277 Septic Permit & Site Review CHECK OR FILL IN WHERE APPLICABL7
Installer 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
Disposal Trench—No Width Total Length
Diatneter Depth below Ml
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Diameter Depth
Total leaching area sq. ft.
et Total leaching area sq. ft.
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
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
0 ceelt.t;,,7 ,itto(1 fdlei
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 pi health.
Signed__.......
Application Approved By
/1 Date,
e-b.vs• 4.7
Date
Application Disapproved for the following reasons
1
Permit No Issued /
THIS IS TO O,ERTIFY,
by
at
.77 L.(-4-f
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
re, OF
Oltrtifirate at Tuntpliattry
That the Individual Sewage Disposal System constructed ( ) or Repaired
egti.bv
-
Installer
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in tb9
application for Disposal Works Construction Permit No 4.,3 dated 1/,00-1 ./.4.2`7 f
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE 4res. ' Lk 7•
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
FEE
Disposal arks Olptistrttrtion lftrrmtt
Permission is hereby granted.7...
to Construct ( ) or Repair ( an Individual Sewage Disposal System
at No ' ote. )4:
Street 2 i 7/ 7
as shown on the application for Disposal Works Construction Permit No - Dated
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Board of Health
•
fOT'J IDNWTLALTII ()F NASSAI. LIIISLJJS
Boor('if Heal, L%OBT//Amp7bt) NA.
APPLICCATION UOR DISPOSAL SYSTEM CDiNST1?I!CTION 1-hRN1I
Application for a Permit to Guist)nut( Repair(ps'j Gp„�ade( ) Ahandi n( ) - $Complete System J Individual Components
Location AuDur30.v PL
Owners Name Ricgaed caeuel
Map/parce]# S
Address 2j7 AUDupon) Ra
Lm# /9
Telephone# S8q 0i98
Installer's Name Rt V a .beive ExcAVRTi f.16
Designer's Name h r wa HA A) 4C •ac /.-C •
Addtets RtoEiL ielu/ NafltLy mA
Address /96 myr_o2 ST 6-kA,tty MA
Telephone# 523y /13 i v
Telephone# v 13 tin zez,2®
ripe of Building IU4eL41N 6
Telling-No of Bedrooms 3
Other-Type of Building No.
)tf ei FixtlIleS Fix
Design Flow (min_required) SS gpd Calculated design flow .330 Design P
'Ian: Dt . 918199 Nmnher of sheets / Reunion Date
ride Dd.6 4' 99171-1 1=,aR
Description of Sod(s) SNA)DY LOAM
Soil Es alining:Form No Name of Soil Ea aiming R F.SN'FHftA) Date of Es
Le sin. 6, 994ffrea Wi�qt.HL
Garbage grinder /mart
Showers( ).Cafeteria (
DESCRIPTION OF REPAIRS ORJITER TIONS . C t ATTACNES r #--r
pi Os ded
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
it614E1i � Yo1 It ;:i.,
fir R / Yki
PERCOLATION TEST(S)
I Time: I I Time:
Observation Hole #1 Observation Hole #2
Depth of Perc - . Depth of Perc
Start Pre-soak — Start Pre-soak
End Pm-soak _ - End Pm-soak
Time at 12' Time at 12'
>n
Time at9' r 1 i Timeat9'
Ci
Time at 6' ,/ Time at 6'
Time(9'—6') / lime(9'-6')
Rate Min/Inch Rate Min.11nch
I *minimum of I percolation test must be performed in both the pdmary area AND reserve area.
r ■
• • •-I-Performed by I
Witnessed by I I Witnessed by
Comments:
NORTHAMPTON BOARD of HEALTH- Title 5- Site Review
Location Address or Lot#
Owner _L LQ A •Y/
Date 5
Time
Sod Color
(Munson)
Owner's
Address
9 / -7 1-L.,;/7-7J-- --_
Engineer .
Weather `—. Phone#
S L
/ �.y
Land Use
(:.
%Slope
I Surface Stones
Landform
^✓O/V la I Weeping hon Waco I N(7 ,
Ve!etation Start Time
Position on Landscape(sketch aee back)
Distances Stop Time
Drinking Water Well
feet
Property Line
feet
Open Water Body
feel
Possible Wet Area
feet
Drainage Way
feet
Other
feet
DEEP OBSERVATION HOLE LOG`
Deep Hole#: 'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSEDDISPOSAL AREA
Depth from
Surface(Ind. )
Sail Horizon
Sol Texture
(USDA)
Sod Color
(Munson)
Soil
Mottling
Other
(Structure,Stones,Bathers.Cacsstenry,%Gavel)
r -"
co .
S L
/ �.y
lu ;t 'r-
I O ci"''41y
(
(:.
r\.,,,,t j-St :;,,..4-2,
Parent MataI(geolgic) I I Depth to Serried I /-J
Depth to groundwater. Standing Water in to Hole
^✓O/V la I Weeping hon Waco I N(7 ,
Estimated Seasonal High Ground Water
DEEP OBSERVATION HOLE LOG*
Deep Hole#: *MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Soho:(Inches)
Sod Hat=
SorTe:ure
(USDA)
Soil Color
(Munsell)
Sod
Molting
Other
(Sbucture,Stones,Boulders Consaency,%Gravel)
Parent Mabel(georgic) I I Depth to Bedroll
Depth to groundwater. Standing Water In the Hole
I Weeping from Pit Face I
Estimated Seasonal High Ground Water
L.
I