Misc. Septic Application 1 ERE APPIICABLE
CHECK OR FILL IN
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratinu fur Elinpnsat Marks Qinustrurtinu ljermit
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at:
raum.Address or La No
owner
Adder,
IInstaller Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow
Septic Tank—Liquid capacity / t
Disposal Trench—No.
gallons per person per day. Total daily flow
gallons Length Width Diameter
Width Total Length
Seepage Pit No .. Diameter Depth below inlet
Other Distribution box (� Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
gallons.
Depth
Total leaching area sq.ft.
Total leaching area 6 0 0 sq. ft.
Date
Depth to ground water
Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has Wen issued by the board of health.-
Signed'_ j. Va-1 . it$1-
Application Approved By
Date
Application Disapproved for the following reasons'
Permit No Issued
Date
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Tertifirnte of @lumplianre
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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE
Oispnsnl iHi nrks Qinnstrurtinn timid
Permission is hereby granted -
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No �-T ..
Street
as shown on the application for Disposal Works Construction Permit No Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of x®l�
2c0 Jackson Street
Northampton,Mass.
June 2",1963
City of Northampton
Board of Health
City Hall,
Main Street,
Northampton,Mass.
Attention of Plumbing Inspector
Gentlemen:
Enclosed are the results of the percolation testa performed by me
on the property of Mr.Donald Wade on Chesterfield Road, Leeds. These holes
were dug according to the State regulatlons.The three holes were dug in a
triangular form,two of them were 21-6" deep and the third 21-6" deep.
They were located about 40 feet in front of the foundation.
Hole +1
12" water level maintained for 30 minutes
9" to 6" level took 30 minutes
6" to 3" " 42 11 or 14 minutes per inch.
Hole #2
12" water level maintained for 30 minutes.
9e to 6" level took 30 minutes
6" to 3" u ° 46 " or 16 minutes per inch
Hole +3 indicated heavy soil of stone,loam,orgenic material
some send and granular material around the four foot level.
Very
ruly yours,
) /4J .
Registered Civil Engineer