App-Permit-ComplianceNo....Fm .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------....T0 k ....------..OF.... V1 uTi1..
Appliratilan for Disposal Warks Tnnstrnrtion rumit
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
Location - Address or Lot NL
x_.1.2 73 1.t1_€ r ...,!V1,� :.........-.
Owner ddress
�ii
Installer Address
Type of Building Size Lot ----2- z-gZ �...._Sq. feet
aDwelling —No. of Bedrooms ..•........ 3.............................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
a' Other fixtures -------------------------------- ------ -
W Design Flow --------------_------_��--------.-gallons, per person per day. Total daily flow __-_-___..._...._.3' d._............gallons.
WSeptic Tank—Liquid capacityl.6OP..galions Length.9.1--6.`1... Widthl.:J0`� Diameter ................ Depth.g!-4L9.
x � Pae11Vo. ___ W--6 --. Total Total
asq. ft.
Seepage Pit No.. Diameter
- 1Depth belowlet_-6...__._.__Totalleaching areaA...-�------sq.
ft.
Z Other Distribution box (K) Dosing tank ��fe�,e Percolation Test Results Performed by..$'_L4%