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33 Application & Permit 1967 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Fax Application for fl;sposal rw orks Tonstrurtion jrrmit Application is hereby made for a Permit to Construct ( ) or Repair (' ) an Individual Sewage Disposal System at: !' L i/ i..-�. Lotion-Address -sn Type of Building Dwelling—No. of Bedrooms No. of persons Other—Type of Building Other fixtures Design Flow gallons p Septic Tank—Liquid capacity gallons Disposal Trench—No. Width Seepage Pit No Diameter Other Distribution box ( ) Dosing Percolation Test Results Performed by Test Pit No. 1 minutes per inch Depth of Test Pit Test Pit No. 2 minutes per inch Depth of Test Pit or Lot No. Address Address Size Lot Sq. feet Fxpansion Attic ( ) Garbage Grinder ( ) Showers ( ) — Cafeteria ( ) er person per day. Total daily flow gallons. Length Width Diameter Depth.... .- .- Total Length Total leaching area sq. ft. Depth below inlet Total leaching area sq. ft. tank ( ) Description of Soil Date Depth to ground water Depth to ground water Nature of Repairs or Alterations—Answer when applicable f/ cno-efz.%t The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with Agreement: 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 /, Cua,/(en Application Approved By Application Disapproved for the following reasons- ryI Date ri . Date � ?? Issued. Permit No set Date ' 7x7 D by has been installed in accordance with the provisions of Article RI of The State Sanitary Code as described irythe at �Y l.k { application for Disposal Works Construction Permit No �-s � dated - I� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f OF /Pi-4:k.TW 4lH v Qltrtifiratr of (QAntiliantr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( Installer No Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF .. . ....... . %panal rrnrks hianntrnrtinn Permit FEE Permission is hereby granted " "ty a to Construct ( ) or Repair (I4 an Individual Sewage Dispbsal System at No j-_1.'._,tanift-L L...ciiiectiwt Street as shown on the application for Disposal Works Construction Permit No Dated Board qY Health DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS