1383 Septic Application 1980 CHECK OR FILL IN WHERE APPLICABLE
No.._ .1.7
THE COMMONWEALTH OF MASSACHUSETTS
FEE / ev
BOARD OF HEALTH
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OF /y lafrA
Apvliratinn fir his nsn1 l arks Cnnnsirnr-inn Permit
Application is hereby made for a Permit to Construct ( ) or Repair (") an Indic idual Sewage Disposal
System at:
1,3k3 ant ..n417Sa
kthir / or Lot No.
��yy��jj ,qq ��pyc� �j" Address
LEYAnILInLInstaller CKI[P./f
Installer �Q Address
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 gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trendy—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. I 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
Nature of Repairs or Alterations—Answer when applicable_ - aQ441--
JLisk XX
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T__.._. 5 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 hoard of healtttt�_!
Signed E—C!:Fa'sfIts { ' /'�
�/ ,1�_ `Z 6$
Application Approved By �. d4�_LC<'.yh�''r'e� �'r<-.. �y�
nxie
Application Disapproved for the following reasons'
Permit No 81 7
Date
Issued.
^'t
Date