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