Lot 27 Septic Appication 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
T{{.21LZ�C/<L
by
at ,ie *4 a 7 2ti2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. 1HEALTH
fr
Gat" OF_ 1,FCt #1 Pt;tcl
Trrfifiratr of Tnmplianrr
THIS IS TO SERTIFY, Tha the Indi dual Sewage Disposal System constructed (ror Repaired
Jti r«z �C <.> t<
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 J// dated p l,IV i 3U I 7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. (( �� yc
DATE 1 !iv. 34, f f4 P Inspector -4c* 4
No ' !/
Permission
to Const
at No
as shown on the
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Dizp nal llinrka (!t muttit fine 'Profit
erehy granted
140r. Repan ( ),att4 divideuall Sewage Disposal System
-
4,1."
FEE
street
application for Disposal Works Construction Permit No
DATE
FORM 1255 HOBBS & WARREN
C.. PUBLISHERS
Dated
y
Board of.rasamn
ECK OR FILL IN WHERE APPLICABLE
No r1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i i OF / ,y
Appl ration fur Qinpnsul nrks Qlutwtrurtinn tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair
System at:
Fee
` 7
I(?
d
an Individual Sewage Disposal
or Lot Na.
Address
Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Fxpansion 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 Diameter Depth
Disposal Trench— N . Width Total Length Total leaching area sq. ft.
Seepage Pit No 1 Diameter Depth below inlet Total leaching area 'O 0 sq. ft.
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
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 been 'ssurd by the board of health.
Signed )." , ^ . .:. .
Application Approved By
v.)
.�rn
J
or'..T
Date
'
Pate
Application Disapproved for the following reasons
Permit No ( / i
Date
J '
Issued...!J. '-
Date