489 Title 5 Application/Permits 1966, 1980 PERCOLATION TEST(S)
Time: J Time:
Observation Hole #1 Observation Hole #2
Depth of Perc �1 Depth of Perc
Start Pre-soak I ` I 0 Start Pre-soak
End Pre-soak I a End Pre-soak
Time at 12" / Time at 17
Time at 9" Time at 9°
Time at 6" 39 Time at 6"
Time(9"-6") 11,( Time(9"-6")
Rate Min./Inch 1 ) Rate Min./Inch
'minimum of 1 percolation test must be performed in both the primary area AND reserve area.
• •
Performed by - Performed by
Witnessed by I Witnessed by
Comments:
NORTHAMPTON BOARD of HEALTH- Title 5- Site Review
Location Address or Lot# �/q
(J 6 I
i Owner J
a q y�-. „
_sk
Date /,,I
w �3 ��
Time
Soi Color
(Mensal!)
Owner's
Address
1 I , p r
w "�`�
�.
I c_k1,.0 -A-..c— -
a,Engineer
Weather Phone# Sf� y/
Land Use
.E (
�c�
% lope
Surface Stones
Landform
y3
Ve•etation
Distances
Drinking Water Well
Start Time
Slop Time
feet Property Line
feet
Posilon on Landscape(
Open Water Body
ketch on the back)
feet
Possible Wet Area
feet
Drainage Way
feet Other
feet
DEEP OBSERVATION HOLE LOG'
Deep Hole ft: *MINIMUM OF IWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface(Indies)
Soil Homan
Soil Texture
(USDA)
Soi Color
(Mensal!)
Soil
Molding
Other
(avenge,Stones,Boulders,Consistency.%Grave9
H- f
Other
(Share,Stones,Boulders,Consistency,%Gravel)
�-
.E (
�c�
10 1w'
4 i ,
>C„
It yu
c
y3
Parent Mahal(geologic) I I Depth to Bedrock I /
Depth to groundwater. Standing Water in the Hole
I Weeping from Pit Face 'I
Estimated Seasonal High Ground Water
I Depth to Bedrock I
DEEP OBSERVATION HOLE LOG*
Deep Hole#: - *MINIMUM OF IWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface(Indies)
Soil Horizon
Soil Texture
(USDA)
Soil Cold
(Munsell)
Soil
Mottling
Other
(Share,Stones,Boulders,Consistency,%Gravel)
7
\I j
\_Lip/
C
' ,
�`
5v
c
35
,° ;i
�.
� �
I
I
Parent Matrial(g eolith k) I
I Depth to Bedrock I
\ U
Depth to groundwater. Standing Water in the Hole
I Weeping from Pit
Face I
ID's_
Esdm ted Seasonal High Ground Water
-IECK OR FILL IN WHERE APFL1UAULt
No...Q..f t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEE
U
Application for Disposal dories wnnstrnrtion hermit
Application is hereby made for a Permit to Construct ( ) or Repair (s ) an Indic idual Sewage Disposal
System at:
neda
or Lot No.
Address
In In - ...T 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
..
Nature of Repairs or Alterations—Answer when applicable-._t✓%a�� ..(;_pC�QLL[�.ZR�� tot- - '.__....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of nil hp 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha been issued the bgaid of icalth.
Signed j �,••-"'a ga�ea'� � �nDaeS,
Application Approved By S iii ... ( Q -.- I T./-Q1�-1
note
Application Disapproved for the following reason•
Permit No ?re) Issued
/y (/Datat�e
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrrtifiratr of hinmplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Installer
at
has been installed in accordance with the provisions of TI 5 of The State Sanitary 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
CHECK OR FILL IN WHERE APPLICABLE
NO FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
ApplAration far Binpunal ltlurb Gattartutimt Vrrmit
Application is hereby made for a Permit to Construct
System at:
Location-A ddrc.ss
Owner
• Installer
Type of Building
Dwelling— No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity gallons
Disposal Trench—No. Width
Seepage Pit No Diameter
) or Repair (r<an Individual Sewage Disposal
or Lot No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Dosing
Performed by
minutes per inch
minutes per inch
Length Width Diameter Depth
Total Length Total leaching area
Depth below inlet Total leaching area sq. ft.
tank ( )
Date
Depth of Test Pit Depth to ground water
Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable , ' • — • ' 'Tr? 0/.. 2- .4214,fag
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Tin.: 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
Signed 1 t
Application Approved By
Application Disapproved for the following reasons
DatC
I I,iez
Date
Permit No —
Date
Issued_
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Crtifirtttr of Tnmplinnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
)
Installer
at
has been installed in accordance with the provisions of TIT-. 5 of The State Sanitary 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
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No FEE.
flinpnnnl Itivritn Qtnnntrurtinn 11rrmit
is hereby granted; •
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No ) - Street
as shown on the application for Disposal Works Construction Permit No Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health
k
NNt
Cri
1.____ 940
.
r C ti Zki
-o
o f_
ti
II
t3 ti . .
.�
4
-4
a
No.P
THE COMMONWEALTH OF MASSACHUSETTS
/7 BOARD OF HEALTH
Application for Disposal Works Qlrnsinuiinn Patna
Application is hereby made for a Permit to Construct on f(
System at:
Fee
) an Individual Sewage Disposal
Itig /the* / ricz•SzArriw 1.5.5
Address
Inst
Type of Building 7n 4(e aiet
Dwelling--No. of Bedroom_
Other—Type of Buildin
Other fixtures
Design Flow �'� gallons
Septic Tank—Liquid_ c
Disposal Trench—No—. -A1
Seepage Pit No Diameter
Other Distribution box (X) Dosin g
Percolation Test Results Performed by
Test Pit No. 1.7t.. minutes per
Test Pit No. 2
!gallons
4:C/r Expansion t ( ) Garbage
No. of persons Showers ( )
i8
Address
Size Lot
per personaiday. Total
Length_ 1 - Width
Total Lena h..
Depth below inlet
Grinder ( )
Cafeteria ( )
gallonssiT
Diamete
Width._'_/i Depth_..
___ Total leaching area_. .sq. ft 3 e�X
Total leaching area sq. ft.
Date._0 C-/C)
epth of Test Pit. ' Depth to ground wate
Depth of Test Pit Depth to ground
north: of c.4,59
r
Description of Soil .
minutes pe
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 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
Application Approved By
Application Disapproved for the following reasons-
Permit No
Issued
Date
Date
Date
Date
No.:f
THE COMMONWEALTH OF MASSACHUSETTS
FEE
Application age Disposal
System at:
BOARD OF HEALTH
- oF_. %. a
Application for i]ispusttl nrk &marut on Permit
tion is hereby made for
Permit to Construct ) or Repair ( ) an Individual Sew
'`.A44r s- or Lot No.
- - Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder ( )
Other-Type of Building No. of persons % Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow -s Q gallons per person per day. Total daily flow , 0 0 gallons.
Septic Tank—Liquid capacit 01 gallons 0 gallons Length Width Diameter Depth
Disposal Trench— No. ; ....... Width Total Length Total leaching area 0 0 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft
Other Distribution box ( ) Dosing to ( /f )
Percolation Test Result Performed by l' 11_Ltr'- ' tr, t Date
Test Pit No. I minutes per inch Deleth of Test Pit....J,r2 t Depth to ground water
Test Pit No. 9 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
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 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
Application Approved By x;A�4 t may.... f"Aar) c- — -172 e e
Application Disapproved for the following reasons--7
r-Y.t '.cam.
J a
Permit No
Issued.
3 /9G !
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF /I tei
(trrtifirnte of Ctotnpliaurr
THIS IS TO CE,I2TI% ', That the Individual Sewage Disposal System constructed (E ) or Repaired ( )
by .H7,4-(
/ crht�
1 ( j 7/ F / �9 .. i1 etziler
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No 1 ' y dated '( i 7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
N
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF_.71 elLT �' &a'!
�inpnuttl orks (innntnrti
tntt Permit
Permission'a erehy granted
to Construct (/ ) or Repair ( ) an_Individual.Sewage Disposal Systeifi
at No '—f
Street
as shown on the application for Disposal Works Construction Perwitrio.—J-`.-j Dated .),Ate-el ` I
j G ,{e(erk I
Board of Ream'
DATE I,' r I ,(/I
FORM 1255 -HOBBS & WARREN. INC-. PUBLISHERS
FEE