258 Septic Permit 1973 CIIECK OR FILL IN WHERE APPLICABLE
FEE L5 d
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
A.ppliratiun fur ih.pusttl 3Nurkn Cann utrurtinn 1,3rrutit
Application is hereby made for a Permit to Construct (K.or Repair ( ) an lndit;dual Sewage Disposal
System at: /, ` ` + ,/'�
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Iasol r� Addms
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallon. per person per day Total daily flow
gallon..
Se-tic lank Liquid capacit�.d 'dlons Length Width Ifinmeter Deptl'
Disposal Trench No. Width Total Length Total leaching arcn__156!Esq. ft.
Seepage Pit No Diameter Depth bel ow inlet Total leaching area sq- it
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 watt.-
or Lot No.
Address
Description of Soil.
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed 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{�ealth.
Signed .. - _ /It(
Application Approved By Q-36,943t -n py( to/. eLa! (!
O nit!
Application n Disapproved for the following reasons'
Permit No.._1P_�.a
Date
Issued 72W,0!-7../.943
Date