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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 arks QQnnstnutinn %hymit 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