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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............OF.........................................................................................
Appliration for DWVosal Works TonstrWiatt thrutit
App,I lica, is hereby made for a Permit to Construct (Vj"or 'Repair an Individual Sewage Disposal
System at: ):�U4.40a&J wt4z�_V i-4,vA w&4 1 IS/
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Location-Address or Lot No.
...............................
.... .... . ....... ................................................................
Owner Address
..........................................................................iff"s....................
4=LMC --------
Installer Address
Type of Building Size Lot....4... ....5..jR.Sq. feet
U
Dwelling—No. of Bedrooms......rk..�.. ...................Expansion Attic (w*) Garbage Grinder (Lbo)
N Other—Type of Building ...aAIA............. No. of persons.......h-41A.......... Showers (wlo) — Cafeteria (w/4
04 Other fixtures ..........."..1A.................................................................................................................................
Design Flow..........0 .........."...".......gallons per person per day. Total daily flow.......:��S53 .........................gallons.
04 Septic Tank—Liquid'0" 'c"apacity.15Ao.gallons LengthJ!.'.CP-._ Width.;P 1.�... Diameter..!-A/A..... Depth.....e...9!.".
Disposal Trench—No.....NYA..... Width.. 1-44A...... Total Length...... Total leaching area....!.-4JA.......sq. ft.
Seepage Pit No......)......... ameter.....f�.......... Depth below inlet................ Total leaching area!L��'!,.!..sq. ft.
Z Other Distribution box ( D6*,ing tank (i4A)
0-4 Percolation Test Results Performe&by................................................T........................ Date........................................
P4
Test Pit No. ...minutes per inch Depth of Test Pit..... Depth to ground water...H,/^...........
rL, Test Pit No. 2_1:41A.....minutes per inch Depth of Test Pit---NJA....... Depth to ground water...k!AIA..........
04 A AO- CiAt A.....V.tj
..•........... . ......................
0 Description of Soil..............<9-" -5' I.
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I re...160A ......C.WV. ..6A I—J4 . ........
...... . . ........ .. ... ........... .... . ................. .........w......ri...
U Nature of Repairs or Alterations Answer when appl i cable....k....�.
...PL
.. . .. .. P
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been uied by the�oa�rof health.... ... 43
Signed.. .... .............................. ........... ...... L
Date
ApplicationApproved By.................................................................................................. ........................................
Date
Application Disapproved for the following reasons:..............................................................................................................
........................................................................................................................................................................................................
Date
rermitNo.................................................... IssuedL......................................................
Date