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24 Application & Permit 1976 THE COMMONWEALTH OF MASSACHUSETTS ,FSOARD OF HEALTH Cti .> of l sirtet ,[ Appliration -fur Oi:ipn al Iilurkdt oeenuutrurtiatt piPriuit Application is hereby made for a Permit to Construct ( ) or Repair (( n Individual Sewage Disposal Iystem at: ace-c-44- pe of Building Size Lot Sq. feet Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No of perauns Sho■ven ( ) Cafeteria ( ) Other nsutres .. . design Flow gallons per person per day. Total daily flow gallon- i(--slic fank Liquid capacity g:dlons Leng*h Width Dupil )isposal Trench—No. AA Idth Total l.ength Total leaching, ar _ -- q fi. ieepage I'it No Diameter Depth bcl ow inlet Total Ieacl:ing err'-. _ ap ft )fher Distribution box ( ) Dosing tank ( ) 'ercolation Test Results Performed by _ _ _ Date Test Pit No. I minutes per inch Depth of list Pil Depth to ground watrr. Test pit No. 2 minutes per inch Depth of 1 est Pit Depth to ground watt,- . of Lot No. Description of Soil - <:nure of Repairs or Alteenions—Answer when applicable lgrccment: The undersigned agrees to install the aforedesc ribed Individual Sewage Disposal System in c nre wit]: he provisions of Article Al of the State Sanitary Code—The u16,N-signed further agrees not to ystem in rperation until a Certificate of Compliance as been issued by the board of h -rle. th. Signed hw�d kpplication Approved By 4pplianion Disapproved for the following reasons' Permit No Issued by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF 1trrtifirate of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ia:macr 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. DATF Inspector No... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `( a c r flhipomal illorko (tionotrurtion Permit Permission is hereby gr nted(' y p - >i' p -�-«. to Construct ( ) or.Rep3r - ) an I54iv ual Sewage Disposal System at No a.-/.�/..... / / / s - 7 as shown on the application for Disposal Works Construction Permit' No/ Dated .., ! 1 L7--J%y' FEE) (l DATF FORM 1255 HOBBS & WARREN. INC-. PUBLISHERS