84 Septic Application 1966 No
THE COMMONWEALTH OF MASSACHUSETTS
BOAR41 /OF I�yEALTH
t T OF.NOT�.74t'wv:P4, .I.44-4
1'4'EE
Appliratinn/fur Disposal Works Citnnstrurtinn Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at;
mil_ c4_
•AIdrrss
„scour,
Type of Building
Dwelling--No. of Bedrooms
Other—Type of Building
Other fixtures
Design flow --Sr gallons per person per day. Total daily flow
Septic Tank—Liquid capacity/OP Ckallons Length Width Diameter
Disposal Trench— No. Width Total Length
Seepage Pit No Diameter Depth below inlet
or Lot y4i t– L
�0 2.. tic li ♦ AMmssoc
AMress
Size Lot...-7 t -± Sq. feet
m 3 Expansion Attic ( ) arbage Grinder (
No. of persons Showers ( ) -- Cafeteria ( )
7 icy
gallons
Depth
Total leaching area/7140 sq. ft.
Total leaching area sq. ft
Other o Distribution box ( ) ' tes per inch Depth of Test t Date.. /Z P(e
Dosigg'tmr1< j( )
Percolation Test Results minutes Performed nc L.�2 h{ t �}
pit \ ['z. Depth to ground water.r..e'l.P"`�--
Test Pit No. 1.. 3 P P
Depth to ground water
Test Pit No. o �u per in e�th of 'L 2 Pit tr P g
y
T... .Q-Lt2n.:S.1t.11--., ... .
Desenption of Soilt4.e_
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has been issued by the board of health.
Signed.—.
Application Approved By
in accordance with
place the system in
Application Disapproved for the following reasons
Permit No
Issued
Dam
Date
Date