851 Applications & Permits ORIGINAL
COMMONWEALTH OF MASSACHUSETTS
Board of Healthi1/410414104 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
��
EO gry1Tt�
ration for a Permit to Construct( ) Repair( Ipgr Aban
ade( don( ) - lerrnplete System U Indrvidval Corompon
-anon
15l Ae
Owner's Name Palki laMQf-g
0
p/Parcel#
Address a� ra1U c /I'
#
Telephone# /C7. 30
filler's Name
4.A.u'
Designer's Name 41,, f/v' f
Iress _
���lv�
fw lneg �
Address
ephone#
•
- /- 0
Telephone# /' -3- 3-
of Building
ing-No.of Bedrooms
•-Type of Building No.of persons
Fixtures
n Flow (min.re/quirk;
sq.ft
c grinder VIV
Showers ( ),Cafeteria ( )
I.otSi.'e iV
110
gpd Calculated design flow
330
Date 9 211 Z Number of sheets
Sephc Sisk ay. r 20 i
iption ofSoil(s)
valuator Form No. Name of Soil Evaluator 4. /55
Design flow provided 327 gpd
Res siou Date
Date of Evaluation 74.116Z
:RIPTION OF REPAIRS ORALTERATIONS /Vac) S .- I ojk d- . 'L. /C/Iks
ndersigne s to i above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
er agree to plac e tem in operation until a Certificate of$omphance has been issued by the Board of Health.
d , ✓` Date y 7 Sd
etions
COMMONWEALTH OF MASSACHUSETTS
Board of Health, A01e-kha4Mpi-oN MA.
CERTIFICATE OF COMPLIANCE
iption of Work: ❑Individual Compovent(s) y�('omplete System
ndersie ned hereby certify that th- Sewage Disposal System; Constructed ( ),Repair
a .f Cu S
7c1 IA ►f ifyir r•
tolled in accordance witO the provisions of 810 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
anon No. /3' 7 rdated
1--(933—Approved Design Flow -39 d
per T
u i )
Inspector: #W / Is Date:
r
nuance of this permit shall not be construed as a guarantee that the system wJl function as designed.
FEE 4/C
),Cpgmded O-Abando ned ( )
uanee of this permit shall not be construea as a guarantee that the system will function as designed.
yz
COMMONWEALTH OE MASSACHUSETTS
Board of Health,
DISPOSAL SYSI{ CONSTR CTION PERMIT
FFF
eion is hereby granted to; Construct( ) Re air U(pgta e( ) Abandon( ) an individual sewage disposal system
/, Ipo p'
5 / v(� ���'q�vtq7 /_K/, as described in the application for
al System Construction Permit No /Y—O dated ' ' —(Y.- —
ed Construction shall be completed within three years of the date of thisvermit. All local conditions must he met.
ees 5ee6 eMSwr4co.aonon MA Date 7 i ( .)13oard of Health /L -Ls_ "�- / e--
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY oFNORTHAMPTON
Qlrrtifirttte of Tomptianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (G)--.
Installer
s been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
,placation for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT SE CONSTRUED AS A GUARANTEE THAT THE
TSTEM WILL FUNCTION SATISFACTORY.� � �..
ATE / 1 y - 77 Inspector i ea(4 tom, ,t ..-1----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CITY o1NORTHAMPTON
flthpanttl 3 1t Ai i strttrting ; FYmit
z
Permission is hereby granted
i Construct ( ) or Repairan Ittditidual-Sewage Idtsposal System'
No —4 71
7—•_--
Sttee['� y,
shown on the application for Disposal Works Construction Permit i' Dated. ,-1/
SATE / Y
FEE/. L.i
Board of Health
i
t
1,, � �2_2 Ems /O
THE COMMONWEALTH OF MASSACHUSETTS
I Sin RRA RwM 'LTH
Appliration for Disposal D irks Tonstrnrrttion ratan
Application is hereby made for a Permit to Construct ( ) or Repair ({4j an Individual Sewage Dispc
System at:
4121/4) 60.(
Locano re IRes 7 Air Lot So IC
W Address
ci t�Lau:: ,j mere..
pa
U Type of Building Size Lot Sq. I
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder
"1 Other—T e of Building Showers
W Type g No. of persons ( ) — Cafeteria
a, Other fixtures
W
Design Flow gallons per person per day. Total daily flow gall(
Septic Tank—Liquid capacity gallons Length Width Diameter Depth—._
W
x Disposal Trench—No. Width Total Length Total leaching area sq
• Seepage Pit No Diameter Depth below inlet Total leaching area sq.
z Other Distribution box ( ) Dosing tank ( )
.] Percolation Test Results Performed by Date
1.1 Test Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water
L Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
a
O Description of Soil
UW AA V
Nature of Re r Alttipns f A when applitablps yd
Agreeme : T
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance u
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system
operation until a Certificate of Compliance
--°_������--``�-bee: issued by t e board of health.
fir . / t�
Application Approved By _ i . ._ .•a�:�f�./.e-25
Application Disapproved for the following reason • M e
4 l 1�/r/ / Date
''•_ ° Issued / ""t'Y Fy