Lot 14 Title 5 Application 1966 L IN WHERE APPLICABLE
No
S
THE COMMONWEALTH OF MASSACHUSETTS
BOARD�OF 1EALTH
FEE
Appliratinn fur UiopnnaI Wnrlui Qlnnntrurtinn lrrmit
Application is hereby made for a Permit to Construct (L-- or Repair ( ) an Individual Sewage Disposal
ee at:
—Ad ess
Installer
CD-t-0‹-&-.4— Cr-
Address
Type of Building
Dwelling—No. of Bedrooms ? Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow » gallons per person per day. Total daily flow 3.cU.0 gallons.
Septic Tank—Liquid capacity4200gallons Length Width Diameter... Depth
Disposal Trench— No. Width Total Length Total leaching area. 3OCI_sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft
Other Distribution box ( ) Dosing )
Percolation Test Results Performed by _
Test Pit No. 1 i minutes per inch Depth of Test Pit ‘..3(e rt both to ground water_aietiszsce__
Test Pit No. 2 minutes per inch Depth of Test Pit // Depth to ground water
Description of So' I) F cG-e-nL�Y-I�_ .. .. .. -4
Kett-- '
Address ��yy
Size Lot__0.:.,..J..-Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria (
Date_. —/t —LSa
Nature of ltpairs
Iterations—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... c�' L e
Application Approved By
,_. S- I I -C.4.
Date
Date
Application Disapproved for the following reasons
Permit No
Date
Issued
Date