Loading...
122 Septic Application & Permit 1986 CHECK OR FILL IN WHERE APPLICABLE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Clll'OF lit LL:Ji ?SODi FEE /' Appl ration far 3Jispusnl 11 arks Cnunstrurti n Permit tion is hereby for a Permit to Construct ( ) or Repair ( an Individual Sewage y age Disposal System at: /' I i Locatirin.Address - or Lot No. , /' pwner TAddress 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 Diameter Depth Disposal Trench—No Width Total Length Total leaching area sq. ft. Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by Date Test Pit No. I minutes per inch Depth of Test Pit Depth to ground water Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water__J.%' Description of Soil T t L t d`I Na�ure of Repairs or Alterations—Answer when applicable �u is /mac /_ . . (1_C.0 , t V • Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bedn issued by the board of health. Tgned Application Approved By Application Disapproved for the following reasons Permit No Issued.7'°� �r Date Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY OF.NORTHAM PTOD" tdrrtifiratr of Qlnmplianrr THIS ISll.T-O CERTIFY,'That the fruity/dual Sewage Disposal System constructed ( ) or Repaired by arr at has been installed in accordance with the provisions of TiTLE 5 of Tile State Sanitary Code a; descr�.tr��5 in the application for Disposal Works Construction Permit No C(—Fj dated 1/ �+' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIOsN SATISFACTORY. ,-- DATE / 7:1 /2/ Inspector No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY OF NORTHAMPTON Uinpngnl °rho @Tnnntrnrtinn tirrmit _l Permission is hereby granted to Construct (, )_or Repair (✓) an Individual Sewage Disposal System at No steel ( -. as shown on the application for Disposal Works Construction Perthit No " Dated DATE r f FORM 1255 P. M. SULKIN, INC.. BOSTON Board of Health