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462 Application & Permit 1983 v - ? 3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C/771 OF Y . t'/!� /l�ia/! FEE /Q o/ Appliration for 3Ui5pli al 'irks Cnunutrurtiun hermit Application is hereby made for a Permit to Construct ( ) or Repair ( ✓) an Individual Sewage Disposal brZJ tia.,w..sAnv1 :. em at: Tan) /'49 M'2 4Y vveeNG Ill or Lot No. Installer Address e of Building Size Lot Sq. feel Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building Other fixtures ign Flow tic Tank liquid capacity iosal Trench--- No. page Pit No Diameter Depth below inlet er Distribution box ( ) Dosing tank ( ) colation 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 No. of persons Showers ( ) — Cafeteria ( ) gallons per person per day. Total daily flow gallons. gallons Length Width Diameter Depth Width Total Length Total leaching area sq. ft. Total leaching area sq. ft. cription of Soil Pure of Repairs or Alterations—Answer when applicable REP,48c _bM hee- 6DQ rGf,7cH F(Eine tvagai New 6SO - 700 'LEnc/J F/w GA reement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with provisions of?1T12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in ration until a Certificate of Compliance has been issued by the board of health. Signed plication Approved By� �LLL/� !% plication Disapproved for the following re¢sons 7/TFN .r Date Permit No f) -b' 3 Issued- 7. /k/73 Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH sr/r/ OF_.ifiSt,-.?`r : .`:Y . .. ffiertifutttt sf ( omplittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (V) Installer ¥b- 42,4.0-c*',MMr✓Ah/•49A.D been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a des9ribed in the lication for Disposal Works Construction Permit No /1.4E4 dated 7 LP at THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE T AT THE STEM WILL FUNCTION SATISFACTORY. P� TE /l.QAe3 Inspector /t. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 313is.pnsttl nrks Qinnstrurtisn 11rrmit Permission is hereby granted rdit2)...fJia_ y..-g./dam Construct ( ) or Repair (✓) an Individual Sewage Disposal System No 461.2 Ln&c FEE/ Street shown on the application for Disposal Works Construction wicNo/ 3— c Dated - _/..E7 t ✓, ap _. tTE IM 1255 A. M. SULKIN, INC.. BOSTON