Lot 18 Septic Applications & Permits CHECK OR FILL IN WHERE APPLICABLE
No y_�./..l
THE COMMONWEALTH OF MASSACHUSETTS
FEE i5 ' 4�
-,r BOARD OF HEALTH
�y
Pppliratiun for /r �ispuont arks innnstrurtiun hermit
Application is hereby made for a Permit to Construct i or Repair ( ) an Indic idual Sewage Disposal
System at•
3.245•1 ,
I. tl 1. .e;.' or Lot No.
Address
Type of Building
Dwelling--No. of Bedrooms Expan
Other—Type of Building No of persons
Other fixtures
A ddress
Size Lot Sq. feet
on Attic ( ) Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Design Flow gallons
Septic Tank—Liquid capacit0 Silgallons
Disposal Trench—No. Width
Seepage Pit No Diameter
Other Distribution box
Percolation Test Results
Test Pit No. 1
Pit No. 2
per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching areatelild sq. ft.
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
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescrihed 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. 17
/�
Signedue--a z-(Arb-4 C! 2 /.Gill- ("
Application Approved By....................Ci e-as2-
� Dam
Application Disapproved for the following reasons
by
Permit No.
Issued
Date
-n_ mss;....C.Q7_:'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Clrrtifirate of fbomptinnre
THIS 1S 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.
DATF Inspector
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Trrtifirate of Oloutpliann
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
No • 4°
Permission
to Construct
at No
as shown on the
DATE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. -31
OF ,i/ ,4re
13isponat E nrks Cianntntittint Prnnit
isjereby
epgrran(ted
an IndividutiSeymce. Disposal stem
Repair
4:-.444+244e-s -Atires
application for Disposal Works Construction Permit N o 41.Sik., Dated
-<9) 441 BoVnii: -441.
Street
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No Iaa
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY OF NORTHAMPTON
Appliratinn fur Uiupunal Turku Q unsirurtinn lirrmit
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
FLOBENCE...R.QAR 18
LoaGon-AddFea La! No.
1SEITH..E...HARVEY 60 CRAI.WELL..AVE......WEST SPRINGEI.ELR..
owner Address
W
tt 1 Installer Address
?' Type of Building Size Lot 15r000 Sq. feet
`' Dwelling—No. of Bedrooms 4 Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No of persons Showers ( ) — Cafeteria ( )
6 Other fixtures 800
ad W Design Flow 513 gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity 1200 gallons Length Width Diameter Deppth
[*1 Disposal Trench—No 3 Width Total Length Total leaching area 8"0 sq. ft.
L. Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( X) Dosing tank ( )
Percolation Test Results Performed by
Test Pit No. 1 .3 minutes per inch Depth of Test Pit 36" Depth t. - p- Not Found Test Pit No. 2 minutes per inch Depth of Test Pit 84" Dept l •t Found
O Description of Soil ill'
14
0
AtGK:s
Data
12" LOAM 36" SANDY...LOAM
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedcscribed 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