25 Septic Application 1971 Fea.a , l r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
( 1? ,) or /c:,: C�,:
Appliratinn for Disposal Iil urks` Qlnnstrurtinn drrmit
Application is hereby made for a Permit to Construct
System at:
Location-LL6^.k"Y`1" 41S. /16'/ `.
4'!
5
°lNie
Installer
Type of Building
Dwelling—No. of Bedrooms / Expansion Attic
Other—Type of Building No. of person
Other fixtures
Design Flow A7 gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacityjIL gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area .(tsq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distrihution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
or Repair ( ) an Individual Sewage Disposal
or Lot No.
Address
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Description of Soil
Nature of Repairs or Alterations—Answer when applic able/ XljR: kdss_ 12fi..{,..51-Z r ( hie
ttF .1J/' y
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 b issued/�./hee boardf health./b
Signed Cl/7 GtLL'6LX1 /e
)
Application Approved By 1z1. f JL_..i . I 0 Lt2.1 / h. '-I-
Application Disapproved for the following reasons'
N.:C >; 'o1[ .i
Permit No...4- ,:3
'/]'�l ] Date
Issued f.25.Ld.yD �._1�..,1f