380 Septic Applications & Permits ,1. I
It
COMMONWEALTH OF MASSACHUSETTS
Board of Health, NORTHAMPTON MA.
FEE 2(2
APPLICATION Ff)R DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(Vc Upgrade V Abandon( ) - 0 Complete Syst m Individual Compone
.Llrt c�E e ra, u rh r/
Location SS CW IGw RP
OWnerSSame/ -+rte=1 4 di./
Map'Pais el*
Address 3 CHES'ieW RD
Telephone# /3 �s-- 7499'
Lot*
LrwIler's Name q -/ gltNom A 6M+ J � u�
i (
D Designees Naneir A 07H mA6„uN u /es
Address 3 i f/ , l✓ /f.-_ , /r , ,,;,
'Add'es` 90 m&o /11-6UE R&- W H>4l
'1-elephone* llt j tp -` = 1 3- a
1 lephone# (413) 4-2.7 - ¶2J• / P
Ts-pc of Building
Dwelling-No_of Redi ooms
Other-Type of Building
Other Fivtl ees
5/,v6-AE
114-
Lot Size
sq.
.6 C
No.of persons Showers /Cafeteria( )
Design Flow(min regaured) 4 V O gpd Calculated design How 45
4
Plan: Dam /0 0 - 1 p Number of sheets
itle ' • , of 'go ' 54) ' wA
"Sri iIQ
Description of Soil(s
Soil Evaluator Form No Name of Soil Evaluator Z IV 5E Date of Evaluation /0 2
, Aletchu ti p .l- AI.
DESCRIPTION OF REPAIRS OR ALTERATIONS REOLAC� �A)Lil�i(Cs 5u4SuRFRC� SEwaKC:
Design flow prrnided
Revr.a m Date
c
Solt-
gpd
D/5Oo 5fC 5yst,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es to not to pla e the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Xigued _ .tea, a , Date far - ?” 97
Inspections
COMMONW EALTTIOF-AMASSACITIISFTTS
Board of forlii >j/j I4M 7741/t/. L4
[PT1FICATE OF [01 PLIANCF
FEE
The uncle)signed hereby ccrdf/e that the Sewage Disposal System: Consino:ted O,RepairedX.Upgraded ( ).Abandnned ( )
bf. %!0//(P/ p /l/il�ad<-' U�2. 1' Ff«�
has been t lI d in oydance with the prosisions of 310 CMR 15.00 (Td 5) and the approved design plans/as-h 'It I lams relating to
PI licat No L dated /,1 — 9.-527 Approved Design Flow 5� (gpd)K ii
It tape '" ( NCO ri t C.,
D sig 7FN /ilA4U/A(i/ 4 InspecInc F / ylf X Date: r-.?�,,<-7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
i s,
/
COMMONWEALTH OF MASSACHUSETTS
finard n�/lea(th, 72ila.44.Y%
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hcreby_graaLjJ77 ted.try+Cons t}'uct( )
J ( ftii 6-EL%^-,�.C<
at
air( 'r Lipgrade(
rtt:
c3-19c
Abandon( ) an individual sewage disposal system
as described in the application for
4 /
Disposal System Construction Pe mit So. - dated
Provided: Construction shall be completed within three years of the date of this,peirryR. local con ions must be stet
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Farm 1255 ee% 596 Am.swam Co.Boston MA Date ' BoardofHe--alth
IN WHERE APPLICABLE
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6 VNatur Rey/firs or/Alterations-Answer whep appli ble
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No-.y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HBALTH
OF Ai/A <-'N/: �-1
.Appliratinn1fnr Elispnsttl hcnrks OlzMatrnrtinn remit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
y�FjJ�j�32 CLL(t A. ;¢r (
lion Address •
11406,•••••• or Lot Na.
4/:..\•=d—
I,/ _—{ Address
Type of Building
Dwelling—No. of Bedrooms Expansion Attic (
Other—Type of Building No. of persons
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity./St1gallons Length Width Diameter Depth
Disposal Trench—No Width Total Length Total leaching arm sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water__.__..............
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Install
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Description of Soil
Agreement:
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 ha„vbeen issued by the board of health.
Application Approved By +: ?�%i^^
Application Disapproved for the following reasons'
' , f f1
czyr
c
Permit No
Issued
THE COMMONWEALTH OF MASSACHUSETTS
t
/ BOARD OF HEALTH
f r OF
Qlrrtifiratr of Qtvmpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (y)
by r/u. 6./...:.n .6 N._ra...,ti.,.: :: St •• :
at
has been installed in accordance with the prbyisions of TITLE 5 of The State Sanitary Code s de ribed in the
application for Disposal Works Construction Permit No JG it.,— dated I//.1. ..f-Ls
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RA E THAT THE
SYSTEM WILL,`F�UNCTION SATISFACTORY. -�
DATE lY .1 / 21. x,,.1.7:..4. W�.'�.
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Street
.� i
Uispns . n pri (¢nnstrttrtinjt lrrmit
Permission is hereby granted...-. 44" e2.._,r�-.t,.C. -. - ! System"-w5""gi
to Construct ( or Repair j1L/) ary Indivir�al Si7ge Die( l Sys
at No 3-V:4) Ye'._.._
e
Fmt 3�
(( Svat '�^-<
as shown on the application for Disposal Works Construction Permit np� .�j/Y-`_. .r,D-gac..2
j 1
, L44 ? 1..f91—'
DATE
FORM 1255 A. M. SULKIM. INC.. BOSTON
d of Health