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