Lot 12 Septic Application CHECK OR BILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
City. OF Northampton
1 ppliratinn fur £Ii%pn.snl Mirka (ll nsiruninn Vrrmit
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
Lot 12 , Claire Avenue Extension
Location-Address
$ar'97d._K Iitzaerald
Owner
m,mca.-
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons
Septic Tank—Liquid capacity gallons
Disposal Trench— No. Width
Seepage Pit No Diameter
No
Lot No.
340 2r.idreEQaO Cjr_y
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder (
of persons Showers ( ) — Cafeteria ( )
Other Distribution box
Percolation Test Results
Test Pit No. 1 7
Test Pit No. 2
Description of Soil
per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by .Alm er Htm t l ey,
minutes per inch Depth of Test Pit 36!!
minutes per inch Depth of Test Pit
Jr
Medium sand, some silt, pebbles
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance et
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.
Signed .1p-z9-65
Dare
Date 10-14-65
Depth to ground water None.
Depth to ground water
Application Approved By
Application Disapproved for the following reasons-
�r��Permit No
Date
Date
Issued
Date