717 Septic Applications Permits & Compliance A No //7" O-.
CHECK OR FILL IN WHERE APPLICABLE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY oFNORTHAMPTON
urkn tuunfrurfinn lrrmit
Applirttfinu fur Dispniwt
rr;
Fiss4C Ore)
Application is hereby made fforr -
aPer Amitt to Construct ( ) or Repair ( Individual Sewage Disposal
System at:
Add
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow
Septic Tank—Liquid capacity
Disposal Trench—No.
Seepage Pit No
Other Distribution box
Percolation Test Results
Test Pit No. I
Test Pit No. 2
or In No.
Address
Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No. of persons Showers ( ) — Cafeteria ( )
gallons per person per day. Total daily flow gallons.
gallons Length Width Diameter Depth
Width Total Length Total leaching area
Total leaching area
Diameter Depth below inlet
Dosing tank ( )
Performed by
minutes per inch Depth of Test Pit
minutes per inch Depth of Test Pit
Description of Soil
Date
Depth to ground water
Depth to ground water
q. ft.
sq. ft.
Natur of Re i
Agreement
The undersigned agrees to install the aforedescrihed Individual ewage Disposal System
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to
operation until a Certificate of Compliance has/be-.• is ued by the a f health.
era7nhitz9ns hen pplica p()��1L/ s--�
Application Approved By
Application Disapproved for the folio
easons•
in accordance with
place the system in
NPY
Date
Permit No
Issued.
by
a.
f he State Sanitary Code as described in the
has been installed in accordance with the provisions No TIil°W j p r Y
application for Disposal Works Construction Permit No dated L'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. /'i�
DATE
I'!r't 1 17 j Inspector./a.l._._e-t�ic� —rl "C (b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY oF.N. QRTHA. MPT0.N
hCrrtifirate of (lrum#dittnrr
THIS IS TOOg I TIFF;What Ike Individual Sewage Disposal System constructed ( ) or Repaired
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No `/ Qt(
!' 11 CITYoF..NORTHNORTHAMPTON FEE/r- ,
Tis}Tnnat Wart Ci nstrnrt n Vr its•
Permission is hereby granted 71 't' eV i _I
to Construct ( ) or Repair��/ ) an Individual Sewage Disposal System
at No 7-i 7 '`ti-fr-w k F- ' •
Street
as shown on the application for Disposal Works Construction Permit No ti , r .Dated
p .-''r ems-t G t
Board of Health
DATE
FORM 1255 A. M. StJLKIN, INC., BOSTON
No 32—?7
/
THE COMMONWEALTH OF MASSACHUSETTS
��tt
t�iC9fl {AMP MA
A�tTTSSACHUSETTS
,L�apticatiun for Pismo{ `$gstrnt Construction Permit
Application is hereby made for a Permit to Construct ( ) or Repair(X an On-site Sewage Dispo al System at:
I ocation Address or Lot No.
717 ruofeailc2 4
Installer's Name,Address and l el.No.
Name Address and lel ?o. ,� "
y Cy4PT i `717 F/t_ORa KF v)
Awi/ Oratil 41
D si Nome.Address a Tel.No.
� .4Hf�f1AV Ssoe Iic /4e qco
Sr a,- ff4A- 'k3 4112-28
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder( (�
Other Type of Building No per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 440 gallons per day. Calculated daily flow 5Ite
-:/SC) 4'7
nDry Q7 r?5
Plan Date
Title
Description of Soil
Number of sheets
gallons.
Revision Date �-
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected-
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Tit e 5 of the Environmental Code and not to place the system in operation until a
if Certificate of Compliance has been iss1. i /�% SA
Signed 'O� /A/_ � , Date
App'cation by
Application Disapproved for the following reasons
Date
Permit No Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
NIomWM-AA r'n7t-J MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( )or repaired/replaced-EX) on
q for
at ill (--0 ee 'A Jr 0 I`1A has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
AJOQTHRMvn' -' MASSACHUSETTS
Certificate of Compliant)?
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( )or repaired;replaced (K) on
for
1 has been constructed in
at �J1 r•-CC `n)C f (`� dated
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE
[''7-
be v o c
O r�. ermissmn is hereby granted to 'T 1
a$
S. a oTStmet ( ) or repair I Aj an •
On-site Sewage S}stefurlocated at _ -
_•y t. descrtlted)in the above Appltd2tion for DisgowL.Astem Construction Permit. The applicant recognizes his her
t comply,with Title 5 and the foifpwing load#provisions or special conditions.
F' / 1 / '�
ruction must be co f)Ieted w�'thiitfiree years of the date below. , j
fire vs*se;C /l Approved by J ..0 L
Inspector
•
•
THE C QMMONWEAVTH.9f MASSACHUSETTS
A,MA THAauiTDk1 MASSACHUSETTS
Disposal $gstem Construction Permit
P"'T,_ -2// 27
- _ c ,
FEE
••4 tixwam•255 Re 395A
*ti. rt :Yaw
No. t°10' il
THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD
(� OF HEALTH
C ' OF A/PetAntely
APPLICATION FO DISPOSAL SYSTEM CONSTRUCTION PERMIT
ora Pemtit to Construct ( 7 Repair ankle ( ) Abandon ( ) - ❑Complete System ❑Individual Components
e.yyu�au�u.
717 k'Mru+ae pis(
To set )) T.w?or*ofLlI D
hci l
'i/3 X48 lthi )
R4,14)..4 � Vt t CS
goi,44- NYA,0 l s stilt-
Doi se's Vamc
, . • •
,
IH
siallvrs
Pro, NA IPPSt" i3v�o�l+v+ON EA
t3 436- )367
q1,3 4745 36
41
Rlcphnoa,
Type of Building: P1,144 e- Lot Size /N,&V&'Sq.feet
Dwelling—No.of Bedrooms 3 Garbage Gnit(der ( 4/p
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min. required) 33 P gpd Calculated design flow 330 gpd Design flow provided 340 gpd
Plan: Date Number of sheets 3 Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. 9 Name of Soil Evaluator F. Dithil r 1 kA% Date of Evaluation 7✓
DESCRIPTION OF REPAIRS OR ALTERATIONS Rop)Abe etth 4(t a
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TIRE S and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Date
Signed
Inspections
DEP APPROVED FORM 5/96
FORM I - APPLICATION FOR DSCP
No. 'Du' I C THE COMMONWEALTH OF MASSACHUSETTS FEE 4 'N
E rf./t BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: V Individual Component(s) ❑Complete System
The undersigned hereby ce rtify that the Sewage Disposal System:Constructed( ).Repaired(V).Upgraded( ),Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 1500 (Title 5) and the approved design plans/as-built
plans relating to application No. dated . Approved Design Flow (epd)
Installer
Designer: Inspector Date
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
No THE COMMONWEALTH OF MASSACHUSETTS FEE
NIbl 1 Year,21::1A BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at i I t I)(art'
r._I( a as described
in the application for Disposal System Construction Permit No. Zo In- 1 Y dated /I ;y . : )cYLI)
Provided: Construction shall he completed within three years of the date of this pyriny.,All local cop' must he met.
Date so s-P+' is 7:. 0 C Board of Health ( ia.,G e„
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 LREV 5/961
�kI�WJ Hoses WARHB+'m
PUBLISHERS - BOSTON