142 Septic Application Compliace & Plan CHECK OR FILL IN WHERE APPLICABLE
No 1 ...�
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
4OF1-2„zC!'1 00 i
Z4pplirntinn -t6r Uispn.'u1 Mirka nntitrurtinu lrrntit
06
Application is hereby made for a Permit to Construct ( ) Repair ( ) an Indir idual Sewage Disposal
System at: .
/L
y� , i ail e�1y�Ly�ices —{, or Lot No.
i- LA .)Q. p '� c en t
Ox Address
It
asraller Address
Type of Buildin' Size Lot Sq. feet
Dwelling—No. of Bedrooms 3 Expansion Attic ( ) Garbage Grinder (✓)
Other—Type of Building No of persoue Showers ( ) -- Cafeteria ( )
Other fixtures
Design Flow Sk gallons per person per day. Total daily Row -3O Z) gallon.
Septic Tank—Liquid capari .Q gallons- Length Width _.. Diameter Dj pth
Disposal Trench—No lA idth,: Li l Total Length-Si)/ Total leaching area—(i,el el sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. 1:
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. 1._Jj-._minutes per inch Depth of Test Pit-_xt_..._-- Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test I'it-S_'-4 r' Depth to ground water 7 '
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 AI 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.
Si ned.
Application Approved 133. C-.
Dale
'/__� .
Application Disapproved for the following reasons' ✓ J
Permit No
74
Date
Issued )J.4 t“ 1/ 197.E
Date
-
ki No
CHECK OR FILL IN WHERE APPLICABLE
FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T r- OF /bieR714441 nue;70
ikp Haitian fur latiputiat oats Tonstruntinn hermit
(i.gApplication hereby made for aptit to Construct or Repair ( ) an Individual Sewage Disposal
System at: u•r-<-4-11--y- 7"
2 nhee Mg.(00i-t/ LA MC /
/1714 rjdl . . or Lot Ne
4P/ .
Owner .
Address
Installer Installer Address ..—, , __,
Type of Building Size Lot...J..4.3.6...Z....Sq. feet
Dwelling—No. of Bedrooms a Expansion Attic ( ) Garbage Grinder 0-1
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow -5.0 gallons per person per day. Total daily flow 3QO gallons.
Septic Tan-iquid capacity/an,gallons Length.I.(2.-no..1 Width.5'0" Diameter
F Depth
Disposal No / Width Z 0 Total Length asa i Total leaching area_....(22.0 sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results . Performed byEarge4.21/i2:14.&il -1011J2Z-Cid-;14Date. ..-.5/ZW.74—
Test Pit No. 1 i•i minutes per inch Depth of Test Pit...5 Cy" Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit 5 -6' Depth to ground water 7 t O
Description of Soil a" ors i t 6" 5/47
/ €5
621./LPF-05
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•
Permit No
Date
Date
Date
Issued
Date
=-/3 eta Ovw0t) 1)?-- '
THE COMMONWEALTH OF MASSACHUSETTS Fir/a(0,
BOARD OF pppH...ErrrAmmnLTH �`✓may
6 rr y OF I�OZI- �F�r�TOi lv`ake
ON FOR pISPOSAL SYSTEM CONSTRUCTIONPRMITa2/9-,27,
nnit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components
Type of Building: S 1.o6 ciorrecy tFOswE
Dwelling—No.of Bedrooms
Other—Type of Building
No. of persons
Lot Size Sq.feet
Garbage Grinder
(1�
Lo Showers (✓f aaietri( )
Other fixtures
Design Flow(min.required.) gZC gpd Calculated design flow Q7c gpd Design flow provide 'S-gpd
Plan: Date c--.2.--05 Number of sheets a- Revision Date
Title S.b5 td1.FACE Sao»G€ brSQaSAc_ 5y c.4)ell. DESL fJ
Description of Soil(s) GO (cp�tt,/
Soil Evaluator Form Nof B-O7 Name of oil Evaluator ' / 5EN Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
Intl 5 and = agrees not to system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
Date
Inspection:
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
LCFN 1 - DumpAy talus"
T)lout.
-
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hi
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iiati0L
Po a
owner Como
Address
1 or2 1 o p
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Tt.At
Telephone
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9
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vu RAO�sl tr�I
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s2'J - Si4 1
Tetcrnune a
Telephone
Type of Building: S 1.o6 ciorrecy tFOswE
Dwelling—No.of Bedrooms
Other—Type of Building
No. of persons
Lot Size Sq.feet
Garbage Grinder
(1�
Lo Showers (✓f aaietri( )
Other fixtures
Design Flow(min.required.) gZC gpd Calculated design flow Q7c gpd Design flow provide 'S-gpd
Plan: Date c--.2.--05 Number of sheets a- Revision Date
Title S.b5 td1.FACE Sao»G€ brSQaSAc_ 5y c.4)ell. DESL fJ
Description of Soil(s) GO (cp�tt,/
Soil Evaluator Form Nof B-O7 Name of oil Evaluator ' / 5EN Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
Intl 5 and = agrees not to system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
Date
Inspection:
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. -4/'/) ct _/ 3 THE COMMONWEALTH OF MASSACHUSETTS
;V,;,,—T4/ 7,,,c) BOARD OF HEALTH
CERTIFICATE O COMMMPLIANCE
Description of Work: ❑ Individual Component(s) C6mplete stem
The undersigned hereby certify that the Sewage Disposal System;Const cted(v).Repaired( ),Upgraded( ),Abandoned( )
by: .411:::-/—: '!Az T2 ,- ) /A 'C _)ii:{r1): ri-2545
at , cs .2,2141 in iG s / J?° 4.‘--1_i
has been installed in accordance with the provisions of310/CM� 15.900(Title 5) and the approved design plans/as-built
plans relating to application No. _• s'dated `-)/ a , S . . Approved Design Flow -20 A/ (gpd)
'/Jd. a t„
Designer /. - Art ! AC Inspector '-(0 I411'/-i0A7 Date %' '!.L
The issuance of this ceitificafe shall not be construed as a guarantee thakdu system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
' 7
THE COMMONWEALTH OF MASSACHUSETTS
^H ,ari/BOAF D OF HEALTH
DISPOSAL SYSTEM CONSi`I UCTION PERMIT
Permission is here s granted U Construct (\,4 Repair ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at as described
t -
-r,,,,,---r,,,, U".rJNN
in the application for Disposal System Construction Permit o.,.�� ' 4 -/� ° datea m,
� a ,3o1�
/
Provided: Construction shall be completed within three years of the date of this permit. All local(conditions must be met.
Date �' �Q 4- .1 / 1�' , Board of Health ,^1iv iCt77�
FEE /
73 » -„
{ c'l
FORM 2 - D5CP DEP APPROVED FORM 5/96
FORM 1255(REV 5/96)
f{{ • HOBBS&WaenENrm
PUBLISHERS BOSTON
Important:
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MYR
Commonwealth of Massachusetts
City/Town of Ktorcit-IavnApToaJ
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with
the local Board of Health to determine the form they use.
t5form3.doc•06/03
This is to Certify that the following work on an On-Site Sewage Disposal System
® Construction of a new system
❑ Repair or replacement of an existing system
❑ Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
DSCP Number DSCP Date
Justin Dionne
Facility Owner
SITE: Lot# 1 - Dunphy Drive
Street Address or Lot tt
Northampton
City/Town
Designer Information:
Timothy E. Maginnis R.S.
N
Ma.
State
01060
Zip Code
Timothy E. Maginnis 8 Associates
Name of Company
August 28, 2005
Date
Cooper Excavating-Westfield, MA
Name of Company
Signature Date
Use of this system is conditioned on compliance with the provisions set forth below:
Due to the inexperience of the installer and observation of latex paint in the new septic tank,there is
no warranty, expressed or implied,that this system will function as designed. The designer assumes
no liability.
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Approving Authority
Signature
Date
Certificate of Compliance•Page 1 of I
No.1OJ
THE COMMONWEALTH OF MASSACHUSETTS
IL ' %-Af ),-CA) BOARD OF HEALTH
CERTIFICATE O COMPLIANCE
Description of Work: ❑ Individual Component(s) mplete stem
The undersigned hereby certify that the Sewage Disposal System;Const cted( Repaired(
by: '1// ),Upgraded(( ).Abandoned( )
/ Y" s-e////244(1/6-- Nr4/%. ? /,TiS%i� 2/�' J Jff j
at
lieiv LE7-'�`1
has been installed in Accordance with the provisions of 310/EM 15,Qp (Title-5) and the approved design planYas-built
plans relating t/o application No k i-13 dated C / 2 . l'art . Approved Design Flow 217_ (gpd)
Installer /",.., t"2 (LJ r
7�i},� /e,„/A1<'f!FtIJ rra-. Mvi 90)7- .S
Designer ',?t ik: /y7.:C/.4-4(//1,C Inspector S -spate (.G"C{= sc.
The issuance a this ceitificele.shall not he construed as a guarantee th. system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
"ILA e 'er/. -
.Driveway
Existing
3 car
Garage
Existing 2000
gallon septic tank
Existing
5 bedroom
House
AS—BUILT DIMENSIONS
401f of 4" pvc perf pipe
Existing SAS
„C,I •
0
* No expressed or implied warranty *
Pumping manhole ("C)
4 pvc solid pipe
Existing
distribution box ("D")
As—built plan
White Oaks Woods
Lot # 1 — Dunphy Drive
Northampton, Massachusetts
Dionne Mgt. Team
PO Box 294
Sunderland, MA. 01375
( 413 ) 219 — 2799