669 Application 1976 nnTirrnMWIP1011•111 •WrINPIIIITOnlITYMT'
No._�Q'5
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
of
Appliratiun-fur Bthpnsttl liurkn Cnnn_Mrurtinn lJrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( an lndiridual Sewage Disposal
�Ted
stern at:
Address
bGA k.YZ t1 1 t,..1ta,_ Address
Size Lot . Sq. feet
Type of fling Building - Garbage Grinder ( )
Dwelling—No. of Bedrooms Expansion Attic ( ) g
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures _gallon:.
Design Flow gallons per person per day. Total daily flow - g s
Septic Tank—Liquid capacity gallons Length Width _— Diameter Depth
Width Total Length Total leaching area sq. ft.
Disposal Preach—No. Total leaching ores sq. ft.
Seepage Pit No Diameter Depth below inlet
Other Distribution box ( ) Dosing tank ( )
Date
Percolation Tsl'it Test No.Results minutes per inch - Depth to ground avuter_
Test Pit So. 1 minutes per inch Depth of Pest Pi[ I
minutes per inch Depth of Test Pit. Depth to ground water -
Test Pit So. per
Description of Soil
of Repairs or Alterations—Answer �ndaplira le
Qn c:.'hrues C✓�
Agreement:
The undersigned agrees to install the aforedescribed individual Sewage Disposal System in accordance with
the provisions of Article SL 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 th board of health.
Sign
Application Approved By
Application Disapproved for the following reasons•
Permit No._.7Q /
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