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711 Application & Permit 1969 No...�.:-....r....._.. FEE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH or •r. Appliratiun for Disposal is arks Qlunstru�rtiun hermit ris. Application is hereby made for a Permit to Construct ( ) or Repair Van Individual Sewage Disposal System at: µ. ..Location-.........._.....r'._L... ._ c. .: r . _... Location Addrtss or Lot No. •....... -..- ._.A.y Owner Address m Installer Address U• Type of Building Size Lot Sq. feet Dwelling-No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) d Other-Type of Building No. of persons Showers ( ) — Cafeteria ( ) G Other fixtures W Design Flow gallons per person per day. Total daily flow gallons. rL Septic Tank—Liquid capacity gallons Length Width Diameter Depth xDisposal Trench—No. Width Total Length Total leaching area sq. ft. Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft. z 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 w Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water O Description of Soil M U UNature 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 to place the system in operation until a Certificate of Compliance has been issued by the board of.health. Signed - ._ Date Application Approved By AApplication Disapproved Date te pp pproved (or the fo!louring rearons' Date Permit No • - Issued Date by at THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF . . oerrtifirate of Qtmtiplitture THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (!l Installer 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. DATE - Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF No r FEE Binomial r:i:urks Ojnnntrurtinu 1rrmit Permission is hereby granted _ to Construct ( ) or Repair (/J an Individual Sewage Disposal System at No Street as shown on the application for Disposal Works Construction Permit No ...._._....__ Dated DATE FORM 1255 HOBBS & WARREN a.era of Health