Lot 5 Title 5 Application 1972 CHECK OR FILL IN WH
No Fax
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
art/ OF........Nc.P7NElm/'Tu-✓
.Application far Disposal
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Application is hereby made for a Permit to Construct (4 or Repair ( ) an Individual Sewage Disposal
System at:
1_....AV 190 r
I p�ahon Address '/ or Lot No.
Owner Address
Installer Address
Type of Building Size Lot..Le Oa d ` 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 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..✓.f(A.QZ.:"yv4L7'^°Y 6-4 4+'P Date.-'' 'a
Test Pit No. 1 a minutes per inch Depth of Test Pita Depth to ground water 4 O VE
Test Pit No. 2 minutes per inch Depth of Test Pit..7'—o " Depth to ground water 8-o'
Description of Soil...(..ve' Ter a1/410/.cr1 co" sec_. 5'—o"./47e.2' Ale- SAc✓Q.r a 'o SFND I
GLAy Wild..AB....7RACC or C40RIy&S-
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 b the d f health.
,(�ZIT1 V LEY 11011i NC. MAY 269 1972
Signed -Rtw�t Date
Application Approved By
Application Disapproved for the following reasons•
Date
Date
Permit No Issued
Date