87 Septic Application 1995 CHECK OR FILL IN WHERE APPLICABLE
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THE COMMONWEALTH OF MASSACHUSETTS
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BOARD
,t OF}7-fHEALTH
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iratiun far ilis#fusttl Mirka Cnunstrurtian f ermi#
Application is hereby made for a Permit to Construct ( ) or
System at:
CHasitREIELO ROAD
6ob 647:r
Installer
Type of Building
Dwelling—No. of Bedrooms
Individual Sewage Disposal
ca (ma F ,0
Address
0
4.y'r � Expansion Attic
Other—Type of Building .51Nire... LrIt No. of persons Q
Other fixtures
Design Flow SS" gallons per person per day. Total daily flow
Septic Tank—Liquid capacity
sal Trench—No. i"
Address
Size Lot Sq. feet
Garbage Grinder (L-
Showers ( ) — Cafeteria ( )
gallons Length Width / Diameter Depth
gallons
Dispo Width 3 Total Length 35 Total leaching area._..✓]%&.sq. ft.
Seepage Pit No ',( Diameter Deptl below inlet
Other Distribution box (v / Dosing tank
Percolation Test Results Performed by_..l.Lw'
Test Pit No. I s?--- minutes per inch Depth
Test Pit No. 2.......1 —minutes per inch
nn Depth o
Description of Soil LFO N\- $&A0/6— t k_ - M f' StewP
Total leaching areas sq. ft.
Date..11v6V.]1 1491
est Pit j..2..0:Depth to ground water.../J.ONC...
Test Pit /ZV Depth to ground water....8'
Nature of RepaAs or Alterations—Answer when applicable__.K.EP. .._Paulo_& L.e ::tip-I Cr
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 board of health.
Application Approved By
Sfy llorr
Application Disapproved for the following reasons
Permit No
Date
Issued.