Lot 21 Title 5 Application 1972 NoFas......... ..._......-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TY of .4401.Y9->n°7c.r/
Application tor flispnnttl
I,
nrks (?Znnstrurtinnrrmit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:�i ,/— /
f�ou.�7A/E,/ .�1,t N1 21
Location•Address
Installer
Type of Building
Dwelling—No. of Bedrooms 3
Other—Type of Building
Other fixtures
Or
Address
,Ca.tarn/rer
Size Lot/4. 0/3 Sq. feet
Expansion Attic ( ) Garbage Grinder (✓f
No. of persons Showers ( ) — Cafeteria ( )
Design Flow , o gallons per person per day. Total daily flow �O CL. gallons.
Septic Ta squid capacityS0..0...gallons Length. '/e n Width.i '4" Diameter Depth¢'/o"
Disposal TieneF—No. / Width Z/ Total Length 3 s Total leaching area 73.3 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by. ./Meer XtWTt-EY akk Date..,01/72—
Test Pit No. 1 /0 minutes per inch Depth of Test Pit L 3° Depth to ground water..AL¢J/=
Test Pit No. 2 minutes per inch Depth of Test Pit r.O" Depth to ground water..ti/0" a:.......
Description of Soil /<-o" Tr/i JQ.nc ....Z_.-.p` S1/44 /'—!e.°.e/CRY `ia/r £*4'Q It -•0' C6A1
eui7y Col LAWS oP eGe<gX 6' CeR4Veg._
Ce.... V To Se /er. 011CP /e 4,64 of LtiKwiw/6 °rte
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