Misc. Lot 6 Septic Application No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C,Ty OF •01,‹TirtelenPZos /
),ppliration for Qisponat rr; nrks (1Cnnsirnrtinn Prrmit
Application is hereby made for a Permit to Construct (4 or Repair ( ) an Individual Sewage Disposal
System at: �
eO[_e-3 4-379Ddu1 ED.
Caution-Address
Dauer
Installer
Type of Building
Dwelling—No. of Bedroo.
Other—Type of Building
Other fixtures
Address
Address
Size Lot // 4' c _Sq. feet
Expansion Attic ( ) Garbage Grinder (✓f
No. of persons Showers ( ) — Cafeteria ( )
Design Flow -.cd gallons per person per day. Total daily flow 3Q gallons.
Septic Ta Liquid capacity&Q.Q..gallons Length/a -e " Width -l'-'6" Diameter Depth 'leo''
Disposal r--No. / Width 33 Total Length 33 Total leaching areal°e"C sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box Dosing tank/ ) ,, .
Percolation Test Results Performed by✓Hf� T— i -•-'T4E7/ ENL.cP... Date.. .-7/2/43
Test Pit No. 1 — minutes per inch Depth of Test Pit 8 i d" Depth to ground water 7'
Test Pit No. 2 r° .minutes per inch Depth of Test Pit a7 '!' Depth to ground water 4/44/E
Description of Soils "Cte6A4/4 7-o/1A�3L.e.t" Sic i 7'-q " Cc de:AC 7i 4,c_
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.
Signed.
Application Approved By
Application Disapproved for the following reasons
Permit No
Date
Date
Date
Issued.
Date