Lot 25 Title 5 Application 1972 THE COMMONWEALTH OF MASSACHUSETTS
BOARD ��OF HEALTH
/de 7/14 n`Waretj
Application for Disposal
Application is hereby made for a
System at:
Location Address
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toner
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Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
Installer
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
3
/z.3 M%QA/
Address
Address
Size LotZ‘.3.000 Sq. feet
Expansion Attic ( )
Garbage Grinder ("f
No. of persons Showers ( ) — Cafeteria ( )
Design Flow -50 gallons per person per day. Total daily flow 30 0 gallons.
Septic TanK Liquid capacity/001"gallons Length.P-fa ° Width-S�-¢" Diameter Depth9 Via'
Disposal T. : +—No / Width...2/ Total Length 22 Total leaching area Cs 0 0 sq. h.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by_✓.//Aeer 'e-iiuMT,EY 44€P Date....7/72--
Test Pit No. 1...Q..e.7 minutes per inch Depth of Test Pit..Z --r7 ir Depth to ground water A/°4/C
Test Pit No. 2 — minutes per inch Depth of Test Pit iQ,_a.. Depth to ground water At et/E
Description of Soil..,7” Q.CC.4'A/1//c 7lPJa/eq / 7•' SA- 7,..$ .-o:, '2 lrywr j O
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•
Permit No
Date
Date
Date
Issued
Data