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46 Application & Permit 1980 • CK OR FILL IN WHERE APPLICABLE No FEE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Applirutinn far fiinpnsai iliarks Tnnntrurtinn 1rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location•A ddress or Lot No. Owner Address Install 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 ( ) 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 aforedescrihed Individual Sewage Disposal System in accordance with the provisions of TITLE 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 hoard of health. Signed Date Application Approved By Date Application Disapproved for the following reasons Date Permit No . - Issued , Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF . /(: .. i-rd. QP!1I t![rrtificntr of tdnnt4+linnre THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (.� by - . /, Installer at 1; .1 c,.;: - ; .�.- r_ has been installed in accordance with the provisions of TI LC, 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No At THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF flin.pnnttl Marko fdnnntrurtian 1rrmit Permission is hereby granted. - to Construct ( ) or Repair ('' ) an Individual Sewage Disposal System at No FEE s,r as shown on the application for Disposal Works Construction Permit No Dated Board of Health DATE FORM 1255 Noses a WARREN, INC . PUBLISHERS