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Lot 22 Title 5 Application 1972 CHECK OR FILL IN WHERE APPLICABLE Na FEB THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 6/TV OF Application for Disposal Harks Olonotrurtion Application is hereby made for a Permit to Construct ('-1 or Repair ( ) an Individual Sewage Disposal System at: leckAik74/4./ "(feu 442 Location•Ad ress or Lot No. EIZA4./7.4 7,0 41 4 - -y .12 -5 "razz Owner Installer Type of Building Dwelling—No. of Bedrooms Other—Type of Building Other fixtures Address Size Lot /00.-27/ r Sq. feet Expansion Attic ( ) Garbage Grinder ( ) No. of persons Showers ( ) — Cafeteria ( ) Design Flow gallons per person per day. Total daily flow gallons. Septic Tank—Liquid capacity gallons Length Width Diameter Depth Disposal Trench—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.d..//447 -h'u&ZE Y .&4/6k- Date..5.724./7 Test Pit No. 1 S minutes per inch Depth of Test Pit a Ll " Depth to ground water Test Pit Pit No. 2 minutes per inch Depth of Test Pit& "--4 " Depth to ground water 9' ' Description of Soil / rate/tan /r-10" J1/2- 7 7/-6 " ft,t11.7..atftP 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 f health. PLANi'AT10 V LEY 110 INC. MAY 26, 1972 Signed, Application Approved By Application Disapproved for the following reasons• Permit No Date Date Date Issued. Date