35-217 (5) THE COMMONWEALTH OF MASSACHUSEI
GAR, BOARD OF HEALTH
CITY NORTHAMPTON
Oi
I lication. is hereby made for a Permit to Construct (X ) or Repair an Individual Sewage Disposal
stem at:
Owner A'd*'d'ress
Dwelling—No. of Bedroom, ..Expansion Attic Garbage Grinder
Percolation Test Results Performed by VA Y... ......NONNI,... Date.6m1ma4,45,29m8_4
Test Pit No. I......Z.......minutes per inch Depth of Test Pit...... Depth to ground water..NONE........
04 i[' ........................
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Z .............— ............................................... ---....................'...... ................................... —.........................................................
U Nature of Repairs or Alterations--Answer when applicable............... .............................................................................
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Agreement:
The undersigned agrees to install the afozedescribed Individual Sewage Disposal System in accordance with
the provisions of T 2'AlE 5 of the State Sanitary Code — The undersigned 6`cUrr agrees not to place the system in
operation nod( u Certificate of Compliance has been issued by the board ofhealth.
Signed..................................................................................... ________________
Date
ApplicationApproved By.................................................................................................. .......................
Date
Application Disapproved for the following reasons:................................................................................................................
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Date
PermitNo........................................................ Issued.......................................................
Date
THE COMMONWEALTH oF MxssAmnusErrs
BOARD OF HEALTH
.............CTT°�______«�F___���T��Y��T�y�_________—__--
Tertofirouxr of Tox4rphanur
THIS {STO CERTIFY, That the Im&v@ual Sewage Disposal System constructed (X ) or Repaired ( )
by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
at................................................. � __ Installer ______.______________.__________________
has been i000JlnJ in uccorJuorc with the provisions of TITLE* 5 ,f The State Sanitary CnJc as described in the
application for Disposal Works Conutructi'm Pc,onit No--------.-----. dated. ------- .......................
THE ISSUANCE OF THUS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector..................................................................................
THE commomvvsALr* or mAssAo*uscrrs
BOARD OF HEALTH
-----��ITY..............OF—NORTHAMPTON--- .................................
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Permission is brncby granted----��-��!�.�..���.�..��������!.!.�... --- ......................................................................
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to Construct (X B ) an Individual Sewage Disposal System
at YJo.................LOT...NO—...2-2.°...LADYSLIPP.Ek-LJ\NE-------- ---- .......-................................. ..................................
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as shown on the application for Diayoau) 'VVo,ku Construction Permit No................... Dated..........................................
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Board of Health
DATE...................... .............................................. ..........
mn~ /oye xneBSmWARREN, INC_ PUBLISHERS