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973 Septic Application 1972 I . ■ CHECK OR FILL IN WHERE APPLICABLE No.-533 THE COMMONWEALTH OF MASSACHUSETTS ht-BOARD OF HEALTH .Application for f3ispnnal Hocks oaks Q nnntrnrtinn Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 7 3 .=..2 J d14;:e Locadq��ldress or Lot No. Type of Building Dwelling—No. of Bedrooms Other—Type of Building Other fixtures Design Flow Septic Tank—Liquid capacity gallons Disposal Trench—No. Width Seepage Pit No Diameter Other Distribution box ( ) Dosing Iemnrr Address Add, Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) No. of persons Showers ( ) — Cafeteria ( ) gallons per person per day. Total daily flow gallons. Length Width Diameter Depth Total Length Total leaching area sq. ft. Depth below inlet Total leaching area sq. ft. tank ( ) Percolation Test Results Performed by Date Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water Description of Soil Nature of Repairs or Alterations—Answer when applicable_O alitierlY[:. attC GI Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by thee]board of hc��i-th. Siened i43-ham ! taa ltrl-Ia..1 a Application Approved By i ..LC..cwgzeA.✓� [, 4. . �/ )3 7'2 Application Disapproved for the following reasons Permit No -6 3 Issued 5.*-"i .� 't'1 .. -1.. Date by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Trrtifiratr of f nmplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Installer at has been installed in accordance with the provisions of .Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector