50 Application & Permit 1988 1 ---
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ECK OR FILL IN WHERE APPLICABLE
No. __
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i.ITYOF NOn,l_NA....
.Application for 13isposttl 'rinks Cnonstrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( 4 an Individual Sewage Disposal
System at:
Location-Address
Owner
Installer
or Lot No.
Address
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench— No.
Seepage Pit No
Other Distribution box
Percolation Test Results_
Test Pit No. I 1S..
Test Pit No. 2
No. of persons
Address
Size Lot Sq. feet
Garbage Grinder (>}
Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow L- '- - gallons.
Diameter Depth
Width Total Length Total leaching area sq. ft.
Total leaching area sq. ft.
Date ° 1.......e......
Depth to ground water -
Depth to ground water
gallons Length Width
Diameter Depth below ink
Dosing tank ( ) ,
Performed by
minutes per inch Depth of Test Pit -
minutes per inch Depth of Test Pit
Description of Soil - =: -' J ,• _ 1.
Nature of Repairs or Alterations—Answer when applicaFTle
Agreement: Lc�. ' a(---,--,. s u_ L._ ,- [
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)seed issued.by the-board of health. _
Signed ....... :v
Application Approved By
Application Disapproved for the following reasons'
Date
Date
Permit No
Issued
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
O'nor_NORTHAMPTON
Qtrrtifirate of ftumplianre
THIEsS T CERTIF , That the Individual Sewage Disposal System constructed ( ) or Repaired (7)
by
at So �i
has been installed in accor nce with the provisions of TITIS 5 of The State Sanitary Code descri n the
application for Disposal Works Construction Permit No ..y.(—X¥ dated LO.! �O l
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
lJ
DATE % .�:.dl. Inspector
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CiTYor NORTHAMPTON
%panal
Permission is hereby granted
to Constr ) or Repair ( A') an Individual Sewage Disposal System
at No street
tdunstrurtiun 1rrmit
F>ze
as shown on the application for Disposal Works Construction Permit No
DATE
FORM 1255 A. M. SULKIN, INC., BOSTON
r
Dated
Board of Health