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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