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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