308 Septic Application & Soil Tests 2013 Important:
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Min
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
00/3-/
Number
$ 15
Fee
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Application is hereby made for a permit to:® Construct a new on-site sewage disposal system
❑ Repair or replace an existing on-site sewage disposal system
❑ Repair or replace an existing system component
1. Location of Facility:
308 Chesterfield Road
Address or Lot#
Florence
City/Town
2. Owner Information
Patrick Melnik Jr.
Name
308 Chesterfield Road
MA.
State
01062
Zip Code
Address(if different from above)
Florence MA
City/Town State
(413) 586-4825
Telephone Number
3. Installer Information
TBD (10-,moot a.4ce 2)
Name
Address
City/Town
Name of Company
4. Designer Information
Timoth E. M
Name
inn
01062
Zip Code
State Zip Code
Telephone Number
70 Monte ue '-
West ham L'7
Westham•to I 01027
City/Town y Zip Code
`—�L'iJ��' Telephone Number
t5formla.doc•06/03 ���IYRCW7\� Application for Disposal System Construction Permit•Page 1 of 3
Name of Company
1�0
MA.
State
(413) 527-5291
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
.20/3-/7
Number
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building ---- - ------
❑ Showers Number of showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
2
Number of Sheets
❑ Garbage Grinder(check if present)
8
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
440
Gallons per Day
440
Gallons
September 6, 2013
Date of Original
Title of Plan
8. Description of Soil:
Loamy_sand
Revision Date
9. Nature of Repairs or Alterations Of applicable):
N/A-This is new construction
10. Date last inspected:
N/A
Date
t5forml a.boc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
ao/a-/7
Number
/ :
$
Fee
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
not to place the system in operation until a Certificate of Compliance has been issued by this Board
of Health.
Sinnott'
ApAe • n Approve
✓-G/
Name
By;
/
asndk
Application Disapproved for the following reasons:
Be
±74/3
Dat
NORTHAMPTON E'.;AHb Or HEALTH
212 MAN STREET
NORTHAMPTON. MA 01060
t5formia.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMITH,M.D.
JOANNE LEVIN,M.D.
Benjamin Wood,MPH.Director
Javeria Mir,MPH,Health Inspector
Patricia Abbott,RN,Public Health Nurse
Heather McBride,Clerk
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587—1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON,MA 01060
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE: As of 1/1/11, Septic System Permits will not be issued by the Northampton Board of Health
until we receive this form signed by the Northampton Conservation Commission Staff Member.
The Conservation Commission can be reached by contacting:
0 Sarah LaValley, Conservation, Preservation and Land Use Planner
SLaValley@northamptonma.gov
Office of Planning& Development
210 Main Street, Rm. 11,City Hall
Northampton, MA 01060
Property Owner: c.hij %(eith
Engineer /iri
Cgfiservation Com
Date: (1
Address: $%' c 3 a ix-4W
bt/ /�o6 cf et c/ ,
0 CCWS de/-7;:v0)do eicAd bActf uo-Ptiv6A� - `(QO'€ 3 t°rQzi
ion Conservation, Preservation and Land Use Planner
i.OI 2- lc 9 66ws soil_ te, r
@y HA-six nem Read . Soil- E of 5 SRJ b�E C Ni s yke
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Commonwealth of Massachusetts
j=-ziicfir City/Town of Northampton Fee: Paid? Pi:r C 2 O
71:1147;) Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Z f.ec , O
C. On-Site Review (continued)
LOT a
Deep Observation Hole Number:
Redoximorphic Features Coarse Fragments
Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil
Depth(in.) Layer Moist(Mansell) (USDA) Structure Consistence Other
5 Depth Color Percent Gravel Cobbles Moist)
Stones
sr
0-2- " rt TS'yr- >.>'/( SL 14138- tl{
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sib Additional Notes: J �
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3-S!.
z,z.y e z,?:y Id/ - _ c5 - sacs S ,ate
zv f Gr Y yV.& 45 r, sa8 - feat, Ste.-
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Soil Suitability Assessment Form(Northampton)(form 11)•rev. 1/10 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8
C 7&r mist,,,hoe- “,s Ira>$ say - /975
Commonwealth of Massachusetts
9 1: City/Town of Northampton Fee: Paid?
3 Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
,.1 Lot I
C. On-Site Review (continued)
Deep Observation Hole Number: -)
• ( Redoximorphic Features Coarse Fragments Soil
(mottles) Soil Texture h by Volume Soil Consistence Other
Depth(in.) Soil ayes nl Soil Matrix:Color- (USDA) g Structure Moist
Layer Mois[(Mansell) Gravel
(Moist)
Depth Color Percent
o z et ro 10. 3l¢ Jt.ey 1=R1 • . E
e to 'II-5it la-_.• - r,P+Y•
vet
G, L,sy 9V 57/H y,SyR/ >/O f p Mc -t 3 Ftoe y it 2
le 2 -3' . 40 3N,.5.3
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•Additio al Notes: N €
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ittb 0—z A _ 1° yt _i.
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53 —Idon Cx / 4 S?( s,*a Fitts
l6 C
YP` sy °
I 1
Soil Suitability Assessment Form(Northampton)(form 11)•rev. 1/10 Form 11 - Soil Suitability assessment fo On-Site Sewage Disposal •Page 3 of B I m
/4i.4.- oioc.. 2-31, eaSxtS
Florence-1 Markers,Le gth=Ober 308 Chesterfield Road- 002°20'22.2"N, 072`
Copyright(C)1996,Eartvisians,Inc.