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f f � <br /> a P nRI G'P7L X07 7/I1 . . Risoomla Dopertam4 of Health a>d Soolal Sarvieas r <br /> OSvlalon of Health ! <br /> . 4 ' <br /> SEPTIC TANK PERMIT APPLICATION <br /> 1 + e TYPE OR USE BLACK INK - PLEASE PRINT - <br /> tt� ° :A• .ORNBR OF PROPERTY - 2 <br /> tyfn f. rt c'NeeAd <br /> Mass, d'ua (Strati. City, ZSP Coda) •? <br /> E/vE.aFrrr S/����s.: 57.sFr J--T, S-, K' <br /> _ <br /> �.'B. LOCATION OF PROPERTY WHERE SY54RILL BE CONSTPUCTED ALTERED OR EXTENDED COUNTY Xv fqP '-7 <br /> Check Ones - <br /> .-CITY• VILLAGE 'LEGAL DESCRIPTION r <br /> Y� :TOWNSHIP_ '(Block, lot, Be*.) <br /> rC.:.,IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES _No FRMIT NUMBER <br /> x <br /> fiV 58PTIC TANKCAAITY QALONSt NEW LNSTAL4TION—L REPLACEMENT�.-ADDITION <br /> I1ATFAIALS, PREFAB CONCRETE POURED IN PLACE STEEL�OTHEI <br /> vNUMBER OF'TANKS TO BE INSTALLED, <br /> *f z L E.' TYPE .OF OCCUPANCY .. `. . •% ° , <br /> t ;Check Onei ,one or Two Family Reeldeaoe..A�Camerolal_Industrials Other_(Spsolry) - <br /> s y N er of persons to be Aocomodated A Nu¢ber of Bedroom <br /> F. <br /> �A ^ <br /> F.':' APPLICAL'CES ETC, Food Haste Grinder YES �NO Autonatio Closter Rasher _�Y85 <br /> 1 Diahmaher —YES NO Autocatlo-Potato Peeler YES SPO <br /> OMER (specify) ';—YES NO � <br /> ( <br /> MASTER TLUUER MAKING INSTALLATION - - <br /> b ,t �Nenae -I hAJ�n.5 7-A&D k- Addrnas /I �/ ✓G k"t�lQ �t•AS� - <br /> f SIONATUM,OF APPLICANT s� �iv <br /> Lioeme Nuffiers " MP <br /> ( - ". ADDRESS, - - ttP RSIs.—'- _ <br /> ( H (TO BE COMPLETED BY ISSUING AGM) <br /> S <br /> Data of Application J Pae Paid4 ! <br /> t . . <br /> PesvdPIssuad (dots) Parnit tAVLer <br /> Agent (mule) . , Fors r*. <br /> city <br /> , oountya etc apeoify) <br /> .NOTE, The Applicutim eemot be considered for f11L4 v„til'all of the above questlone-ara amend;' ' ✓ <br /> F . and the fee paid. Agents will fo,wssrd applications the fee of $1.00 for,each esptio t ulk cold) <br /> ✓ W the third copy of the permit (aimry) to the Division of Heelth.c.Choojci pd money ordirs should _ <br /> ' be code payable to the Dleteion of Health* <br /> is 12 <br /> - COfOLEPE OTHER SIDE <br />