124 Septic Application & Perc Test No
r/1-17
THE COMMONWEALTH OF MASSACHUSETTS
NORTHAMPTON MASSACHUSETTS
FEE 175
cApplirution for iisposal System Construction 1ermit
Application is hereby made for a Permit to Construct ( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No.
124 Chesterfield Road
Owner's Name.Address and Id.No.
John Zieminski
18 Dwight Street, Hatfield 247-9014
Installers Name.Address.and Tel.No
Wade Excavting
422 north Farms Rd, Northampton
584-3492
Designer's Name:Address and Tel. No.
James A. Gracia, PE
99 Glendale St, Easthampton 527-5290
Type of Building:
Dwelling No.of Bedrooms
Other Type of Building
Other Fixtures
3
Garbage Grinder Q0
No per Persons
Showers( ) Cafeteria( )
Design Flow 518 gallons per day. Calculated daily flow 495 gallons
Plan Date October 11 . 1999
Title
Yu •S•—••
Description of Soil
Number of sheets
Revision Date
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the af edescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
)(Signed
Application Approved by
Date
Date /0 /f-55
Application Disapproved for the following reasons
Permit No Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( )or repaired).replaced ( )on
by for
at has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE Inspector
i
Address
NORTHAMPTON BOARD OF HEALTH
PERCOLATION TEST DATA
Owner Engineer/Sanitarian
Lot #
Date
Perc Rate v--min/in
Depth to water -
min/in
min/in
min/in
Sketch of Lot w/ Location of Test Holes
Witness Fee Witnessed by
NORTHAMPTON BOARD OF HEALTH
PERCOLATION TEST DATA
A d d r e s s
Lot if
7/ifs- 4i *
Date
/701A) 14
Owner
8
sifts
EngineerySa%itarian
qtly
Sat mw w
Pere Rate //, -5min/in min/in
Depth to water NpAJC.
/1/0A/C--
- - - - -
min/in
iVoNe-
min/in
/JiaAla
^(.
0-3
a- 9
Sketch of Lot w/ Location of Test Holes
Witness Fee
Witnessed by