Lot 1-B Title 5 Application 1971 IECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ 7✓ OF NO.e7We tm0>c.t.)
Appliratiou fur Biripnnal Qlnustrurtion Permit
Application is hereby made for a Permit to Construct V) or Repair ( ) an 1n Iii ideai St-wage Disposal
System at:
I%Rg✓A•/ ST
cavie dwe Lion-Address
Owner
Installer
Type of Building
Dwelling—No. of Bedrooms
Other--Type of Building -_
Other fixtures
Design Flow gallons
Septic Tank—Liquid capacity gallons
Disposal Trench—No. ....._............. Width
Seepage Pit No Diameter
a4 /23
Lot Na
or SrQeeT
Expansion Attic
Address
Size Lot /0,000 2 �r: feet
Garbage Grinder (
No of persons Showers ( ) — Cafeteria ( )
per person per day. Total daily flow gallons.
Length Width Diameter______.. Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Yra l SZ 42E4O ^-1, dWic.atate 7/[5_77/..._-_
Test Pit No. 1 /'3 minutes per inch Depth of Test Pit 2 C I rr Depth to ground water ohwe
Test Pit No. 2 minutes per inch Depth of Test Pit S C ' Depth to ground water_..V.O.f0E
Description of Soil it " Tese/% A 4 r 6 ' F/(VE ySiND w.T:r SAf,T 1...6PQUr.C.. _/ 1'0 w
J?a40 in .9ey.0 i of C.g/
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'
D:.te
Permit No Issued
Date