687 Septic Application 1971 . I- .r.. ,,... . ...,.....-. ,... .... ........ . ....:. ..,.,:.. ,...
CHECK OR FILL IN WHERE APPLICABLE
No.. _O��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,,Ww
Appliratinn far Eispnsal 3 nrk fllnnstrurtinn ihrutit
Fizz /-5- ‘;°
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Indit idual Sewage Disposal
System at:
i'
or Lot No.
Owns{
Ir seiller 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/c _64gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching area /G_t to. 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. 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 water
Address
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 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.
Signed..atC fl4
y i 1 )j . IFC«...y7ylApplication Approved B
bat
Application Disapproved for the following reasons'
Permit No {.d.r
Date
Issued £(t..L,.. , /.�7.�
Date
lra&r.t. • ,rr• r'art