Lot 9 Title 5 Application 1972 No.
THE COMMONWEALTH OF MASSACHUSETTS
FEB
BOARD OF HEALTH
(/71' OF 44,47/71/21/27,a70"./
Applirafinn for Disposal i. nrk`s Qinnstrtu#inn rrmii
Application is hereby made for a Permit to Construct (+// or Repair ( ) an Individual Sewage Disposal
System at:
�.4)
,4r+tion•Address or Lot No.
RN Ty aete.../.?4L.E.Y._ //a'VC
Owner Address
Instiller Address
Type of Building Size Lot /a, G 90 < Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
W Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
GOther fixtures
Design Flow gallons per person per day. Total daily flow gallons.
W Septic Tank—Liquid capacity gallons Length Width Diameter Depth
.r y. Disposal Trench—No. Width Total Length Total leaching area sq. ft.
• Seepage Pit No Diameter Depth below inlet Total leaching area . sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by✓f/Rtt7"t /4-407«y 4rr/GiP Date 573-46-1-
aj Test Pit No. 1 .2.5- minutes per inch Depth of Test Pit a c y" Depth to ground water NO 0
(s" Test Pit No. 2 - minutes per inch Depth of Test Pit..9''O" Depth to ground water 6 c-e"
C4
O Description of Soil f" 70,354{ter /'—Q" err," 7 7'"o' "'en./ E%Q%E S/"/O eV/7/t ,5"MAY-t-
U 7AXa%F of GL.A...y
UNature 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_ LANT ITr ON V f110111ES IN MAY 262 1972
e9./sv.w Data
Application Approved By
Date
Application Disapproved for the following reasons
Permit No
Date
Issued.
Date