275 Septic Application Permit & Compliance THE COMMONWEALTH OF MASSACHUSETTS
NORTHsant:TR / MASSACHUSETTS
natation for !CSpuzat !System Construction Permit
FEE 71 D.c.9
Application is hereby made for a Permit to Construct ( ) o
c')an On-she Sewage Dispo al System at:
Location Address or Lot No.
&' s Mfi rpl&LO sr,
A/uRT ri-mpTDN, met
Owner's Name,Address and Tel.No.
Ro mazy Kurd
205 H/3TF/a7.0 6,7
5844 74.04-
Installer's Name,Address,and TcLNo_
/(ggLrs rFcpu'4917/1C
Designers Name.Address and Tel.No.
Type of Building:
Dwelling No. of Bedrooms 3 Garbage Grinder(so<
Other Type of Building 5/N11,. FRM.9 No per Persons 4, Showers ( ) Cafeteria
Other Fixtures
Design Flow
Plan Date
Title
Description of Soil
gallons per day.
Calculated daily flow
Number of sheets
gallons
Revision Date
Nature of Repairs or Alterations(Answer when applicable)R(A[.4 & 906 &rALL0A1 5�C i7 Tut ONLY
00 •L_/ • L - • :Ga• OA ,'t • �: t
To ',Rowing n .SrHBLE LsvaL BASE
• rt.
Date last inspected'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been i� ed by t is Board of Health.
Signed —r a l._
£,
A s.
Date
�
�i1 �ll
Application Approved by _-° :�_�.r�_/-! /' Date o 1 g--s%
Application Disapproved for the folio
ng reasons
Permit No 3 3 -16 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
C/T/ OF /YU' - ij .MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( )or repaired'
y
repair� ed(4 on
r.- f /(-7/ -
(-7G- ry _ for 67' �rA
has been constructed in
at . Z >5
accordance with the provisions of Title 5 and the for system col System
one Construction c Permit No 39 s 9G dated
low-
Use of this system a conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the sy
Certificate expires on
DATE /2 7' X .
Inspecto
ill function as designed. This
THE COMMONWE LTH OF MASSACHUSETTS
MASSACHUSETTS
spoon' *stem Construction Permit
Permission is hereby grand to
0C -4 Ku TAh'
to con ( ) 'r( an On site Sewpge System located at
construct
A
o repat -
E -Cbt s1A ( i dJFU)
e
FEE
a-
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
DATE h — 7 7E
FORM 1255 Rev.955 AM.SULKIN CO-BOSTON.MA
Approved by
r
��—
'
• }--
` r .
THE COMMONWEALTH OF MASSACHUSETTS
NORTHAMPTON MASSACHUSETTS
FEE
Application for Disposal §ystem &Instruction permit
Application is hereby made for a Permit to Construct( )or Repair( X)an On-site Sewage Disposal System at:
Location Addrets or 1M No.
Dull%Name.Address,ud Tel.No.
BOB KUTA
584-7409
275 HATFIELD STREET
InslJkla Name.Address.and Tel.No.
CLEAN SEPTIC,INC.
4sigpn s Name.Address,and Tel.No.
[CEA]Civil Engineering Associates
10 Crane Avenue
East Longmeadow.MA 01028 Tel:(413)525-2874
Type of Building:
Dwelling No.of Bedrooms 2
Other Type of Building
Garbage Grinder( _)
No per Persons
Showers( ) Cafeteria( )
Other Fixtures
Design Flow 222 gallons per day. Calculated daily flow 220 gallons.
Plan Date 09/18/02 Number of sheets 4 Revision Date
Title Proposed Sewage Disposal System Prepared For: 275 HATFIELD STREET NORTHAMPTON
Description of Soil See Attached Soil Profile
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
` Signed
Application Approved by
Date
Date
Application Disapproved for the following reasons
Permit No a 3-0 "")-- Date Issued .S • j5 aOO
THE C MMONWEAL OF MASSACHUSETTS
MASSACHUSETTS
(Rertifira r of (7omplinnrr
Sewal Disposal System installed(„)orreppjrei/_{Fplaced( on
for OOU K V--�1s
has been constructed in
5 and the for Disposal System Construction Permit No. aS— O dated
Use of this system is conditioned on compliance with the previsions set forth below:
7' I CERTIFY, t the On-si
b by
at
accordance accordanceitevrtpprs of Tit
-s
The issuance of this c e r t i f i c a� not rnled as a guarantee that the ill function as esigaed. This
Certificate expires on
a 0
DATE e a--' Inspector I tilt,-/.
•
as•
FORM 3A • CERTIFICATE OP COMIPLIA:4
vat-3-0-2_ „ c
COMMONWEALTH OF MASSACHUSETTS
Board of Health, tVaili H ^Y7iifi , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Components) Q2omplete System
The undersigned hereby certify that the Sewage Disposal System;
Constructed I ), Repaired IA, Upgraded I I, Abandoned 1)
w• CLenIU Sri}PLC c.
27 S pm-mit LQ cit.
has been installed in accordance with the provisions of 310 CMR 13.00 (Title 5) and the
approved design plans/es-built plans relating to eppiiation No.
dated 9pelo a Approved Design Flowaaa lgpol
Designer: i,-/ �%n (CEA) Inspector
Date 9-Z POE
The issuance of this permit shall not be construed as a guarantee that the system will
function as designed.
Swijjpe o y , 11,t� U
00, ••110140 r0ew IN