39 application 1987 CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town OF Northampton
Applirtttion for flinpastti
Hi
arks Cnountrurtion hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Louaixy-.Way.--liortbamat011,-_H6. Q1060
Location-Address or Lot No.
Karen L.rkia 18 Laurel Rd„ Northampton, MA._...._._.
Owner Address
Installer Address
Type of Building Size Lot O.rgp...Ag.....
Dwelling—No. of Bedrooms 4 Expansion Attic ( ) Garbage Grinder ( X)
Other—Type of Building No. of persons 8 Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 55 gallons per person per day. Total daily flow 440 gallons.
Septic Tank-Liquid capacity 1500gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No 1 fAafIDxat..15.7x1$' Depth below inlet .31/2' Total leaching capacity 776 gal.
Other Distribution box ( ) Dosing tank ( ) / ; `-
Percolation Test Results Performed by RPB..of. r
A ate ..Huntley Date ./ n '
Test Pit No. 1 2 minutes per inch Depth of Test Pit 7 Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
See attached plan.
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 TITLE 5 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. i
Signed
i/1
Application Approved By
Date
Application Disapproved for the following reasons
Permit No Issued ' r
Dau
Date
b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifirtttr of Tampliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Installer
at
Sanitary been installed in accordance with the provisions of TITLE 5 of The State San Y 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
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEALTH
y .. .. ..
OF .4%.
Uispoottl rh orko @innotrnrtinn f rrmit
Permission is hereby granted
to Construct ( ) or Repair ( ) anIndividual Sewage Disposal System
at No
FEE
Street
as shown on the application for Disposal Works Construction Permit No Dated
DATE
FORM 1255 HOBBS & WARREN. PUBLISHERS
Board of Health