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412 Application & Permit 1964 No THE COMMONWEALTH OF MASSACHUSETTS BOARDcy OFntIEALTH Application for ljiupuuut Marko Qlrm,wtrnrtiun 11rrmit Application is hereby made for a Permit to Construct Q' ) or Repair ( ) an Individual Sewage Disposal System at: Locattp.AddnAst 4 nstnller or Lot No. Address 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 t .gallons per person per day. Total daily flow gallons Septic Tank—Liquid capacity_I0 U gallons Length Width Diameter Depth Disposal Trench-No. Width 1.3 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 aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not place the system in operation until a Certificate of Compliance has fbeen rpeped by the hcalg�lu //// t _ . Signed /i'Ly'4,�..,,, s'",w�q Application Approved By Application Disapproved for the following reasons Pie Date Permit No ! Issued --Date Data - I'is7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF //Oltn,?owpfBX rrtifiratr of Tontoiiotur THIS IS TO.CERTIFY„That She Jndividual Sewage Disposal System constructed Lti L't't4LJ C ( ttiii by % 'C at °L ite Fs. has been installed in accordance with the provisions of Articl I of The State Sanitary Cpde as d scjribed in the application for Disposal Works Construction Permit No dated r-y''d F F y THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE ) or Repaired ( ) Instancy SYSTEM W L UNCTION SATISFACTORY. DATE eL i I / Inspecto THE COMMONWEALTH OF MASSACHUSEf TS BOARD qF HEALTH OF /? <rvrC'� .-p^Lin 1 fi FEE Elispnnal Work, ¶ n tturtinn tirrinit Pevnission�ercby granted to Construct (I ) or Rep ir,( ),an ividtnnl Sewage Disposal System at No .-. ,;i. . .. Street / / 2 J ' /%, / as shown on the application for Disposal Works Construction Permit(No S Dated JJL li-�j Jr rrL q jj Mir..;�t.;yl BALM of Health DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS