11 application and permit 1991 _
I
'1
CHECK OR FILL IN WHERE APPLICAB
No ?IP I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Application for Disposal Works Cltonstruction Permit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at: A/�,J . a MA •
// awns or L,Oy�No. r
1'd!S.if1B' ,,%,. a bi/o/r SOt% ' za N� F ,USA' n/ ip S%..a.ylHd
vt C ..i
Installer
Type of Building
Dwelling—No. of Bedrooms 3 Expansion Attic
Other—Type of Building WC No. of persons
Other fixtures .3. race?
Design Flow I/O gallons per
Septic Tank—Liquid capacity gallons L
Disposal Trench—No a.aWidth._.../8-
Seepage Pit No /Diameter
Other Distribution box ( 1 Dosing tank ( -)r��� 4540 Percolation Test Results Performed by �)N" / st
Test Pit No.C 2 minutes er i inch Depth of Test Pit
of Test Pit Pminutes
Test Pit No.Ct per
Address
Size Lot Sq. feet
Garbage Grinder ( i—)'"
if Showers (74'— Cafeteria ( )
person per day. Total daily flow ?/Yo gallons.
ength.../O Width 4 Diameter # Drat ..�
Total Length iSC g Total leaching area..,.,S, sq. ft.
Depth below inlet Total leaching area. sq. ft.
of Soil 7/1.. tt../"Sa..T — (^NS TV ��
eAet1(56 tat./
Date S 7'6 — F9
Depth to ground water_---MO.N.6_.
Depth to ground water....,[f °&.fi...-
S/<T— — AWE YD
Nature of Repairs or Alterations—Answer when applicable
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b s ssue�bb the bo rd of health.
1( ed_�.
Application Approved B
Application Disapproved for the following reasons
Permit No
Issued
Due