51 Application & Permit 1985 S � I
go SD
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY oF.NORTHAMPTON
lgi}IliratioIt for Dizpon zt arks Qonotrurtion lrrmit
Application is hereby made for a Permit to Construct (
iystem at: S�-.�
JD PIA
Lo<a ;Jr
) or Repair ('<in Individual Sewage Disposal
or Lot No.
Address
Installer Address
rype 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
Septic Tank—Liquid capacity./gallons
Disposal Trench—No. Width
Seepage Pit No / Diameter
Dther Distribution box (
_Percolation Test Results
Test Pit No. 1
Test Pit No. 2
per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area
Depth below inlet.. Total leaching area.
) Dosing tank ( )
Performed by Date
minutes per inch Depth of Test Pit Depth to ground water
minutes per inch Depth of Test Pit Depth to ground water
r
Description of Soil ./`�v
Nature of airs or Al rations— s ver hen ppli le ..
Agree t: �yt _ .
a - 3 P(lU•l
The undersigned agrees to nstall the aforedescribed Individual Sewage Disposal System in accordance with
:he provisions of TITLE 5 of the State Sanitary Sad_—The undersigned further agrees not to place the system in
)peration until a Certificate of Compliance
Application Approved By
ued by the boa
Application Disapproved for the following reasons
Permit No .I.i--Q's
Issued
Date
nue
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITYoF NORTHAMPTON
'Infiltrate of ftompliaurr
by THIS IS TQ„G i2TlF.Y,iPtidt 7jre Ip tv ual Sewage Disposal System constructed ( ) or Repaired (�.Y
Y %// ice( 1...l� w `.�.
tas been installed in accbfdance with u , �
at ti.e t
' the provisions o T j f The State Sanitary Code as des ribed in the
r $
application for Disposal Works Construction Permit No... a 6 � dated tot / F7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST A GU RAH EE HJ$Y THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE /`?/ 3"/ 5 Inspector
t
V
No
� ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITYoF NORTHAMPTON
3liopoNl r1 lIoi _ruction 1rrmit
Permission is hereby granted.. ib
to Construct (`.4 �r Rer mid
at No ...1 �r..f '
st
as shown on the application f Disposal Works Construction Perm
e Disposal
DATE
'ORM 1255
FEE
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