Misc. Septic Application 10 No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
City OF Northampton
Application for Disposal
FRB
arks Olonotntrtion lfivrmtt
Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
Chesterfield Road
Location•Address
John Scanlan
Owner
or Lot No.
Address
Installer Address
Type of Building Size Lot 13 A .154Xidef
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder (x )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Depth
Disposal Trench—No. Width Total Length
Seepage Pit No Diameter Depth below inle
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by R....Brazeaa - ituntley...Engin-.... Data Spril..25.....19.7.5
#3 Test Pit No. 1 .7...Q minutes per inch Depth of Test Pit 42 Cl" Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit 7.1 Cr Depth to ground w
Diameter
Total leaching area sq. ft.
Total leaching area sq. ft.
Description of Soil 222...CITS.,....12.z.12.-Silt..zaaablaleg.t...ganciy..
Nature of Repairs or Alterations—Answer when applicable
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Agreement:
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The undersigned agrees to install the aforedescribed Individual Sewage Disposal System m accordan e 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 been issued by the board of health.
Application Approved By
Signed
Application Disapproved for the following reasons
Permit No
Date
Date
Date
Issued
Date