Lot 4 Title 5 Application 1972 THE COMMONWEALTH OF MASSACHUSETTS
BOARD O. F HEALTH
OF .ente.4,ne 7o^1
Appliratinn for Disposal
Fez —
arks (Qnnstrurtian Wroth
Application is hereby made for a Permit to Construct ( y'or Repair (
System at:
.tctei71,.Zei7'/Q
Mation Address ne
R�G cam1 Ojet?lt:7
°wiles
an Individual Sewage Disposal
ftg
or Lot No.
Address
Installer Address
Type of Building Size Lot...41$..c*s2a r Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( ) /
Performed by -4/44'7 `/u✓7ca/ Etta'C Date s/ -¢/7p-
minutes per inch Depth of Test Pita=t' Depth to ground water /1/41r Ate
minutes per inch Depth of Test Pit& -a" Depth to ground water...c /--.6 "
Other Distribution box ( )
Percolation Test Results
Test Pit No. 1 /
Test Pit No. 2 -
Description of Soil.../.L-A " 7DFIcrus- :-! .-a" J/Cj .142CX.f.-69e O 1'-(.'.CLAY
/-6 " C4'2Y{ fR"t!O Awn(...a._neAcc of 6,e4A-lr
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.
P "PATIO - VALLEY HON
I�'C. MAY 26, 1972
Signed. �m,..... .n..aw.--Y.. Date
Date
Application Approved By
Application Disapproved for the following reasons•
Date
Permit No Issued.
Date