Lot 6 Title 5 Application 1972 Na...._.......__..._.. Fax
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFD HEALTH
C/7/ OF NO2T/fR171 ,- '
Application for 33isposnl
orks Tnnstrurtion Vrrmit
Application is hereby made for a Permit to Construct ('<or Repair ( ) an Individual Sewage Disposal
System at:
!_j?_Z___-///i
r Ion-Address e or Lot No.
1.02;45t/71.7704.7
Owner Address
Instiller Address
Type of Building Size Lot1'r/6 7 2-4 Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
yOther—Type of Building No. of persons Showers ( ) — Cafeteria ( )
O.
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
W Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Z Disposal Trench—No. Width Total Length Total teaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
4 Other Distribution box ( ) Dosing tank ( ) _
Percolation Test Results Performed by_✓..NA'Q7 14dLz..C/ SA/6'e Date 5-,A-11/7...1—
j Test Pit No. 1 7 minutes per inch Depth of Test Pit " /'" Depth to ground water:4La4/
Test Pit No. 2 — minutes per inch Depth of Test Pit../Cz.o " Depth to ground water..t/—o"
a
O Description of Soil 7-0 72,e,Yt'" ,./.. -_4_".174 7 4 =Le ` /taw/ &r SegA/P .yr/ a-cB/ i.fv"
w _S2tztin.._; C24Y R2L XK..29 7.2i4C8 .aF I CQ9r/42_ '
UNature of Repairs or Alterations—Answer when applicable
Ag.mnent:
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.
y-t, PLAyTATI LEY II INC. MAY 26, 1972
Signed..'-X.(aG s..�,,.s.c. .
Date
Application Approved By
Date
Application Disapproved for the following reasons•
Date
Permit No Issued
Date