84 Title 5 Application/Permits 1985 CHECK OR FILL IN WHERE APPLICABLE
No j1 • 7S
THE COMMONWEALTH OF MASSACHUSETTS
FEE 71,/(9
BOARD OF HEALTH
CITY OFNORTHAproTCN1
1ppliratinn fur Binpu,uttl 1lUurku (!Iuiwtrurtintt lrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal
system at: Q...1 /
cc �e .Address i or Lot No.
Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
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 Diameter Depth
Disposal Trench—.-No. Width Total Length Total leaching area 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
Description of Soil
Nat of R airs qr Altemti s—A s er hen a le- ... _ -
- . ..%y
Agreement:
The tinders gned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigne further agrees not to place the system in
operation until a Certificate of Compliance has bra • sued b/he n • health.
Signe. _.. :. ... S
Application Approved By
Application Disapproved for the following
reasons —
f
Permit No SW 7.]
Issued
LW Date
Er
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY OE NORTHAMPTON
trrtifirtttr of Qlomptiaurr
THIS IS C$$RTIFI hattife Insliiii4ual Sewage Disposal System constructed ( ) or Repaired U-
at
4-f kV f_.4--4s ^ C stiller
--
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 35< if 5- dated ;f/.._6.7. .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FILNCTI Si SATISFACTORY.
, / / 1/ S - t
DATE f Inspector j..
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY or NORTHAMPTON
flin}TOnttl Ant Qlpuntrixriio rmii
Permission is hereby granted
FEE f0 d
to Constrict ( ) or Re r 4/) an Individual Sewage DissoAt System
at No s"(� b V- t
Street i / < , tC
as shown on the application for Disposal Works Construction Permit Nq.• ._1/ - Dated'`/` 16 J'
hoard of Health
DATE
C J
FORM 1255 A. M. SULKIN. INC.. BOSTON