776 Title 5 Applications/Permits 1999, 2003, Soil Suitability Records, Pumping Record 2016 Commonwealth of Massachusetts
City/Town of Northampton
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
iform4.doc•11/12
2.
System Location:
776 N King Street
Address
C y/To own pt nyrt
System Owner:
Sandri Sunoco
Name
Address Of different from location)
City/Town
B. Pumping Record
MA
State
01360
Zip Code
State Zip Code
Telephone Number
1. Date of Pumping April 1, 2016
Date 2_ Quantity Pumped:
3. Component: ❑ Cesspool(s) 21 Septic Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
Amberlyn Beausoleil
Name
Bostley Sanitary Service, Inc.
Company
1.500
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
7. Location where contents were disposed:
Montague Wastewater Treatment Plant
Signature f Hauls
Vehicle License Number
April 1, 2016
Date
Signature f Receiving Facility or attach facility receipt) Date
System Pumping Record•Page 1 of 1
No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
Date: GA)/ 99
Commonwealth of Massachusetts
k)O Fit)Qn9 assachusefts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By: ni iChae..) Date e: 6//i9
Witnessed By: Pc+e r- rn et)) la.ln'l.)
�i Kam s 966 Cam@ ma r4-11 Kt>niSf
yew construction ❑ Repair gj
o - «�. Fi 1St x Real -y
AI OIaS PO /box Sd)to
r.kWuer Wo CO 1YX
Q67i17/-Ba,to
Office Review
Published Soil Survey Available: No ❑ Yes ❑
Year Published Publication Scale
Drainage Class Soil Limitations
Surficial Geologic Report Available: No U Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No Oyes ❑
Within 500 year flood boundary No Dyes ❑
Within 100 year flood boundary No ❑Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Soil Map Unit
Current Water Reiource Conditions (USGS): Month
Range :Above Normal ❑Normal ❑Below Normal ❑
Other References Reviewed:
DEP APPROVED FORM•13107/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
FORM 12 - PERCOLATION TEST
Location Address or Lot No. /&7& i) /UCJIIi V{my )6•
COMMONWEALTH OF MASSACHUSETTS
Vonti in l) , Massachusetts
Percolation Test'
Date: 6/1/?9 Time.
atin N9
,m7d__
��
Observation Hole #
P_ 1
Depth of Pero -
Co "
Start Pre-soak
I ( ; as
'End Pre-soak
) ( a Yo
Time at12"
1 ( , 14 a .
Time at 9"
H .• 5-0
Time at 6"
h9 05
Time (9"-6")
(3
Rate Min./Inch
5'm6.\-))Pilch
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed Vg. Site Failed ❑
Performed By: WIC h OL CuJ(9? L
(�� l
Witnessed By: Y-PTILL- MCA\cl/IL.)
Comments: .__._...... ......._., -T—.---- -
'PEP MFROVBO FORM-r1/O7a5
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 07053
1413/ 586-7200
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. 76'(D(v) 'VO 141,03 vt
On-site Review
Deep Hole Number (*c Date:///g 9
Location (identify on sit plan))1�S Cc- cLav
Land Use ._WSOd,S tr-F-Ir`4S11ooRe (%)O 07
Vegetation -i-r-e P..S 9-b- `-,7af--`/-
Landform
Position on landscape (sketch on the back) SC C. Sg.,e./ Chi.9)a
Distances from:
Open Water Body 0 feet Drainage way ' 0 feet
Possible Wet Area i /00 feet Property Line 2 LO foot
Drinking Water Well >100 feet Other
rr
O
Surface Stones -ECU-) ape— C G
Time:..mOCN i 9J q
JJ 1
Weather
DEEP OBSERVATION HOLE LOG' t_
Depth from
Surface(Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
IMunsell)
Soil
Mottling
Other
(Structure.Stones,Boulders.Consistency. %
Graven
0_ LIa9/
Lid"- NW'
F.
C
=
S G Aid
L
o7SVRSA
L
xuc/A-e.
Assorttd top SoiI )
Subsoil J tat/l
0 - /f
3(0'/- /?O"
1=
C
Z
Sc0ci
i.J Vas,
L
AIO/oC.
ASsori-e d tbpsot I/
SUbso1 1 r- tai 11
PDSAL
REA
MINIMUM,OF Z HOLES HEUUInzi}AT EOCRY PROPOSED D S �. i/ /,
Parent Material(geologic) (mt. , t• 1Q r;->h -� T DepthtoBedrock:? 1LILI n� (a.V ,
Depth to Groundwater: Standing Water in the Hole: t J RLI I t )R Weeping from Pit Face:D atL D R. Y
) I/
Estimated Seasonal High Ground Water: � 11-11-1 I c�iJ
DEP APPROVED FORM. 12/0195
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. 1647 et) A )(n l0%
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole ... inches
❑ Depth weeping from side of observation hole inches
• Depth to soil-mottles >Jae inches
❑ Ground water adjustment feet
Index Well Number Reading .. Index.well level
.....,_......... 9 Date n
Adjustment factor Adjusted ground water level
Depth of Naturally Occurring Pervious Material
naturally Does at least four feet of
observed throughout the area proposed cfor�the pervious it abso ption material system?in aIf.F as
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on I I- 9U (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above analysis
w sc
described in performed by me ist 7 consistent with the required training, expertise and experience
DEP APPROVED FORM•.11/01/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
FORM 11 - SOIL EVALUATOR FC
Page 3
Location Address or Lot No. /�n «/) A )(DM 1(,4y
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole inches
❑ Depth weeping from side of observation hole.. inches
0 Depth to soil mottles >/20 inches
❑ Ground water adjustment feet
Index Well Number Reading Date _.. Index well level
Adjustment factor Adjusted ground water level
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all are
observed throughout the area proposed for the soil absorption system? V 12,7)
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on I /' C4 (date) I have passed the soil evaluator examinatio
approved by the Department of Environmental Protection and that the above analyse
was performed by me consistent with the required training, expertise and experienc
described in 310 CMR 15.017.
DEP APPROVED FORM.11/07/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
/4131 586-7200
FORM 12 - PERCOLATION TEST
Location Address or Lot No.9 47(CCI) A0001i1 V71C% :Si='
COMMONWEALTH OF MASSACHUSETTS
vor -t7 oin p-1-00 , Massachusetts
Minimum of 1 pe colation test must be performed in both the primary area AND
reserve area.
Site Passed M, Site Failed ❑
Performed By: m l C h (/ cuu
Witnessed By: (0--(7t5 LL f 0tH\ Pfli
Comments:
DEP APPROVED FORM-12/07/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
Percolation Test*
Date: 6a/// ? 7 Time:,
/7 id-..mot71(0y
Observation Hole X
�_-
Depth of Pere
Co ! "
Start Pre-soak
1 I ■ 3.
End Pre-soak
) 12` Y
Time at 12"
t 11 9
Time at 9"
I I rl
Time at 6"
I� os�
Time 19"-61
13
Rate Min./Inch
5mVIInC, I-
Minimum of 1 pe colation test must be performed in both the primary area AND
reserve area.
Site Passed M, Site Failed ❑
Performed By: m l C h (/ cuu
Witnessed By: (0--(7t5 LL f 0tH\ Pfli
Comments:
DEP APPROVED FORM-12/07/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
FORM 11 - SOIL EVALUATOR
Pag
Location Address or Lot Igo. / iC�nirI) lt.)U f/i 5 f.
Oil-site Review
Deep Hole Number I '+a Date:(P///9 (/) Time: /170fnJIr
Location (identify on sit plan) S CC q(LL' IC,
Land Use Woods riciikg Slope (II%)0 M Surface Stones -'ew
Vegetation fr e- C�
-e S - k S ),.._5,-
Landform
Position on landscape (sketch on the back) St f
Distances from: Se,-P 1 c h / ph;
Weather
Open Water Body • 100 feet
Possible Wet Area >IDO feet
Drinking Water Well >100 feet
Drainage way >-S-O
Property Line T l U
Other
feet
feet
DEEP OBSERVATION HOLE LOG.
S2
Depth from
Surface(Inches/
Soil Horizon
Mottling
Other
(Structure, Stones,Boulders, Consistency,
Grave»
ASSorlyd 1430; (
sf( bsc / j6711
Fl55orir d 1pso1 i
SL bsofl v ill
• . rlr,a
•a at • r .
Parent Material(geologic) C r'i-( t I1
Depth taG t� DepthtoBedrock: = lLf �r lap"
d t Standing Water in the Hole t tS\I bR\I
Estimated Seasonal High Ground Water: ILI Weeping from Pit Face: \_r T D I t
1 '�YLLiY
DEP APPROVED FORM-12/0735
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
1413) 586-7200
No.
FORM II - SOIL EVALUATOR FORM
Page I of 3
Date: 6/L)/ 99
Commonwealth of Massachusetts
l�GFAO yn assachusetts
soil Suitability Assessment for On-site Sewage Disposal
Date: Qi/99
Performed By
Witnessed By.
111 chae ) LCxL?■8 C-
e e r fin cf lIcun■J
9r0, Ci') Nort Kc 112 $-
Yew construction ❑ Repair 0
a.....w�. F rst K Reril, ')'y
� .b Po 3DX 8c�llc
7e�kPy*. , Gun CO ,TX 00/11-,S�)(p
Office Review
Published Soil Survey Available: No ❑ Yes ❑
Year Published Publication Scale
Drainage Class Soil Limitations
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit)
Soil Map Unit
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No Elves ❑
Within 500 year flood boundary No Oyes ❑
Within 100 year flood boundary No ❑Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions(USGS): Month
Range :Above Normal ❑Normal ❑Below Normal ❑
Other References Reviewed:
DEP APPROVED FORM• 12/07195
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
14131 586-7200
•
•
l LTuir[ 7^. i}^1- '1.-71 Ili t 1r'1.1
PERCOLATION TESTIS)
I lime: I I Time: I
Observation Hole #1 Observation Hole #2
Depth of Perc Depth of Perc
Start Pm-soak Start Pre-soak
End Pre-soak i 0 End Pre-soak
Time at 12' Time at 12"
lime at 9' / ' �� Time at 9'
Time at 6' Time at 6'
/ >- - O5
Time(9'—61 / Time(9'—6')
Rate Min./Inch Rate Min./Inch s 0,4"-----
) 'minimum of/percolation test must be performed in both the primary area AND reserve area.
Witnessed by I ry-� J�e.�I Witnessed by I I
WiNessed by li
Comments:
bil t19, -711 ,- -
1
l _
Address or Lot#
NORTHAMPTON BOARD of HEALTH- Title 5- Site Review
iC1.{ /l /
Owner
i9�'�y (
Time
�I ' �J
um
Wens)
L Owner's
Address
Soil Texture
(USDA)
r
I
Weather _ Phone IS
Ind Use
p—w.c r
%Slope
Surface Stones
rndfonn
i
V etation Start Time
ion on Landscape(skeet on the back)
Distances Stop Time
Water Body
feet
Drinking Water Well
feet Property Line
feet
Is Wet Area
feet
Drainage Way
feet Other
feet
DEEP OBSERVATION HOLE LOG*
le#: *MUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
tom
ties)
um
Wens)
Soil Hainan
Soil Texture
(USDA)
Sol
Motling
Sol Color
(Monet)
Sai
Molding
E
Other
(StL Lure,Stones,Boulders, %Gavel)
.0-
r
t
C
<�u � 1
-;
• � �,»
4/O x ,
Estimated Seasonal High Ground Water
Consistency,
/4i-4 a2TC4I '-h-,?'d-zA.C.
S,J-&oLJ 1 c-C
G
Va Ilia!(gedoge) I
I Depth to Bedrock
I
apt to groundwater Standing Water in he Hole
I
Weeping from Pit Face
Estimated Seasonal High Ground Water
DEEP OBSERVATION HOLE LOG'
Its#: *MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
tom
ties)
Sod Horizon
Sal Texture
(USDA)
Soil Color
(Munsd)
Sol
Motling
Other
(SWCWre,Stones,Barters,Consistency.%Gravel)
ov
E
5m---"
-5 `
/Jors
y , L C
Maeial(geologic) I I Depth to Bedrock
epth togmundwater Standing Water in the Hob
I Weeale from Pit Face
Estimated Seasonal High Ground Water
II Location Andreakor Lot it II
I Date 1 j
I
PERCOLATION TEST(S)
I Time: J I Time: 1 I
Observation Hole #1 Observation Hole #2
Depth of Perc Depth of Perc
Start Pre-soak Start Pre-soak
End Pre-soak End Pre-soak
Time at 12" Time at 12"
Time at 9" Time at 9"
Time at 6" Time at 6"
Time(9"-6") Time (9"-6")
Rate Min./Inch Rate Min./Inch
*minimum of 1 percolation test must be performed in both the primary area AND reserve area.
SITE I SITE . SITE I SITE
PASSED _ j FAILED,- ..._ /PASSED __ I FAILED _
Performed by I Performed by
Witnessed by I Witnessed by 1 i
Comments:
-2t/7 /
--
, ,
-
)
L._
-___-
,..__
----,--'
- — —
NORTHAMPTON BOARD of HEALTH— Title 5—Site Review
)le#:
ran
nches)
DEEP OBSERVATION HOLE LOG*
Jld OF TWO HOLES REOUIRED AT EVERY PROPOSED DISPOSAL ARE
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil Mottling
Other
(Structure,Stones,Boulders,Consistency,%Gravel)
(atonal(geologic) I
groundwater::Standing Wateriglhe$lole r�
timated Seasonal Htoh Ground Water
Hole#:
h from
(Inches)
I k'
Depth to Bedrock I j /
I,,,Weeping from PR Face
/ Gr
DEEP OBSERVATION HOLE LOG*
T.turoufd OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Soil Horizon
Soil Textur
(USDA)
C
Soil Color
(Munsell)
Soil Mottling
Other
(Structure,Stones,Boulders,Consistency,%Grave
it Materidl(geoIogid
B
ing
Pit Face
Es Sea sonalf±y71?.G
ENVIRONMENTAL FIELD SERVICES, INC.
P.O. BOX 518
LEEDS, MA 01053
1-413-586-7200
October 19, 1999
Board of Health
Town Offices
Northampton, MA 01060
re: Inspection of Septic System at Childs Lot, 766 North King Street
Dear Board:
On October 18, 1999, a representative from our office performed an inspection of
the septic system installation referenced above. The system was installed by Tom
Childs Excavating of Westhampton, MA.
Our representative found that the system is installed properly and in accordance
with our septic plan dated 10-10-99. The as-built locations of all system
components have been documented on the attached sketch.
This letter shall serve as Engineer and Installer Certification that the system was
installed in accordance with Title V and our approved system design. If there are
any questions, please contact our office.
I hereby certify that the above
T --V and • - ass r•ved septic
Sincerely yours,
0
ich. - J. vigne
Environmental Engineer
referenced system was installed in accordance with
design prepared by Environmental Field Services.
is r • •• 1 - • • u • • WS
Ids
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), am
9 �'
SEPTIC
TANK
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File F BP-2003-0888
APPLICANT/CONTACT PERSON THE O'LEARY COMPANY INC No-
ADDRESS/PHONE
P O BOX 377 (413)527-1360 ,1.--14 C Lt" 6 L I
PROPERTY LOCATION 766 NORTH KING ST
MAP 08 PARCEL 021 001 ZONE HB
THIS SECTION FOR OFFICIAL USE ONLY
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
W 514 tmE---
58S - 3"FT0
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T..eof Constructi on: CONSTRUCT 2 STORY MEDICAL BUILDING
New Construction
Non Structural interior renovations
Addition to Existing
Accesso ry Structure
Building Plans Included:
Owner/Statement or License 079899
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON T
INFOIATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Findin g Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW
Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
1A
S APPLICATION BASED ON
Permit from Conservation Commission
Permit from Elm Street C sion
Signature of� Budding OH'l
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
Permit from CB Architecture Committee
Date
g O
G p -. _ T 6e "Removed
Cloy And
VCNI TO Jr /01-STALLED LED AGOVE Loyal'
n .5an-
(se EDbE OF PAYED AREA �__ n o/ /h Clean af
(-sea A[fo-ched De[o;,� / Sand /lei 7. 0/. S,
/ .San./ai C.c/a, CH.R. S/c
/ / /502./7 lace Ah4+c%.eo'.J
/ /
//'
- ��
peoPO.3 ED /Sa
/ .3 EPT/c T.aNK
o C //
PNp�sED Soo G,.rLLON •�l
LEOP ST° P/T. •41.4 /
.•o OF S NE ALL ...49/20L/A/0 / / I �c
d� _ �in
Lass
/� /
f /
EX"-,T/NG
/ e, p.'/ - /0000
LINI
r
/ t' A: ;a/� 4 ... . I ; O/L SEPARA7/O�/
// tY � ' ' a ` M.dNNOLE W/7N
F / /
//'J hi'� I V p HEAVY OuTT 14'
' �' y FRAME ANO roVE.Q
/
• , L W
.� -� A _
/ / io --
THE COMMONWEALTH OF MASSACHUSETTS Ft
BOARD OF HEALTH
%0t, "J of A1nr+hGAJ
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
AI-wk.- on lot a Per it to(, ,.nur, IXI ac,,:ur I I t p,,ncw t I Ah,ndun 1 /(LmpleIe SC t -IndlluItaI(onponents
O66 ,Dorth K " , St
Join (97/ Ld__
I..,, an
Ownu A,am,
9ylau d, u)eSth p*n,-mn
- yn3n 0/0-39
c9
p{
�A VIScLjMPAJ nfl i i ,SPCUt4)
T��
NS/Witt n
'�'1
n can,, ��
UGifit.
o.,�r�. .
_ E3oXSlk� L2CCls mra rigs,_
ray.i„•�:
Iaapnane
pope of Building-
Dwelling—Nu.of Bedrooms
Dthcr—Type of ulding ,S2 ru (A__Slk:d1Dti No.of persons
Dther fixtures
Design Flow (min. required)1-i 51-0 gpd Calculated design flow Bpd Design flow provided( gpd
Plan: Date /0-I=1i -99 Number of sheets / Revision Date
rtle Sv la D1 OS(74. ciSf f Y C'
- h, /d 3
Description of Soills) 5o.e d - S SO Soil Evaluator Form No. Name of Soil Evaluator j(`rl V t s)Q. Date of Evaluation ,-( -9'9
DESCRIPTION OF REPAIRS OR ALTERATIONS U
Lot Size
Garbage Grinder
Shows
Sq.feet
I. Cafeteria ( )
The undersigned rees to insta I the a ove escribed Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 - - • rther a =s not to place ste In • -ration until a Certificate of Compliance has been issued by the Board of Health.
Signed
Inspections
Date
it /3 j
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
THE C MMONWEALTH OF MASSACHUSETTS
J.,
l -CN i1,4-" BOARD OF HEALTH
CERTIF'[CATE OF COMPLIANCE
Description or Work: k.Individual Component(s) 0
Complete System
The undersigned hereby certify that the Sewage Disposal System'.Constructed( 1-Repaired t 1.❑pgrad d( 1.Abandoned( )
by: -771,44 luiA P �/_q/•�' .A-- - —
[.r lac-(Spill
has been installed in accordance st(li the Pros nton' I f 310 t S1R 15.00 (lisle ')��"dro�ed Design approved
Flos plans/as-built
toa application No ?r/ dated- ' -
plans relating i, / r I • -
�4 L% ° t i r ..
Installer _Ti �'� c, r T / %���
-r� I /Zf2 5 Inspector ° e� `
Designer: Ln�l 7 ` ifi "'� ranee thanhe system will function as designed.
The issuance CERTIFICATE TIFIsATE OF shallnotI Aaonsnued os aDEP APPROVED FORM 5/96
calkFORM 3 - CERTIFICATE OF COMPLIANCE
ap3/>
THE COMMONWEALTH OF MASSACHUSETTS FEE /
'QOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
U�erade ( ) Abandon ( ) an individual sewage
Permission is hereby granted nted to CII siruct (f iRcp�IiJ ) �
as described
t
disposal system a t •, dated
in the application for Disposal System Construction Pe it No. --h ce/e oTc cmµ AN co ht he met
Provided: Constm'uction shall he completed within three scats of a _
-:yl Board of Health F/ I c —
Date ��
FORM 2 - D5CP DEP APPROVED FORM 5/96
ryBW j HOBBS&WARREN TM
FORM 1255 (REV 556)
PUBLISHERS-BOSTON
Us Aa
qa
ERL/TA
3014s
IS l
Ma
r r , /
)cationP/94lti19Pile. MqnL T 9/p,wT/A-/owner's
NayQ4Q/✓.(SAG N PailixAca
ap/Parcel#/(/ /LJ7n X/2' SyzeMT Address 1Z 73- Etizi 572-U T_4, .
,t# /i%0/N//h1/0j- %on/ Ai,455 Telephone#
DesignerName/ /1}m (S/ /W
/n
ddress 4 ci,/o/ /%d/Le
felephone# / _8 -C-
EFE ,
COMMONWFAITII OF MASSACRUSFTTS
Board of Health, /v0)Z%//)%Hi/2/t/ 'ILi.
(CATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
staller's Nam(TW w-%Ta/� Co • l
idress ,coves?' ST w Utr
, eiL M
Jephone# W 2 ro o e
enf Building M,A/Cft o c,cit
'fling-No.of Bedrooms /O) 700 Pre' 21:"
per-Type of Building OGF/ C 4v/6.O/(J
Ler Fixtures / LM90 r Z.)
d Calculated design 900 Design flow provided 9/// gpd
.ign Flow (min.required)//YYl FT Zgpd g /��
n: Date j t 7/4c1 003 Number of sheets / Revision Date
e 5 FO17L 51/STTn'/ /? .flLS///'t/ f0/2 ,41/2■4Di3-E/>-4//G/Y y Ail �i/lf
scription of Soil(s) cad AT1�W�//4
I Es ablator Form No. // Name of Soil Evaluator 7 %Yio C.AJAdna of E:valuanon 7/17 in),
y�e to,one sysl�� fide-
SCRIPTIONOFREPa1RSORALTERATIONS C•O/✓I Al eal
—
Lot Suer
sq.f.
Garbage grinder NO
No.of persons Showers H,Cafeteria(AVE)
O<j/C.o 4ucc d/.0
fie undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
rther agrees not pa place the tern in operation until a Certificate of Compliance h s been issued by the Board of Health.
iced X /r - Date 0Y(/ ae�
~//
6 ect ons
cd6- 3q&0
COMMONWi.ALT11 (1F MASSACHUSETTS
FF
Board of Health, n '.
CPRTIFTCAIP OF COMPLIANCE
caption of Work: ]Individual Component(s) U Complete System
dersigned heebh certify that the Sewage Disposal System: Constructed ().Repaired O.Upgraded O.Abandoned ( )
teen installed iu accordance with the provisions of 3 CMR 15.00 (Title 51 and the approved di
ication So. dated Apposed Design Flow (gpdi
tiler
gncc
Inspector: Dale:
issuance of this permit shall not be construed as a guarantee that the system will function a designed.
CO 1MON'WCALTh OE >1,\SSAi_IILISF:IIS
Board of Health, 4/17111/110 4Erf
DISPOSAL SYSTEM CONSTRUCTION PIRNFI
mission is hereby granted to; Construct(
7 / t? r+( `i
,�ll ;G-% ' Q. dated /! Sift'
,posal System Construction P,brmit No. t
ovided: Construction shall be completed within three years of the date of th
)/5)f j Board of Health
^255 aew.5 ass amsom:co.eoso2ma Date f"/ i
phun/:.bulb plans re
FL t
Repair( Upgrade( ) Abandon( )an in did dual sewage disposal system
as described in the application for
I,I loyal cons.. »nstntu[be met.
ii' ✓
✓ft t/�'�, i
�...G`
cation
ap/Pat
elk
tstaller s Nam
ddress
-alephonek
Oa-
•
COMMONWLAITII OC I IASSAOIUS£TTS
Board of Health, • .4 s • lb
TION FOR DISPOSAL SYSTEM CONSTRUCTION 1)'FINIT
con:uunO Repair/Cpgrade( 1 Abandon( ) - ❑Complete System J Individual Components
••
to of Building
elling-No.of Bedroom
her-Type of Building
her Pigmies
sign Flow(min.required) 93 gpd Calculated design flow �
Alt Date -a8 Q� Number of sheets
tie LAO d iD+J 1-0 LL -AM C P
s
( MA( NWS Date of Evaluation tt
Neme of Soil Evaluamr _
AS) _ w� _ . 'ntJ CS
•
Ct
51
i
Owner's Name Q4YR A'•t>�. (Lu^piLt�
Address ("2/1, 51- /�
TelephoneIt 4.3) OGO
Designer's Name
s1'A - as An
Mr"' 00 INA-0Q ler ✓( fF
Sat-5i4/
LotSve IM ka=6 sq.ft.
Telephon
is a• C
4'I
N �
GAT!nftaerO
No.of persons Showers ( ).Cafeteria ( )
Design flow provided 983. L gpd
Reunion Date
escription of Soil(s)
Evaluator Form No.
ESCRIPTION OF REPAIRS OR ALTERATIONS
fAn
ufrther agrees to not to place the system in operation until adCertifi are Di Compliance has been issued by the Board of Health.
S and
Date
4igned
Inspections
- C
P
COMMON'WL;LLIIN OL 1;1SSr1C USI:TIS
Board of Health,
CLRTIFICATL OF COLIPLL\\CL
:ription of Work: ❑Individual Component(s) 7 Complete System
undersigned hereby cerdfi"that the Sewage Disposal System: Constructed ( ).Repaoctl O. t}graded ( ).Abandoned (
FEE
been installed in accordance with the provision
beation No dated
10 C_NR 15.00 (Title u) and the appro.ed design plans':-rbu'di plans relating to
Approved Design flow (gpd)
alter Date
aissuance Iiepettnr
..nsmanrz of this permit shell not be construed as a guarantee that the.ry tem will function as designed.
CON MONWL;\LTII OF )IASSAIlliCSFTIS
f"/j:l+ /f7/'. Mt.
Board of Health. I/J- %r
DISPOSAL SYSTL 1 CONSIIiL'CTTON PI:P>111
emission is hereby granted to; Construct( ) Repair9( Upgrade( ) Ahaudoii ) an indi'idual+ens age disposalsystem
!i I ,-V els as dc Sri ibed in the appli ration for
isposal System Construction Permit No. s/// / "dated / /5' (
rovided: Coilsu union shall he completed within three ye al s of the date of this permit 1111 cal c untlitions must be met.
i r
551255 1595 5'96 AM SUNII Co emmn.con Date 9 2 Board of Health /frft
/
FEE