Misc. Lot 7 Septic Application ECK OR FILL IN WHERE APPLICABLE
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD`Lb" FjEALTH
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'7/ O iei� G..e>,et.
Fax
Application for Disposal Horn (tonstructiun lrrmit
Application is hereby made for a Permit to Construct (t or Repair ( ) an Individual Sewage Disposal
//System at: �,/ &4ti J
E,.y C. .SA) R
Laam Address
Owner
U e .".
a
IAt N .
Address
Installer
Type of Building
Dwelling—No. of Bedrooms a Expansion Attic
Other—Type of Building 1 No. of persons
Other fixtures / Z._A-AS.i{...S
gallons per person per day. Total daily flow gallons.
Depth
Total leaching area sq. ft.
Total leaching area sq. ft.
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No.
Seepage Pit No Diameter
Other Distribution box ( ) Dos
Percolation Test Results Performed by
Test Pit No. 1.�. .+_minutes per inch
Test Pit No. 2 minutes per inch
gallons Length Width Diameter
Width Total Length
Depth below inlet
Depth of Test Pit..
Depth of Test Pit
Date._.1 -.6 /
Depth to ground water.kLo41.e,
Depth to ground water
Description of Soil L r. -S aLntC...y...4.4.14.w 4.d-:sa.2..._•ea "fit +[/
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'
Date
Date
Date
Permit No Issued
Date