29 Application & Permit 1972 No.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
L/7Y OF /I/ol2Z/i".r.4,//i°7a.r/
Application for Disposal ri.arks (IIons#rurtion fermi#
Application is hereby made for a Permit to Construct (4 or Repair ( ) an Individual Sewage Disposal
System at:
_..Faigwa y 2),e/et'
Location.Address
1 2-7 �+ae j 4�eEs
La No.
/02� ./�i"'vf..T.•.:J rS7 FL a.c?E.✓G°r _..
Owner Address
Installer Address
Type of Building Size Lot-acre'617 les Sq. feet
Dwelling—Na of Bedrooms 3 Expansion Attic ( ) Garbage Grinder (✓f
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 3a
gallons per person per day. Total daily flow 3 cri° gallons.
Septic Ta Liquid capacity/QO.A._gallons Length F=6 ' Width.}—Q-" Diameter Depth..¢=to °
Disposal a.; K—No. / Width a o Total Length 3° ' Total leaching area_.°O sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed byskalCT'-.41,ste7GC?'.tVG a Date.44.17.a-
Test Pit No. 1 A.7 minutes per inch Depth of Test Pit..>2.`.1— Depth to ground water 4/0 n/c
Test Pit No. 2 — .minutes per inch Depth of Test Pit 7'-fe' Depth to ground water 7 1_0 e.
Description of Soil /110 ` 7. /°Sp'4: /'-6 "S.an/v/Sick. 3'-¢ ` ,.....r..144./..0 y /'-et,ft //E2 i
Pi.1/r SA.✓p.
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 of health.
Signed.
Application Approved By
Application Disapproved for the following reasons•
Permit No _
Date
Date
Date
Issued.
Date