47 Application No
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
OF t
Appliratinn h4 Tinpnnnl ttiorks Olnnntrurtinn 1rrmit
Application is hereby trade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
/6 �tN
o
t F L �' ass C .C_ .P/�v7/^-r' r�.
Installer ddres
Type of Building ize Lot 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.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
iaturc of Rep a' Alterations—A wer when applicable 1 /,
Agreement:.'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System '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 isiued by the boa3'd f,heal
Signed a. e .. C/ // -Le!e_3 Q o.,,e
Date
Date
Application Approved B
Application Disapproved far the folio wing reasons
Permit No
Issued
Date