296 Applications & Permits No.-2 5-' 7
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THE COMMONWEALTH OF MASSACHUSETTS Fet ,J o
BOARD OF HEALTH
C;11 OF NI or+Yn pia
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Csi Repair ( ) Upgrade ( ) Abandon ( ) - ere System C In ills idual Components
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2l CL.esi F tee.+ H4+cie(c MAOto
Address
247– 0217
Ma ,Parcel.
Telephone
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Type of Building: $nyle.Rvn:ky lwe l l`∎,5._ Lot Size e.
3 Cz
Dwelling—No.of Bedrooms 3 Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ). Cafeteria ( )
Other fixtures
Design How (min.required) 495 gpd Calculated design flow 6r09 gpd Design flow provided So9 gpd
Plan: D3te 7 7 D3 Number of sheets I Revision Date
Title ewn• 2 15 e a S%//e-��� +
cot �) 1 1. F . I I R
Soil Evaluator Form No. Name of Soil Evaluator M,%Ao.ysan Date of Evaluation 5'25/O3
DESCRIPTION OF REPAIRS OR ALTERATIONS
Description of Soil(s)
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TI111 5 and further agrees not to place the system in operation until a Certificate of Compfan e ha been ued by the Board of Health.
(Signed Date 1 w
Inspections :i ce `4J� i a
i ��'' /iaI`` ara- 7 m
1
6
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. `
THE COMMONWEALTH OF MASSACHUSETTS
/'siar-{hamp{vtn BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Q'Eomplete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( ).Upgraded( ).Abandoned( )
by:
FEE
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated / ,- Approved Design Flow - ' (gpd)
Installer ' v 17"
Designer: Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
THE, ((COMMONWEALTH OF MASSACHUSETTS
Pier i 11a0,plzri BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Constplgt
disposal system at C'j/t'6 -/ K /c d
in the application for Disposal System Construction Permit No.
FFF
Repair ( ) Upgrade S (Abandon ( .) an individual sewage
K "'- ` .</plf /lp✓r -1)1;27 7 as described
dated
Provided: Construction shall be completed within three years of the date of this Permit,/lll cal c).ndt¢ons myetJbe met.
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Date ! �� i Board of Health J �6'�'" [
S G5
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 L REV 5/961 SHONE) H09B5 E.WARREN
PUBLISHERS - BOSTON
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
City OF Northampton
Fax
p rliratiun fur Oisfsusni Marks Clunmtrurtiun f rrmit
pplication is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal
System at:
Sylvester Road 4 nit
f�l
or Lot No.
.RnlaenL.issko-
Loc
Type of Building
Dwelling—No. of Bedroom
Other—Type of Building
Other fixtures
Design Flow 55
Septic Tank—Liquid capacity
Disposal Trench—No.
Seepage Pit No 2 Diameter Depth below inlet 2.17
Address
Address
Size Lot 1.28 AC -gq-fpg
Expansion Attic ( ) Garbage Grinder (X )
Showers ( ) — Cafeteria ( )
No. of persons
gallons per person per day. Total daily flow 440 gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by unt ey Engineer Date 3-18-75
Total leaching area -sgfft-
capacity=998 GPD
Test Pit No. 1 3.3..minutes per inch Depth of Test Pit
Test Pit No. 2 minutes per inch Depth of Test Pit
Depth to ground water
Depth to ground water
Description of Soil 6" OLE 11b" silt,...2..'.0" €ine...sand-i.
ground...stater..at_L'D"
'6" maneese-gr-avel-and-eobbies
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with
the provisions of TITLE S of the State S.sitar Code—The u sign ed further agrees not to place the system in
operation until a Certificate of Compliact has r--n issued by the bohrd of health.
Application Approved By
Application Disapproved for the folio
g seasons
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifirate of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b y.
at
has been installed in accordance with the provisions of TI_Lb 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.
-_._ Inspector