114 Application 1974 THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C'iry OF .... O.eriranlF'r_Csel
A iratiun far 313ispasal 'Jarful U nurtrurtinn ¥rrmit
klAYArpplication is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
Location•Address oe Lot No.o.� l
...Address
Owner
Installer Address
Type of Building Size Lot..L.�4'.O..0 Sq. feet
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder (L
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow .57 gallons per person per day. Total daily flow 3410 Ions
Septic Ta % l_Liquid capacny.A.COga hns.._ Width Depth
Dispo sal � —No L Width. -2s. T otal Length leaching f
Seepage Pit No Diameter Depth below inlet Total leaching area sq.
'
Other Distribution box ( ) Dosingtank ( ) �J %s�iKfj,}�
Percolation Test Results Performed by 't 4'S t.'.,L zC:- i,✓ra.41X AleL..S. Date
Test Pit No.2 'I minutes per inch Depth of Test Pit..1 7 Depth to ground water -4/ -Va.—
Test Pit No. 2 — minutes per inch Depth of Test Pit 9 -° Depth to ground water....7'0
Description of Soil 2" ne6dek!tb z'Pjm,Y --1-31' -1/47-1d'cL4<..JF: 'l:_4=.'et-r?J._SA:✓D szamc
s G ' CQtn p nor satt/.41.d' eIau ,Q
-t- =41EN 9F eED...fesvei_....zT WC 74 2E a7!!4oZ_...1 et7..?St.22...ctiiv Z e7I'✓
Nature of Repairs or Alterations—Answer when applicable
Q'AOtt.
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.
Application Approved By
Signed
Application Disapproved for the following reasons•
Permit No
Issued.
Date
Date
Date
D