103 Septic Applications Permits & Compliance CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
C-/r>' or Net7-414,rP7a/Li
Paz
Application for Disposal ar;arks lBunstrurtion 1rrmit
6h Applicatio�n/s�hereby ma for a Pe mit to Construct (:'<or Repair ( ) an Individual Sewage Disposal
/ System at: 7 1141 �� .���"-(
fJ,�C /• L,?4J L V t
LocaNOn Address or Lot No.
444,0.r_.....C.i& ,ervc-ria.�vi bicr_
Owner Address
Installer nau oa
Type of Building Size Lot._LShOCOL?..Sq. feet
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder (el
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow 60 gallons per person per day. Total daily flow O 0
Septic T -e—d rquid capacity/�pgallons Length./C2 —. Width..5-O r Diameter gallons.
Depth.-5
Disposal '1"-^X a^^
—No / Width Z4?.------. Total Length....SC> r Total leaching area_GO.Q sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( ) '/-a.�^'
Percolation Test Results Performed by..t.B-'h )../2..SiB/--t-/" 5Y Date... /:!??/7e
Test Pit No. l0.4 minutes per inch Depth of Test Pit 4.c-to" Depth to ground water...LUOF•�
Test Pit No. 2 minutes per inch Depth of Test Pit....it?L& • Depth to ground water 2 .-'
Description of Soil 6 a. p-T..S-..y Z •-C'° G>?e:t2e.S-E--5..4NQr-a3�/0 °Fie)a- .SA[L/Q f arty
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 issued by the board of health.
Signed
Application Approved By
Application Disapproved for the following reasons•
Date
Date
Date
Permit No Issued.
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
fbtrtifiratt of atomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
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
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE
Inspector
4- COMMONWEALTH OF MASSACHUSETTS
Board of Health, %.e'Cr/31//i»%J Ci/,NA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCIION PERMIT
t Sr Permit to Consrruct(lAepair( ) Upgrade(y-ssbandon( ) - LW mplete System O Individual Components
Location /453 QL),(Jp/'Lf Q///4&e
Owner's Name•%/'*i .t, L//nG,i/Q
Map/Parcel# / /'r,7/irh7,o/O J f/%7S5
Address A /%/ 'n/9/� ,5 --L' ,4
Lot# /QJ DL'/U 04"-/u--0
Telephone# Lf / /9 i3
"A/Y /
Installers Name / . ,T
`�rt�`
Designer's Name 0-/,f Jt{�.)/,
GL//C C//3r�11
Address
Add ress V4 6.77/!//7// /2 d
/lnty✓ 6,,, /-4 i
Telephone#
Telephone#
Type of Building /L G'S/z/e-nit Cc, //¢ mot-e"
Dwelling-No.of Bedrooms 3 ieP42/1GO/V?
Other Type of Building q G� No.of persons Showers L�,Cafeteria pQ/0
Other Fixtures Ctir/T%0Z/f/ / ° / �G/i' /2d G, I''// r�
Design Flow(min.requiretlj?o 'Y/t�4 gpd Calculated design flow Y' ?$ Design Flow provided SU 3 gpd
Plan: Date�li Cy,97 /998 Number of sheets / Revision Date 04,712
Title / W/'72e rrys/4-in plats/ /v ��de rr, 72/1 y./--,---/ei.vC
Description of Soil(s) . 1 /%/2 27-c1e O
y c9p
Soil Ecalvator Form No. /1 Name of Soil Evaluator /..C.4.7-1572.1/2�'P�of Evaluation j:'-}e_V 7 / / TC J
DESCRIPTION OF REPAIRS OR ALTERATIONS re-1/nil 44-> .,.Cl,//e j-ei f "7-7 e2 9/c-7et
Lot Size r '' ' 5/
q.tt.
Garbage grinder (4 C5
The undersigned es to in : I the abo e des d I 'dual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no o place . • ..to • - until a Certificate o�j�yory�fyas�pus been issued by the Board of Health.
\„_(Signed X � '/"ia ate , / �]YX
Inspection.
„_ 34- �l V
COMMONWEALTH OF MASSA IIUSETTS
Board of Health,
AM.
CERTIEICATE OF CON I)LIANCE
Description of Work: i/ndiridual Component(s) U Complete System �/
The unders gned hjreby terrify tr t the Sewage Disposal System; Constructed ( ),Repaired 1/),Upgraded ( ),Abandoned ( )
/! ./ //,_4i.'
has been installed ,ice wi the nrisiions off 310 CMR 15.00 (Title a e 5) and the proved design plans/as-built plans relating to
application N. �i �a15d /q/55r. . Approved Design Flow SC (gpd)
—c C—v1C'rL
FEE
/C
t
Installer
Designer: u - r Inspector: � Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No 3 /Y
COMMONWEALTH OF MASSACHUSETTS
Board of Health, /0-9 12
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEEL
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( )an individual sewage disposal system
at X03 L/LIC/. /7 J✓' as described in the application for
Disposal System Construction P @rmit No. 31-/—?,, dated 7// 5C
Provided: Construction shall be completed within three years of the date of this per it. All local condi ns must be met.
Form 1255 Rev 5/96 AM.swkn Co Boston.MA Date ca/D %k-Board of Health /—�� rY /-9��� i.
William I Sieruta,P.E
♦*♦
46 Upland Road•H MA 01090•USA
Phaie(413)(413)532-8525
53243525
Board of Health
City of Northampton
City Hall, Main Street
Northmpton, MA01060
Attn: Peter McErlain
August 27, 1998
Subject: J. Raymond Prop.
103 Dunphy Drive
Northampton, MA 01060
The subject septic system has been installed in accordance with the approved plans, 310
CMR 15 and local Board of Health.
If you need any additional information, please do not hesitate to contact me.
Very truly yours,
William J. Sieruta,P.E.
WJS/joc
cc: