Lot 2 Title 5 Application 1972 No
FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, /HEALTH
C 7 y OF /L.Q.e.7fl.ff..02.er
Application for Disposal fl!irks Qtonstnnctiun Davit
Application is hereby made for a Permit to Construct ( I/jor Repair ( ) an Individual Sewage Disposal
System at: ,/
///.7 Xit71 ,f #-
tion•Address or Lot No.
Owner Address
Instiller
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No
Seepage Pit No Diameter Depth below inlet Total leaching area
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.1/bier .///dZ1-6?' zS CpC Data67M",f..,/ 7-2-
Test Pit No. 1 /• 3 minutes per inch Depth of Test Pit °7 _a Depth to ground water do-u£
Test Pit No. 2 - .minutes per inch Depth of Test Pit.?'r i Depth to ground water... '-‘11”
Address
Size Lot. /°..c32 v = Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area
sq. ft.
q. ft.
Description of Soil /CO" T.ae_.Fe,r- ; /-c- J/c 7 f 7'—a //OE/ ,VC FRNn
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 isy albs TAth rdY,o i jtht INC. MAY 26 t 1972
$tgn 1 VT T � [I Date
Application Approved By
Application Disapproved for the following reasons•
Date
Date
Permit No Issued
Date