Lot 13 Title 5 Application 1967 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
,a BOARD OF HEALTH
Applira#inn fur r l9hnnmal Works tnnntrnrliun 3 nmii
FEZ
Application is hereby made for a Permit to Construct (r) or Repair ( ) an India idual Sewage Disposal
System at:
L don pYEeh
r .. . .
Srslaller Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms 3 Fxpansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons b Showers ( ) — Cafeteria ( )
Other fixtures tu
Design Flow -57 gallons per person per day. Total daily flow 3?.d gallons.
Septic Tank—Liquid capacity.r..OQgallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area -6_4 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank 1„ ) /�G -7
Percolation Test Resultsq Performed by Date... p... ._-!
Test Pit No. 1 C minutes per inch Depth of Test Pit Depth to grow water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
or Lot No.
Address
Description of Soil
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 isst#d by the board of eal
Signed q,(� � ' f q Jg
Application Approved By �.� Z -t- t/I._^fet..y •7 -- "'N-.la n)
Application Disapproved for the following reasons u 00
Permit No.. c23 7
Issued
Date