Lot 9 Septic Application CHECK OR FILL IN WHERE APPLICABLE
No
FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH AZ
A2
OF TH9mp''.L;
Application for %pond r,r;nrlw llltuwtrurtinn 1ermit
Application is hereby made for a Permit to Construct ('l' or Repair ( ) an Individual Sewage Disposal
System at:
Cd , 7&&F/GZ1?. a-
Location Address
-4 s) .QicK/eerS4 2 <:"A ZC-:adAeD S7
or Lot No.
Owner
Address
;Ds
Installer 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 gallons Length Width Diameter Depth
Disposal Trench—No. Width . Total Length
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bpi f%ai7 t.
Test Pit No. 1 % minutes per inch Depth of Test
Test Pit No. 2 minutes per inch Depth of Test
Total leaching area sq. ft.
Total leaching area sq. ft.
UWTG.47)(12f ie• Date.YACC/71.
Pit d '_8• Depth to ground water / o
Pit Depth to ground water
Description of Soil._4 " .04C4d4/ 7C i�JJ/C- ej3, '- 2. 6L4C 1/2494- 7i[.(_
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 health.
Application Approved By
Signed
Application Disapproved for the following reasons
Date
Date
Date
Permit No Issued
Date