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669 Application & Permit 1976 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Fes$' 1ppliratinn -fur"fli5pnnni nrkn (4ntt5trur�timt Permit Application is hereby made for a Permit to Construct ( ) or Repair ( System at: 1 .ocat.oa-Add 'tf t:1.1, n Individual Sewage Disposal or Lot No. Address s Addres, a 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 gallons per person per day. Total daily flow Septic Tank—Liquid capacity gallons Length Width Diameter - Depth. Disposal Trench—No Width Total Length Total leaching area sq. ft. Seepage Pit No Diameter Depth below inlet Total leaching area Other Distribution box ( ) Dosing tank ( ) Date Percolation Test Results Performed by Depth to ground water_ 'lest Pit No. 1 minutes per inch Depth of Test Pit p g to Depth ground water Test Pit No. 2 minutes per inch Depth of Test Pit De 1 g gallon,. Description of Soil 1 c. Yttif. -47- Nature of Repairs or Nteranons—Answerwhen ap liel le J - u`?✓5- .UG.e.1_ ._ ll Agreement: The undersigned agrees to install the aforcdescrihed 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 i1, +7a7c2 ;AI Application Approved By 14 Date V Application Disapproved for the following reasons- Permit No Date Issued CeeaL te-f.X (1 Date by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF _ QIertifirate of fltnmplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 1 or Repaired ( IERRIcr 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. DATE Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF /0 M, f �i,pn�tt�tflinrks Tpnatrnrtinn liirrmit Permission is hereby granted t.-f_�LSte.¢(...J,_T-k ritet+-�-L- to Construct�( ) or Repair (✓ Individual Sewage Disposal System at No FE as shown on the application for Disposal Works Construction Per it No..4�.4 � /_L,(��'G/c9. /y/e' Uated. �, DATE FORM 1255 Hoses & WARREN, INC_ PUBLISHERS