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B' C;.f..:~.!? Fu.4.!j.Q ........... . THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .. ........ .. 'l'OW!1 ........ OF .... Amh~:r.!!.t • ... M!:l§!;l .. ............................... .
AltpliraUon for ili!lpo!lul lImurlt!i QIolt!itrurtiou JrrUtit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
........... £.. ... J.l}gJ!'!-.D..yJp.g ... ~:9.l}.~............................... . .... A.Qt ... H ... .2.4 ..................................................................... . Location · Address or Lot No •
....... F.lant.a.tion ... llalley ... liom.e8+ ... InC.......... . .... BOx. .. 7. •... F.lar.e.nc.eZ
... Ma ..... OlO60 .. _ ......... _ ... . ... ~fJ/. c ~ c ,/ ... ~ .. ~ .. L.~":i;~. ..~ . ..s;;..,..r .. :?' ..... ,...... S'tJ ... ~ .. "!.dr ... t!:~.~ .. du .. R..!.P..(,.~
--~ ····r ···· Address
Type of il~'ild;ng . . Size Lot ... '!R .. ,GIG ... : .... Sq. feet Dwellmg - No. of iledrooms .... 3 .................................... ExpanslOn Athc ( ) <::"arlfagl!""Gnnder (Ie ) Other - Type of iluilding . .frame ............ No. of persons .. l1aX •... 6 ........ Showers ( ) - Cafeteria (
Other fixtures .................................................................... ... ...... ....... ................................................................. . Design Flow .................. .5.5 .................... gallons per person per day. Total daily Aow ................ .. 3.3.0 .................. gallons. Septic Tank - Liquid capacity .. l.5Qq-allons Length ...... 10 .. • .. Width .... 6 ...... .... Diameter ................ Depth ..... .5..· .... . Disposal Trench - No . ... .. ............... Width .................... Total Length ... ................ , Totalleachiug area .................... sq. ft . Seepage P it No ........ .. 4 ........ Diameter.15.o. .. K<;l;!' Depth below inlet.. .... 2~.· ....... Total leaching area ...... 800 ... sq. It.
~;~:~I~~~~i~~~tO;~~~t~ X) PerformedD~;i1.;~~ .. b~1Q!LR..S •......................... Date ...... .5J.8.~ ......... ......... . . Test Pit No. 1 .... 4 .......... I11;nules per inch Depth of Test Pit... ... . 3.2.'.~ .. .. . Depth to ground water .. M.o.ne ......... . Test Pit No. 2.!":~.~.~.minutes per inch Depth of Test Pit... .... 13.2.II .. Depth to ground \Vater .. N.Qne. ......... .
Description 01 Soil .. . Q'~ ... :tQ:j?:i :: J9:P.:§:Q:U:: :;:: :§:;;::::t9.:::i~;;: :: :~~~iiQ:;::t:;·.·.·.·i.aii.·.·.·.t.9.·.·.5~·ii .. ·.·.iiii).<iif.· ... ·.·.· .. .. ...... .. gr~.Y~J ... ::: ... 3.f.?~ .... t.Q ... U.4.~I ... Knw~J ... :~: ... U~" .... t;.Q .l.3.;;>." .... !! S\n!1..~ ... nQ ... }:!il,t.~.r. .... at ... 13.2.'~ .• ························· ·· · · ····· ·· ····rvll~rtL'~{f .... ·J::-,·IO.f>.O ... ~Jh. .. ~ ... ................ . Nature of Repairs or Alterations - Answer vhen applicable.. ________ .. __ .............. __ ........ .. .................... .... : ........... -................... .
Agreement: The undersigned agrees to instal1 the aforedescribed Individllal Sewage Disposal System in accordance with
the provisions of ?ITLE 5 of the State Sanitary Code - The l1nuersigned further agrees not to place the system in operation until a Certif,cate of Compliance ha~ , bm. is~ed by the board of health.
. /' ,.. /i", ~ .. ' I- 6/1/84
C /~lIne(l... ... l-4'i/(oIL'lllW .... St~.t'Il... . .. ........ .... . ... .. . ........... ................. .
Application Approved ily ...... ..... e:z\~~\.\., .............................. !~.4<:-.'Jf'.l(~ ...... .c& ...... :t~tJy ....... . . U D;\te
Application Disapproved jor lire jo/lowillg reasons: ........................................... ....................................................... ~ ............. . ..................................... ~.y .. ~ .~~ ........................................................ ...... ·· · ··· · ·· ··· ···· ·· ······ ·· ···(~····ii;~;····· · ·· ······
Permit No ...... CX ............................................. _ Issued. ........... te .. -:-... 7.: .. If ... !. ................. . Date
THE COMM O NWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................... ..... .. ................ OF .. . .. ..... ..... .. ........ .. .. .... ........ .... ... .. ............. ... .. .............. .
C!trrtifitutr of QIoUtpliulttr THIS IS TO CERTIFY, That the Individual Sewage Disposal Sistem constructed ( ) o r Repaired ( )
by ................................................................................................................................................................................................... . In~t;lller
at ..... __ . __ ... . __ .......... __ .. . ____ . __ .............. __ ._ .. _ ._ . ~ ._. __ .-.-.-._ ... _. -_ .. -.... -......... __ ... _ .................... ............................... ___ ...... __ _____ . __ ._ ... .. ....... ______ ..
has heen instalJecl in accordance with the provisions of TI T IE 5 of The State Sanitary Code as described in the applic.'l tioTl for Di~pos,..1.I Works Construction Permit No __ ____ __ ____ __ . _______ . ___ ._.____________ datecL .................. .. . __ ..... .. ... __ .. ______ .. .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.
DATE ..................................................... " ......................... . Inspector ................................................................................... .
THE COMMONWEALTH OF MASSACHU5i!TTS
Ott · 2/. N o ... f2 .. L ......... -: ... .
~ BOARD O~ HEALTH
........... .LQtQIJ. ....... OF ... ....... /:ll!J/:I.(~<;,L ..... .......................... . -;:Y Q 7J FEE .•. ./...( ••••••••• .
FO RM 125!5 A . M . SULKIN, INC • . BOSTON
;51 f'( etJf c... ~
$Q:fvC?ltI 'cP~-'
d S G,-8L(Ca
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Distance = 150>: Slope
1<: ~~ ~ ,
V · .-.....)
L( 2% Min.) Finish Grode
4"Dio. (Alternote) J 12" Min. . . J 12" Min.
Iternoj~~· , J . Tc)p of Structure (Alternate) 1 - --=-~ -, -r~'~::J: :lJlIi. . :"i:;:;~·-~Min, 2"-: 1/8'_1/2" I i
4" Dia. fL- --= .... ' .. _l} . . Inlet'-""J-tT~fos~~ed \ Natura l Soil _.,.. . . "-- I r I Invert
Measure Slope at this Point
- Ii I 1\ _ ----..
':>/4 -I ~2 12" Min. I Washed Stone 48" Max. ~
LEACHING PIT, ~ GALLERY or CHAM"':",S:-'E=-R:-i:>1
rEffective Depth
Excovotion '1' Sidewall - -':"~I 'I I . v I
J I .. . 1 EIf"t;" W;dlh" D;omet" . . ~
. I Min.: Twice EffectIve Width, Diameter
. or Deptrl
LEACHING P iTS ~ 'Gki..L ERIES, •
CHAMBERS .. , No Scole
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I ~. 'Illustration ., .:. ~
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THE COMMONWEALTH OF MASSACHUSErrs
BOARD OF HEALTH Town .......... OF .ltllll:IE!x:?:t;L.Iv1<Ol~ <; .. ~... ...................... .
.i\pplitation for iJi!!po!!ul mork!! <!ton!!tructinn 'rrmit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
.......... ..3.~L!~g.~.~~ ... ¥.:~.P..~ ... ~~!.:~.................... .... ..... .. . ..... !,..~.~ ... f!. .. )~ ................................................. _ ...... _ ......... . Location· Address or Lot No .
........ p..+.;;m:t.,Lt.!.Qn. .. y.9.JJ~y. ... !:l9.m~.§.~ ... ln5;........... . ..... l?Q.~ .. ..7., .... fJQ.r..~n.9.f!.~ .... !1<i!.~ ... QJ~§.Q ........... _ .... . Owner 5 K hAddrcss
...... ~!?~!'!.rs.I? .... JL ... Mv..(X."'<k.'1 .. !!' .. $..e&'s..I-.~~... . . .... 'j!. ... gl!l:~ ..... .'~ . .l ...... :~:ru;.~ai..t·MB.··~t:.eL.e .... . Installer Address
Type of Building Size LOL.:~e ... 5~ ....... Sq. feet Dwelling - No. of Bedrooms .... .2. .................................... Expansion Attic ( ) Garb'age Grinder (X ) Other - Type of Building . .fr.~.m~ ............ No. of persons ... )'Jj<3,:x: .•.... § ........ Showers ( ) - Cafeteria ( )
Other fixtures ......................... ......................................................................... ................................................... . Design Flow ................... 5.5. ................. .. gallons per person per day. Total 'l5ily flow .................. J.~.Q ................. ga!lons. Septic Tank - Liquid capacity.),5.9qallons Length ...... J.Q.' .. W idth ........ ' ....... Diameter... ......... .... Depth ....... :?' ... . Disposal Trench - No ..................... Width .................... Total Length ........... .r. ....... Total leaching area. ................... sq. ft. Seepage Pit No ........... ? ...... Diameter..'l.2.Q ... gil-.l Depth below inlet ....... ?z..~ ...... Total leaching area. ...... ~Q.9. .. sq. ft. Other Distribution box ( X) Dosinf tank ~ ) I Percolation Test Results Performed by ...... r..~.g ...... .i.J.Jg.;:? .. R .•. $.., .......................... Date ........ :? .. !'l~ ................... .
Test Pit No. 1 .... .? ........ minutes per inch Depth of Test PiL. ..... 2.2." ..... Depth to ground water ... ~<:lI1:~ ........ . Test Pit No. 2 .. :-::-:::-::::::minutes per inch Depth of Test PiL. .... J.~.2." .. Depth to ground water ... ~.()I1:~ ......... .
.. f . 0" ··fo· · · 6ii···fo···soIT·~····bi·i···to·· · "l."i3·ij" · ·sUbS·OIy··-..:···lSW···to····3·6i.,..··iiiIXecf····· Descnp~~v"eio~··ji)·ii· ··io··Ti"4·iiP.···rave"l····.:· · ·ii4ii····fo···132·ii····sand···;::···iio···watei;···Eii···132·jj· • ........... g ......................................................... K ............................................................................................................................. .
Nature of Repairs or Alterations - Answer when applicable .......................................... .................................................... .
~'f -2-0 Permit No ....... G. ........................................ __ _ I~Ued. ............ (g.=7 .... eY.. ... ~.~:~ ...... .
Date
... 'O ....................................................................................................................................................... .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... . OF .......... .. ....... ........ ........................... ........................... .
<!trmfitutl' of <!tompliattrr THIS IS TO CERTIFY, That the Individual Sew"ge Disposal System constructed ( ) or Repaired ( )
by ................................................................................................................................................................................................... . Installer
at .................................................................................................................................................................................................... . has been installed in accordance with the provisions of TIT IE 5 of The State Sanitary Code as described in the application for Disposal \Vorks Construction Permit No ... __ . ___ . ___ . ______ ...... ___ ...... __ ____ dated ... . ___ ......................... __ . _________ _ .. .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.
DATE ............................................................................... . Inspector._._._. __ ____ ... ___ ...... __ .. ________________ .. __ ... ___ ............................ .
~ __ ._ • ..--.. ........ ,-i •• ,., .... ____ • ...-' •• _. _ ........................................ _ ........................ _ .... .. ...... ..... _ .......... _ ...................... ..
THE COMMONWEALTH OF MASSACHUSETTS
0tJ-7fJ No .... O .. L ........... .
~ BOARD OF. HEALTH
... ~ ... .. I&A1 .. ..... OF ........... f}z;;~r... ............... . ~OD FEE •... /. .•....••••••.•.•
FORM 1255 A. M . SU L K LN , LN C. , BOSTON
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BOARD OF HE!\L HI
TOWN OF AMHERST I 11ASSACHUSETTS
~1°+-.3.'1 !dDIM fhp?LA , Important Information Regarding Your Private Sewage Disposal Systemo
DISPLAY THIS DOCUMENT IN A PROMINENT PLACE o 0
Owner fLI11V T71-77aU ~Ih u;.y~j Address
Ins ta 11er LA VIKLPy-l-!S;;;J5,. °Actdress
(jar 7 ~c;-uce.....
iZ'{N f?o £~CC-> Date Installation Inspected and Approved __ --'-?.l-..°-__ I_-f--,,_'-I __ _
Description of System: Tank Capacity: _-,/Lo ".::::;6,!...O::::-.O __
Leach Field ( ) Bed (: ).lSeepage Pi ~ ()(J" Square Feet :o 1sD
Garbage Grinder Yes ( X ) No ( ) Noo Bedrooms: ~ No. People t 1\ Jj ~ (l.M-- M>.& P ,"1\5 (J' S~I~ "
As- BUILT PLAN:
PROPER f1AINTENANCE OF YOUR PRIVATE SEWAGE DISPOSAL SYSTEM
10 This sy~tem must be inspected periodically and the tank pumped out at an interval not to exceed ~ years.
2. " For your protection sanitary pumpers are licensed by the Amherst Board of Health.
3. Regular pumping is crucial to avoid early failure and costly repairs "of 0
the system.
4. DO NOT dispose into the system such items as rags, string, sanitary napkins, coffee grounds as they can cause it to clog and fail .
5. Further information can be obtained by contacting your Health Department at 253-7077.
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