57 Septic Applications & Permits THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair(X) Upgrade ( ) Abandon ( ) -M Complete System ❑Individual Components
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I nation
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Owner',Name
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Address
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Map:Parcel4
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Lot 4
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Telephone
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Installer s Name
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Designer,Name
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/ Address
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Address
Telephone 4
Telephone 4
Type of Building: /((" ''�
Dwelling—No.of Bedrooms
Other—Type of Building No.of persons
Other fixtures
Design Flow(mir).required) /(n gpd Calculated design Flow S' // gpd Design flow provided S= gpd
Plan: Date /(ii/?1r t Number of sheets es Revision Date '"
Title (si rl (..(I '7 f'-t-
Description of Soil(s) .6il1UL
Soil Evaluator Form No. Name of Soil Evaluator k ( Date of Evaluation /P
Lot Size /s- i Sq.feet
Garbage Grinder ( JO
Showers ( ). Cafeteria ( )
DESCRIPTION OF REPAIRS OR ALIERAT IONS /_rr-1i ( ;
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
THU 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the :..-. . Health.
Signed Date
Inspections _ �(
FORM 1 - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
No.
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
lUcPjr.alxj7L. BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) ®Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired(X).Upgraded( ),Abandoned( )
by: 7a0LlZ/e .a1/4. 44,1)--) l ��. 7a 4,2•-' %1 j tz MA-
,
a-f Uua/o� %� -,,544 -/f. ,'Y.
at 2 �D�.`LAH/ Oe1v : / eG. �' �2"^.1vv ✓
has been installed in accordance with the pr isions of 310 CMR U.00(Title 5) and the approved design plans/as-built
plans relating to application No924d6 « dated ) "/ , tij)4 Approved Design Flow A S (gpd)
Installer Jot Iti/ UZCf— _. .js/ A.,,at
Designer »t' -, _i I E?ik73 1^)! Inspector / 773 Y'Ct i�i7i --24.1.r. Date /!,/)a 1/41i%
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 t
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No e
THE COMMONWEALTH OF MASACHUSETTS FEE e
77 ,/,A ,,,i 'fir'., BOARD OF HEALTH /7 ,i "
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair,(L�Upgrade ( L Li.Abandon /( ) an individual sewage
disposal system at i / , , r//y, t�`, /%d /I` Ih r � .Y7.4 /r/di asdescribed
in the application for Disposal System Construction Permit No.-- OGE 7 dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date ti4' ' -.< -.. Board of Health - -mot..!- .L-G'- , /
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 ,REV 5/96,
CIII&WjH CABS&WARREN n' PUBLISHERS-BOSTON
CHECK OR FILL IN WHERE APPLICABLE
No
Fos y<
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
iTV 0FNORTHAMPTrr.
)ppiirnttan fur ilispusnl w'i urks Qlunstrurtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: Si '�
.............._. or Lot No.
11 at11on AddreB.
Address
Installer i 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.
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
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
Description of Soil ! .................
Nature of Repairs or Alterations—Answer when applicable /L!
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 as ten issued by thebpard of health.
v Sign
Application Approved By r..:c '-✓'' }V?S 'R f1--
liZe
Application Disapproved for the following reasons.
Permit No
Date
Issued.
THIS I CE
by
at
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF NUM THA1',4P ,
(IIrrtifiratr of QQnm#dianrr
dividual Sewage Disposal System constructed ( ) or Repaired ( S
Installer
has been instalied in accordance 'nh jprovisions of TITiy 5#,,T
application for Disposal Works Construction Permit No (<Q �f
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANT AT THE
SYSTEM WILL FUNNGYIONN SATISFACTORY.
DATE /—l..Fr L5a p7 Inspector
State Sanitary Cot as dgserib iyJhe
dated ✓-.,�J��
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
?\ OFNUIPTHNq PT^^. _ . . ._. . . .
Bisons
Permission is hereby granted
to Construct ( ,4-p? -R-yaair
at No ..D
as shown on the application for Disposal
ono (Construction Permit
l //sn
ividual age Disposal System
DATE =1:i.i�le 1
Street
Works Construction Perrot NO:
FORM 1255 A. M. SULKIN. INC.. BOSTON
Board of Health