259 Septic Permit 1973 'HERE APPLICABLE
CHECK OR FILL
No 1Q1.3
FEE /- d
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CCrAZS °F Appliratiutt - tnpuSaII M urlw��PIIitrllrtinn JPI lltit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an lndit idual Sewage Disposal
System at:
9 2z
or Lot Not
Address
hmal:or t t% Addicts
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .. No. of perwnr Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallon: per person per day. Total daily flow gallon
Septic lank—Liquid capacitilotOgfillons Length Width . Diameter Dc»tI
Disposal Trench No Width Total Length Total leaching area..—J OQ_d.sq. ft.
Seepage Pit No Diameter Depth bel ow inlet Total leaching area =q. f:.
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 wan_
Description of Soil
Nature 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 N1 of the State Sanitary Code-- The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beeq-•sued by the board of health.
Signed
Application Approved By
Application Disapproved for the following reasons'
Permit No.._6 3
Date
Issued. 7/4w, 02.7_1.97.3
Date