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Misc. Septic Application 2 CHECK OR FILL IN WHERE APPLICABLE No % FEE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I I _ OF lr � 1) .t;.rr 1 r. Appliratinn for Tisponni rrnrka (!nnstrnrtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 4:01. Address Ins.aIT Address 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.. gallons. Septic Tank—Liquid capacityLQ gallons Length Width Diameter Depth Disposal Trench—No Width Total Length Total leaching area /SO 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. 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 Description of Soil Nature of Repairs or Alterations—Answer when applicable Agreement: t 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. , Signeg f Application Approved By :}r-F . !['. >>' d h. Cv't i..-51)7r.(!. � m Application Disapproved for the following reasons Permit No Dam Issued._.}2AL1 Date /eY J nm by at has been installed in accordance with the provisions of Article XI of The State SnnitaryyCocde as described in the application for Disposal Works Construction Permit No /7- V dated )a"' . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A D,UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE - / � Inspector THE COMMONWEALTH OF MASSACHUSETTS �y pp BOARD OF HEALTH OF /In. X.7/:.p 611 Qrrtifirtttr of &mindittnrr THIS I$TO CERTIFY, That the Individual Sewage Disposal System constructed (" ) or Repaired fInsfaijat THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF O FEE �in}Tnsttl 3finrkn CIinnntrurtium or 4Jrrmi Permission iyfierelry granted i/ to Construct ( ) Repair ( . ) an Individual Sewage Disposal System at No Street as shown on the application for Disposal Works Construction Permit No DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Doan].