146 Septic Application 1966 CHECK OR FILL IN WHERE APPLICABLE
Ins
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OFyyr HEALTH
OF
FEE
1 polirntiun for Disposal Works (IInnstrurtiun f rrtnit
Application is hereby made or a Permit to Construct Q/) or Repair
Sys at:
kek , ppa� Locatiod-Address
r Owner
Mr",
Installer
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow __ .._St gallons per person per day. Total daily
Septic Tank—Liquid capacity?QOgallons Length Width
Disposal Trench--No. a Width. A, Total Length 2S-
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( )
Percolation Test Results Performed by__C.._.(-...-
Test Pit No. 1 s minutes per inch Depth of Test Pits..?ea
Test Pit No. 2 minutes per inch Depth of Test Pit
an Individual Sewage Disposal
/.64-0/ - ca Ac4-f
zl N c f
or Loo No. n
Address
Address
Size Lot Sq. feet
Fvpansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria
now 3.0 . gallons.
Diameter D th
Total leaching area_J3Csq. ft.
Total leaching area sq. ft.
Date ,LeZ zi " torz_..
Depth to group water..ir4Q ..-
Depth to ground water
Description of Soil .ass.-,_.2 ... .+s X,--i 0--on'-^-'1-t 9-6,44 ) '0-( %
Nature of Repairs or Alterations—Answer when applicable -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By
Application Disapprover) for tha fallowing reasons'
in accordance with
place the system in
Permit No
Date
Date
Issued
Date