Misc. Septic Application 8 ERE APPLICABLE
CHECK OR FILL IN
No
THE COMMONWEALTH OF MASSACHUSETTS
PEE
l��---BOAR OF EALTH
C...t OF dal,CJ..k4
.gpplirtttinn ntn trtutinn 4lrrmit
Application is hereby made for a Permit to Construct
Sy S at:
or Repair ( ) an Individual Sewage Disposal
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building No. of persons
Expansion Attic
m
Lot No
ra.40 ,[1L..1�%�3 )c
.
Address
.
.l
Other fixtures
Design Flow
Septic Tank—Liquid ca acit
Disposal TrenchNo -
Seepage Pit No Diamete
Other Distribution box ( )
Address
Size Lot.... -gC-�._.Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow (SC/.O gallons.
gallons ,Length Width Diameter Depth
iidth.. _..._. Total Length_.Cce Total leaching area 44L-- -.sq. ft.
Depth below inlet Total leaching area sq. ft.
Dos tan ( )
Percolation Test Results Performed by ' t k-"'
Test Pit No. I ./�G
Test Pit No. 2
Deseriptionfof Soil..
.dS..Cr4.. -
4 c Cu
Nature of Repairs or Alte —Answer when applicable
Date..o / --L�t/(/'.__.
minutes per inch Deptl of Test Pi ��_.!. — Depth to ground water f/r'-- `e-
»nutes per inFh Depth of Test Pit Depth to ground water
°tom/ L• se. ac.e c 4- eA
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of Article XL of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has been issued by the boar of he lth.
Signed_ e..S- � _s
Application Approved By
Application Disapproved for the following reasons
in accordance with
place the system in
�> —/ 7 (rF-
Dame
Permit No
Date
Issued
Date