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246 Application & Permit 1973 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i OF Prtttti Application for ttopooat Works �Dtta rrt io Prrl Sewage Disposal Application is hereby made for a Permit to Construct (' ) or Repair ( ) an 'System at: 4.21 .k yya��i R m or Lot No. V Addvess O SC i q. 4e anal Size I of -. -- m ° Garbage Grinder ( ) Type of Building _ Expansion Attic ( ) Cafeteria ( ) -- _ Showers ( ) Dwelling 1h o. of Bedrooms -- - No. of persons -- Other—Tthe of Building -- _. —". ... gallon- Design fixtures gallons per person per day Total daily flow. Depth - U unene it,/.0 Qsq ft Length _. Width - Ue+ign Flow - - - Ih n __Total leaching anti sq ft Tank Liquid cap c t Width ____Total Length_ No . er-- h .__. Total leaching area-- Disposal Trench—L`° -- _ Depth below inlet -- 1 it �o _. Diameter Seepage Dosing tank ( Date .._.. .. . - ate water Percy Distribution n Test No. box performed by - Depth -,_. Depth to ground Test Results -. Depth to ground water — Test Pit No. L____ _minutes per inch Depth of Tot Pit— -- -. __minutes per inch Depth of Test 'rt.- Test Pit No. 2 __ .. Description of Soil -- ---- Answer when applicable _ ____ _ ___ ____ ___ . Nature of Repairs or Alterations— - - Agreement: further the State Sanitary Code—The undersigned further agrees not to place the system in The undersigned agrees to install the aforedescrrbed Individu l Sewage Disposal System in accordance with the provisions t of Article I ... r n,m operation until a Certificate of Compliance has been issued by the ard health. sd y1 [ 4TH. . „Aryl __ - n i= Application Disapproved df the following __. roved for the following reasons. Data Application Disapp -- _ 1lsn._ L 7 /yJ._. ._.. Issned Date _.___ Permit No_.. _i!.��_.__...__._._..____ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rrtt itA ..... pt f to of finm` ltttnrr or Repaired ( ) l T¢a.t the Individual Sewage Disposal System constructed THISi,STOCE�TIF .. Installer by "-` }- ---- '- ode as described m the 1 am acv � with the provisions of Article XI f The State dated IRS h /// application SYSTEM WILL FUNCTION SATISFACTORY. Inspector_` , DATE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH been at installed in acwrda a wr for Disposal Works THIS CERTIFICATE S SHALL THE ISSUANCE OF THIS CERTlFt ORY. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE FEE .va_.' ......... DiRpnattl,311nrkst Tnustrurttnu Prrutit _ em Permission is —Re granted "" -'s _ -- o epav an Individual Sewage slspo it Sy as shown on u Dated it to Construct erne[ No —� application for Disposal Mocks Cons[rucnog VP rood the a IIoa<Wd Health DATE—............................. .... ............... ........ ................ FORM I ass HOBBS & WARREN_ INC. PUBLISHERS