Lot 16 Septic Appication No FEZ...._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C/7/ OF Nowz/fAmean.4/
Application for Disposal r arks (1Cunstrurtinn hermit
Application is hereby made for a Permit to Construct (Plv or Repair ( ) an Individual Sewage Disposal
System at:
&hers P/7 .C70q,0 /6
Location-.Address or Lot No.
Owner Address
Installer Address
Type of Building Size LotZ.33 -± Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ('T
Psi Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Q Other fixtures
Design Flow gallons per person pc day. Total daily flow gallons.
W Septic Tank—Liquid capacity gallons Length Width Diameter Depth
.Z. Disposal Trench—No. Width Total Length Total leaching area sq. ft.
• Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
z Other Distribution box ( ) Dosing tank ( )
"' Percolation Test Results Performed by.LY6Rr^-i%v.L!TL ev.g_,e, Date IA/73-
p-1 *Test Pit No. 1 aZ minutes per inch Depth of Test Pit..L=3" Depth to ground water dC I-0"
W Test Pit No. 2 — minutes per inch Depth of Test Pit_4 .-S 'r Depth to ground water....Z '-n"
O
Description of Soil /CC`r %AP.,iC.LL.s..3:.-t'� tF:A-,.tL2..i..6,ezil!!aZ..,Z.1-s!" L('e AY
w * TE3r Tft,c€d 4fi roe ci< 6'env4,40 a' re .
u 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 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 health.
Application Approved By
Signed
Application Disapproved for the following reasons
Permit No
Date
Date
Date
Issued.
Date