75 Septic Application & Plan •
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
erry OF AioR PrJlp JV
pplirtttion for 33ittpoottl Marko Cnnnst"rurrtinn Prrmit
2epair
cation is hereby made for a Permit to Construct ( ) or C.-4c Individual Sewage Disposal
System at:
ckc.TtRFcu) fio s 76—
at;Akite
s
ilillt f CiR/s11U6 �yN GeznYLtG � gip
13 i
Cam-Q5 1 g2�
lastal!er
•
Type of Building �/ Size Lot - '1lr.Li�«'Sq. La
Dwelling—No. of Bedrooms P`T Expansion ttic ( ) Garbage Grinder ( )
Other—Type of Building 5t rkm,!✓1. No. of persons rj Showers ( ) — Cafeteria ( )
Other fixtures /
Design Flow 65- gallons per person per day. Total daily flow :atca0 gallons.
Septic Tank—Liquid capacity — gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area r sq. ft.
Seepage Pit No 49- Diameter Depth below inlet as Ai Total leaching area f5 sq. ft.
Other Distribution box (4") Dosing tank ( )
Percolation Test Results Performed by -rift A.Tit.?..1ltA1LL%Al'5 Date fZ-IZ-(/
Test Pit No. ]...r%- minutes per inch Depth of Test Pit i.5 Depth to ground water
9F
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil OTS - 5J - jl L - CO SSE ,4) t agAlid-
rauj Ciie .%..(.tS
Nature of Repairs or Alterations—Answer when applicable-._'EN .G- .F/}.I.L..I.N-& track. L Az&
Nf4EYi 0A/Is
Agreement:
The undersigned agrees to install the aforedescribed individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Corn liance has y_ n is ued by the board of h I
Sign
Application Approved By
Application Disapproved for the following reaso
Permit No
Date
Date
Date
Issued_
Daze
EXISTING 4 BEDROOM HOUSE
-EXISTING SEPTIC TANK
PROPOSED
- DISTRIBUTION BOX
- EXISTING LEACHING ARE
PLAN
SCALE
AREA =
EXIST!
PROPOS
INVERT ELEVATIONS
FINISH GRADE