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248 Septic Application Permit & Compliance CHECK OR FILL IN WHERE APPLICABLE No i3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �F OF /y,zSY-elt-rr+nrer Application fur %in.pnnal rl urns(ltuni trurtinu hermit Application is hereby made for a Permit to Constru System at 1. m:A addr��� 0 -i or Repair ( ) an Individual Sewage Disposal or Lot No. Address. 1nrtaTIcr 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 capacity I of- v allons 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. Dosing tank ( ) Performed by Date minutes per inch Depth of Test Pit Depth to ground water minutes per inch Depth of Test Pit Depth to ground water Other Distribution box Percolation Test Results Test Pit No. I Test Pit No. 2 Description of Soil Nature 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 heajth. -tS'ig4ed f _ { 4/.7 vI Application Approved By Date Application Disapproved for the following reasons Permit No 13 0 Date Issued Date by at has been installed in accordance with the provisions of Article x of The State Sanitary Code as described in the application for Disposal Works Construction Permit No U dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM{�WIL} FUNCTION SATISFACTORY. ,'p_ _ J- DATE. �(",F"4, Ye 9` `S Inspector 1 iO� 1ne THE COMMONWEALTH OF MASSACHUSETTS BOARD OF OF HEALTH rrtifirttfr of To liana THIS (A !T CER%7P I ai the Individual Sewage Disposal System constructed ( ) or Repaired ( ) a 4 F ,iala, -a-- Installer No 130 THE COMMONWEALTH OF MASSACHUSETTS yy BOARD /O,F�(HEALTH flispn nl jnrks�@I Permission 9>httrehy granted to Construct. C at No r urtinn tirrmit FEr .ap Individual Sewage Disposal System seed as shown on the application for Disposal Works Construction Pern DATE FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS 0, /30 Dat,ed >41-9,“ J .11 ics„.*v eirri...........