Lot 25 Septic Appication 4
ALMER HUNTLEY, JR. & ASSOCIATES, INC.
Successsors to Davis Engineering Co. Established 1870
Registered Land Surveyors & Civil Engineers
30 CRAFTS AVE., NORTHAMPTON, MASS.
TEL. (413) 584-7444
Cjcec /9, /963
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THIS)
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF,.�HEALTH tett 621
(irrtifiratr of To liaurr
TOLCERTIAY, That the Individual Sewage Disposal System constructed Q/ ) or Repaired ( )
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No `-/ dated /:1.>.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
!.
DATF / Inspector .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t t. CJs
(:.G. G� OF r FEE
Nn._,�C 4
Disposal iliorkz Tottntrurtiott iltrttat
Permission is ereby granted j` f%ire.... d=t>'r
to Construe ( or Repair ( ) an Individual Sewage Disposal System
at Not" �'.� Far-'✓i.y...�y..rah-
st eat ■ 7%212
as shown on the application for Disposal Works Construction Per�tit Nom ...7f. ated
} 61•7
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
WHERE APPLICABLE
CHECK OR
No
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
OF
Appliratian for Disposal ri,arks (ltunstrurtiun remit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
2F
Ucatleq ,dddry
C ,T
Installer
ettie
a'rot Na
Address
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow gallons
Septic Tank—Liquid capacity.94 gallons
Disposal Trench—N Width
Seepage Pit No / Diameter
Other Distribution box
Percolation Test Results
Test Pit No. 1
Test Pit No. 2
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
per person per day. Total daily flow gallons.
Length Width Diameter _ Depth
Total Length Total leaching area
Depth below inlet Total leaching area.J.a..5....
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
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 begn iss4ed by the board of health.
Signed' -
Application Approved Bye t_I�d't �� :%��"r}" -Oi''
Date
_rte. rate
Application Disapproved for the following reasons
Permit No %{_
Date
:17 / (J .J
Issued...i_e.rc_.:—I._.e
Date