Permit 1974 FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
trY OF itioRramrino
L/1- Application for Thopostal
aionotnirtion ilerniit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
iystan at:
41,tur-Err /thfrie- Z.07
Engogr goaflflnn or Lot No.
Installer
:•ype of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
)e-sign Flow .5.0 apt:).
gallons per person R9-day. Total daily lipw ell/0ns.
ieptie Tan14-0,,I(iquid capacity/ZOO...gallons Length.A1 Y1 Width 5-0 ' Diameter Depth -4/1
fisposal Tiene,"=No. i Width.. Zejf Total Length ' O ' Total leaching area....&22.....sq. ft.
ieepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
)ther Distribution box ( ) Dosing' %talc c...)._,
'ercolation Test Results Performed by.giaCei-7W44/724.Y...07fietem.. Date. -5,/Z-eti 741-
Test Pit No. 1..Le. minutes per inch Depth of Test Pit 3, 3' Depth to ground water '"),,e--
Test Pit No. 2
minutes per inch Depth of Test Pit. 7--Cr u Depth to ground water 7 ‘-e2 "
.1,JD i e3a-01.J.T...i....
Address
Address
Sq.
Expansion Attic ( ) e fee
Size Lot
Garbage Grinder (
No. of persons Showers ( ) — Cafeteria ( )
)escription of Soil Lai ZC-C . 5u.LT
b/ature of Repairs or Alterations—Answer when applicable
greetnent:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
he provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
peration until a Certificate of Compliance has been issued by the board of health.
Signed
pplication Approved By
pplication Disapproved for the following reasons•
Permit No
Date
Date
Date
Issued.-
vat.