748 Septic Applications Permits & Compliance HERE APPLICABLE
CHECK OR FILL IN
Nn._.6.RL..__.
THE COMMONWEALTH OF MASSACHUSETTS
OARD OF HEALTH
.Appliratinu foruflinpnuttl �u,trurtinu 1Jrrtnit
OF
Application is hereby made for a Permit to Construct (
System at:
) or Repair (
) an Indic idual Sewage Disposal
�o« °: ukti or Let
«:1 L.lLkt Address
Jast.LTer Add.en
Type of Building Size I.ot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Shower, ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily Flow gallon*.
Setic 'rank—Liquid capacity gallons Length Width .. . 1 eter Dept
Disposal Trench—No Width Total Length Total leaching are sq. It.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. it
Other Distribution hoc ( ) Dosing tank ( )
Percolation Test Results Performed by _ Date
Test Pit No. I 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
Description of Soil.
Nature of Repairs or Alterations—.Answer when applicable__!,{.>,T',- -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article SI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued by the hoard of health.
/0 '{�
Si i nc W. L4.- + Q%
Application Approved By ... . _-t . ` 6f .....9 ',_ 'L97s-
t5ae
Application Disapproved for the following reasons'
Permit No /4 Issued
Date
Dat
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
hlrrtifiratr of Qlvnipltaurr
THIS 15 TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
b
)
at
Las keen installed in accordance with the provisions of Article NI 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
Otrrtifiratr of OCnmplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
at
has been installer) in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application far 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
THE COMMONWEALTH OF MASSACHUSETTS
/ r}
No Diopnoal 'Marko atmintrnrrtinn Permit
Permisson is hereby granted
to Construct ( ) or Repair ( ) an Individty Sewage Disposal System
BOARD
OF
OF HEALTH
Int
at No Stan
as shown on the application for Disposal Works Construction Permit No i Dated
nw.d n[ llaalnl
DATE
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
No 1.- -1 -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY-OFNORTHAMPTON
Applirtttinn for liopoottl Marko Tottstrurtinn hermit
Application is hereby made for a Permit to Construct ( ) or Repair Individual Sewage Disposal
7d 7
System at:
1p1p '' Loradon. dda
Owner.... .. _
Installer Address
Type of Building Size Lot Sq. feet
Dwelling.—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
or Lot No.
ECK OR FILL IN WH
V
lions per person per day. Total daily flow gallons.
Liquid capacity.'(111- lons Length Width Diameter Depth
Tench-- No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ��
minutes per inch
minutes per inch
Test Pit No. 1
Test Pit No. 2
Description of Soil
Nature of Repa
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System
the provision; of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to
operation until a Certificate of Compliance has been issued by the board of health.
Sig
A. -t ev
Date
Depth of Testt Pit Depth to ground wate
Depth of Test Pit Depth to ground wate
erati ns—Answer when at• icable
Application Approved By
Application Disapproved for the following reasons
in accordance with
place the system in
[
#/i(oter
Permit No F- +f
Issued lift ¢y Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY opNORTHAMPTON
hirrtificate of (0114111unit fired
THIS IS TO �jERTIFY, "f�at the noiyidual Sewage Disposal System constructed ( ) or Repaired (`Y
at
has been installed in accordance with the provisions of TITLE S�The State Sanitary i
Cod detribed in the
� dated
application for Disposal Works Construction Permit No 1(-- - Y'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANNJ
E THAT THE
SYSTEM WILL �FU1/�CTIQN SATISFACTORY. it K (/.
DATE (Q.{ 7/ cy Inspector YSLU21. Jam---
! THE COMMONWEALTH OF MASSACHUSETTS J J
OF OO AROORF I-IEA ON
FEE C. re
No
OF
Binposal ranr1ku,4unotr t PP permit
Permission is hereby granted
Construct ( ) epair (V) an Individual Sewage Disposal System
at No Street
r Dated
as shown on the application for Disposal Works Construction Permit N1...;�
Board of Health
DATE
/1/l Q tt
FORM 1255 A. M. SULKIN, INC
BOSTON
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
41 OF / vne4(:arhfton
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
F . ,U FO
t,tet4. iFw t- re6iz7
anon for a Permit Io Construct f1gR epairt/Upgrade ( ) Abandon ( I - ']Complete S.xtem ]Intlic idual Components
7A-8 t:t,i _ ,, P<„a,l
M�v/y Lo� Cur4 ;,
(_h ri a Hain.
742 .-nu.- ",�:rl > r new
Address`
5 S4- - 024i
MA c., G.2.
>IA . ICIZ
Ir.enon
Map Paul e
Lel,
4 � tw..
• t i-(
Pr R(. . ` I-i
lel.phona. i
F pkg:C4o mc.-.jn
t +i c r�
I ,4p r(; lv
.Address
zkre- - 44-91)
Talcplmoe t
I r]lallar'.].vir,
ALMA..
Tcicpdonca
Tvpc of Building: 5r -L
Dwelling—No.of Bedrooms
3
Other—Type of Building
Other fixtures
No.of persons
Lot Size ),7 .4eci Sfrkcr
Garbage Grinder (Ho)
Shower 7 ). Catetena ( )
Design Flow(min. required) 330 gpd Calculated design Flow 330 gpd Design flow provided 763 gpd
Plan: Date Pit fo5- Number obahheets r Revision Date
)'-''
Description of Soil(%) I L .t,,.1 Y r.. ‘
Soil Evaluator Form No Name of Soil FA aluator a. '1 Z.e.,.-Incas Date of Evaluation /8/C-5
. 1.4..1
DESCRIPTION OF REPAIRS OR ALTERATIONS
I ; --F- SA. c■ . 4' , 3S' I �y Ict
k s. A. r 4....k 41 I , it -za .t c - b.0 5 1k°.-'.cv.
The de s g ed agrees to install the above described Individual Se age Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place th system in operoaon until a Certificate of Compliance has been issued by the Board of Health.
. f Signed / A i(��(itn.t✓ Data r7 l:�S� /rr OF
Inspections
J A-,
at
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
ED 04
Description of Work:
THFI COMMONWEALTH OF MASSACHUSETTS FEE 5 0' `_/sd
is, it / THHAI.116,5N BOARD OF HEALTH ,94� ,!y��./'4 (CZ 7
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disppy'o-sal System,,Constructed( ),Repaired( ).Upgraded( ).Ahandoned( )
by: e i A 14 i.d 1 , 44 ,„LAaa- ■ Y'G-,? . -_:6d 46 ill i / s .'66. G � , I,41 ...
at t r J.i�1,7e.-----"-. "__"?4t.,....:>/..., t"
has been rust fled in accordance with the provisions ofd 0 MR 13.00 (Title 5) and the approved design plans/as-built
plans relating to appl cation Noe .Chi. dated %S /f�e�i j Approved Design Flow `���_(gpd)The issuance of this certificate shall not be construed as a guarantee thaf the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
Installer /
i1
N oty -3/ THE COMMONWEALTH OF MASSACHUSETTS FEE )5' (I
�.I;:/ ; N:..�r kh BOARD OF HEALTH /Cisi . S4: a.. -
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair (✓) Upgrade (VAbandon ( ) an individual sewage
disposal system at t e — c.r f / as described
in the application for Disposal System Construction Permit No. 21.1(-)S-- 2 .dated O VO/Al S— .
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must he met.
Date Leis --112-- /c--./ ZOOS Board of Health 1Ctc.
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 1 R EV 5/561 (H&W) HOBes&WARREN
PUBLISHERS - BOSTON