9 Septic Applications Permits & Compliance CHECK OR FILL IN WHERE APPLICABLE
No.._/-(
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEALTH OF
1ppliratinn far 3hispuzat ark h O[unntrurtinn hermit
FEE
Application is hereby made for a Permit to Construct (r) or Repair
System at:
aaarer%e.
.$owl
f/Inamller
Type of Building
Dwelling—No. of Bedrooms Expansion Attic
Other—Type of Building No. of persons
Other fixtures
Design Flow r gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capac .r/. ' gallons aLength Width Diameter Depth
Disposal Trench-No. Length leaching '* sq.
.... Width rze..Q...... Total Lev h......r�r.._(/_._. Total leachin area ..Q � 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. 1 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
an Individual Sewage Disposal
or Lot No.
Address
Address
Size Lot Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
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 XI of the State Sanitary Code—The undersigned fur her agr s not to place the system in
operation until a Certificate of Compliance has bee* issued by tl� b rd of heal
Signed �-�(! I "
Application Approved By '...Lezt'.re... ...r
Application Disapproved for the following reasons
Date
a Date
Permit No / 7
Issued
Date
et !
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.
rrtifiratt of Tons liana
THIS IS TO(j,j RTr1,FY, That thy In&vidual Sewage Disposal System constructed ( ) or Repaired ( )
at fain- -4-frsti
has been installed in accordance with the provisions of Article XI of The State Sanitary ode as deesgrib d in the
application for Disposal Works Construction Permit No / la dated // 7 6 o
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G RANTEE THAT THE
Installer
SYSTEM W L FUNCTION SATISFACTORY.
DATE eQ÷ 9 ‘ Inspector
No...f:_7 a
Permissio
to Construct
at No
as shown on the
DATE_..'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HFpALTH
(✓'•L D of i -u--aa. .�.:r:*�,
t ;ti,: an
Disposal. nrltn (U,mtEtrurtinn Prrmit
z. a,i U>'
erehy granted
or3air ( } yin Individual
FEE
ge Disposal System
Street
application for Disposal Works Construction Pxrmit No./i --, Dated.
-
�Board of Iieelth
/
FORM 1255 t4OBBS R WARREN. INC.. PUBLISHERS
1_1
• No
CHECK OR FILL IN WHERE APPLICABLE
S
FEZ
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(- ITV or NORTHAMPTON
Appliratinn for Disposal i r arks C>tonstrnrtion lJrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: i _
.r Y <
ALL 1t. .2.k� i �/I FL (1141/
Owl* 2 A
Installer ‘Ite Address
Type of Building -. Size Lot Sq. feet
Dwelling—No. of Bedrooms ,'t` Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures _
Design Flow_55....S ). , gallons per person per day. Total daily flow ° '- gallons
Septic Tank—Liquid capacity.2.5. -gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area ft'
Seepage Pit No Diameter Depth below inlet / Total leaching area�(a.Z:1ft.
Other Distribution box ( ) Dosing tank ( ) 4' -
Percolation Test Results Performed by " W �f L!'- Date ' ..._,
l 3 _.
Test Pit No. 1 minutes per inch Depth of rest Pit '^ Depth to ground water C-/
inch Depth of Test Pit__ D to rPun ter....
• r f•
est Pit o. minutes per 4„) " / ! cx......_ • / %F. -.-./ 1 ,( ' i AJ r SGtn� c.
Description of Soil "'
Nature of Repairs or Alterations—A$swer when applicable 1j;E`...L �y.(.(� � r i' " ' °"
4✓! a.
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 been issued by the board of health.
X:Signed
Application Approved By y�'
Da
Dale
Application Disapproved for the following reason;
Permit No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Qlrrtifirate of Qdnmplianre
THIS IS TO CERTIFY That thy Individual Sewage'Disposal System constructed ( ) or Repaired ( y'"•
by .1<
Installer ^ _
at i
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No i , / dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED,AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE t_-_//? ,..1.„ J7 Inspector - . ` -.
No ! I
.r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i' ITY OFNQ.RT.H.AM.aLn.h
Disposal Works Olwttstrurtinn, ermit
r
Permission is hereby granted ! '
to Construct ( ) or Repai�11 an Individual'Sewage Disposal S .rent �. a
at No ' - �1 /'� �'.E
�/f - � �=f Street„ -
as shown on the application for Disposal Works Construction Permit Na Dated '
/
Board of Health
DATE
7
FORM 1255 A. M. SULNIN, INC.. BOSTON