 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. Other Distribution box Percolation Test Results Test Pit No. I Test Pit No. 2 Description of Soil 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 Nature of Repairs or Alterations—Answer when applicable--.,. .r t , r_...u._.._..Lfq Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 7.3.Thif 5 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 Permit No Issued Daze Date Date Date by at has been installed in accordance with the provisions of TI TI-> application for Disposal Works Construction Permit No ' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT SYSTEM WILL FUNCTION SATISFACTORY. DATF . I L :-t r Inspector - - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '«rrtifiratr of (iCnmplittnrr THIS, IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (PI' Installer 5 of The State Sanitary Code as described in the Zr dated ,rats_/ I-k,_J_� BE CONSTRUED AS A GUARANTEE THAT THE No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF �iopnnat 3 orkn @tnnntrurtinn lrrmit Permission is hereby granted ` to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No ' FEE' - Street shown on the application for Disposal Works Construction Permit No DATE FORM 1255 HOBBS 8 WARREN. INC.. PUBLISHERS Dated Board of Health