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4 Application & Permit 1982 No ?3—g THE COMMONWEALTH OF MASSACHUSETTS cOARD Iy'y^F H ALTH OF ' l. Appliratinu far iiiispanat 'Marks QTnnstrixrtinn 'hermit FHH_lit Y.�...... Application is hereby made for a Permit to Construct ( ) or Repair (14n Individual Sewage Disposal System at: or Lot No. Addre Addrea. Type of 1uilding 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 gallons. 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 sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by Date Test Pit No. I 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_ Repairs o; Alter tions—Answer when applicable Clef_—JZ_ 2. Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to operation until a Certificate of Complianc been issu-d by the board . health. Application Approved By Sign in accordance with place the system in Application Disapproved for the following reasons: Permit No '33 r)-- Issued THE COMMONWEALTH OF MASSACHUSETTS Let 0;7)1 liCrrliWatr-vf afmnpliatur THIS IS TO CERTIFyi, That the 'rift:v./dual Sewage Disposal System constructed ( ) or Repaired (t---) BOARD OF HEALTH Installer at has been installed in accordance with the provisions of TITLE,— 5 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 2 No ( THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Eigpanal orkg Tun:grunion frnitit Permission is hereby granted to Construct ( ) or Re7:„ an Individual wage Disposal System z' at No A' FEE C-1 as shown on the application for Disposal Works Construction Permitlir':% ,Dated , , , DATE - Board of Health FORM 1255 A. M. SULKIN, INC.. BOSTON