35-218 (6) ^ =
FEj&
r, BOARD OF HEALTH
ON on is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
Owner Address
Installer Address
C4 Septic I ank—Liquid capacityJ allons Length................ Width...6R....... Dianieter.
Z Other Distribution box Dosing tank
Test Pit No. .......n-rinutesperinch Depth of Test Pi
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.......................'.....''.......................__.......'.._...''.._..............................__....................._.......................... ......................................
---'---------------------------- ........................... ............ ............ -------- ....... ..........................................................................
~� Nature of Repairs or Alterations—Answer when applicable---------.— .............. .......---........................
—�
.............. ....................................................'--'--................................................... ................. ........................... ...............
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Agreement:
The undersigned n to install the afvrdrvcribed [udividum\ Sewage Disposal System in accordance with
He provisions ofZ[TIL 5 of the State Sanitary Code — 7heuudenignn1 Fu,d`o agrees mn to place the system in
operation uud} a Certificate of Compliance has been issued by the board of health.
Signed................ — ................................................_............... ..........................
»"*
Ann�a600 Approved By.................................................. __.___.___________
Application Disapproved^^ "m.
for the following rousnmz:—............... ........'------ ............... ...............................................
....................................... .............................................................................................. ................... --------------- .............................
Date
PermitNb. ...................................................... Issued--------------------------------------------------------
Date
THE COMMONWEALTH orMASSACHUSETTS
BOARD OF HEALTH
........... ....CITY............ OF......N0Rl[HA.MP.T.ON.........................................
.
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*�rrti��route *x� Qlautphmna
THIS D7T0 CERTIFY, That the Individual Sewage Disposal 3}ntcm constructed (X ) or Repaired ( )
by--------------------------------------------------------------------------------------------- ---------............................................................................................
� ���,m"x�
o�---__...LOT_NO�.._21_L/�0 PPER_�/��,�______________.__—.-------------.--'-_-------
has been installed in xoror6,uc, with the provisions of TlTL2 5 o The State Sanitary Code as described in the
application for Disposal Works Construction Permit Nn_... ........................ ....... dated_............. ......___--------------------
THE ISSUANCE OF THUS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector...................................
THE comwomvvcALr* OF mxssxo*ussrrs
!3^_"AFR0 OF 'HEALTH
CITY NORTHAMPTON
___________---CJF----------------------------
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Permission is hereby granted------- '�—J�.�[----R _TRUST___.____ _'__.--------------
m Construct ( X D* osal System
�,u 0o—.--.- - —2/—�&eY* I -/ ER'- A./� -------- ...................
Strem
uo shown mm the application for Disposal Works Construction Permit YJo----'--.. Dated------------------------------------------
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oNIT(t Of Health
DA7]I--._----'--------'-------''-'
FOR',,,-. 1255 HOBBS & 'AARREN. INC.. PUBLISHERS
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