330 Septic Applicacation & Trench Permit 2010 COMMONWEALTH OF MASSACITUS£TTS
Board of Health
Nor-!m
MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
'EE
Application for Permit to Construct( ) Repair(}/Upgrade( ) Abandon( ) - O Complete System ❑Individual Components
Location o 7 t
S /�%e/LbW N
Owner's M, r5 re-r .) e s S,sv
Map/Parcel#
Address ,SG me
Lod*
Telephone#
Installer's Name t< ii su.S 6 x6
Designer's Name
Address -17_, ✓e r ) r-
a2i � 1 ,��
ua,)�e�
Address
�/
Telephone# t..//3-5"I � S3q(6
Telephone#
Type of Building Lot Size sq.ft
Dwelling-No.of Bedrooms - Garbage grinder( )
Other-Type of Building No.of persons Showers ( ),Cafeteria( )
Other Fixtures
Design Flow (min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil(s)
Soil Evaluator Form No.
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS epl G (� C 5 /0 r y//k-J�"/ )'l pe u. t'YI Y(/)
Fr Or+'1 >40ufe —CO Seri; c r4n)Cc
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the s tem in o eration until a Certificate of Compliance has been issued by the Board of Health.
Signed IEI a .. • _ Date /J,'Z1`f/)
Inspections
No
COMMON WFAIN OF MASSACHUSETTS
FEE
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ).Upgraded ( ).Abandoned ( )
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow (gpd)
Installer
Designee Inspector, Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE ,'
COMMONWEALTH OE MASSACHUSETTS
Hoard of Health, ` / !t- , .M,--) MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at 17-:-RC!
Disposal System Construction Permit No. 70 fr-? ( dated o ).29/Iii .
Provided: Construction shall be completed within three years of the date of this permit All local Coll cjrfior S oust be met.
as described in the application for
Farm 1255 Rev.5/9e A.M.Sulkin Co.Chaoeown)M
Date giVi A t iJ
Board of Health
`ec 29 2010 9: 42 City of Northampton DPW
CiJ U j 12_21-IC
CITY OF NORTHAMPTON
DEPARTMENT OF PUBLIC WORKS
125 Locust Stret
Northampton,MA 01060
Phone413-587-1570
FAX 413-587-1576
(413) 597-1578 p. 2
EMERGENCY 330 COLES MEADOW ROAD
Permit --3}
PROVED DISAPPROVED
Date Is streLl ..
By
TRENCH PERMIT
Pursuant to G.L.c. 82A § 1 and 520 CMR 7.00 et seq. (as amended)
THIS PERMIT hill ST BE FULLY COMPLEII )PRIOR TO CONSIDERATION
This permit(License fa cabma on any pdbllc way and private property)6 issued under tbeiremarwin of MOL a 82A 31 cod 520 CMR 1400
and Section285-21 or-the Re.isd Cadinanors of the City ofNrrhampwn subjr7 to tie"Spaaficauons for Care of Stem Clan"armored mod adopted
ea Ix Department et-Public Works on Sentember 21.1991.The applicmt hereby epees to prolat aE cuts with barricades and Tights,andtn save the
Cty of Northampton:iermlem Emir all claims for damages whatsoever rinsing Cram the occupation of all properties affected by this remit until such
time as the work has bornapproved and accepted by the Department of Public Works as provided for below,and in the case of privateimam.to pay all
charges for resurfwsng
Fix.S250.00 Check# f f :Valid for 30 days from date of approval.Expiration Date,e
Cell
Name et Applicant
A
Street Address
Gryrlawn_ - STATE ZIP
Name of Excavator(if different from applicant) ?hare
Strut Address -.
City,Tawn STATE ZIP
Name of Owmets
Street Addrt.t
Tc- ..:.:...r
City/Town STATE ZIP
cell
Ccl
Locator,of proposee trench: -' '._ .. d#::OI.SS ifid = ,»:.
Description and purpose of proposed trench:please describe the exact location of the proposed french and its purpose.Include a
description of what is(or is intended)to be laid in proposed trench(eg;pipesicable lire etc_ )
Estimated daies of occupation of street:
Insurance Certificate#.
Name and Contact Information oflnsurer:
Policy Expiration Date:
Dig Safe#:
ALL PERMITS ISSUED PURSUANT TO 520 CMR 14.00 SHALL DE POSTER IN PLAIN VIEW ON THE SrrE OF THE TRENCH
Note-Contractors win be charged for laspections requested oabide of regular worming hours(7:00 a.m--3:00 p.m.M-F)
NOTE:
ITEMPORARY
PATCPI REQUIRED
Contractor to notify DPW when job is in progress.
Engineers need time to this service for our records-
INFRA-RED SHALL BE REQTAIMD AFTER TRENCH CUT IS MADE
e
6146 o f SZS 1 413 PIIMBPJPAlo POOjAra I P• 3
FMERGENC 330 COLES MEADOW ROAD
BY SIGNING THIS FORM,THE APPLICANT.OWNER,AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT
iIEY ARE FAMILIAR WITH,OR BEFORE COMMENCEMENT OF THE WORK,WTI.1.BECOME FAMILIAR WITH,ALI.
LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGtILAT IONS,31.E R2A,520 CMR
3.00 et. seq-,AND ANY APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENAN 1
AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN
ALL RESPECTS AND WITH THE CON I)I TIONS SE f FORTH BELOW.
THE UNDERSIGNED OWNER AL IHORIZFS TIIE APPLICANT TO APPLY FOR THE PERMIT AND TILE EXCAVATOR TO
UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER,AND ALSO,FOR THE DURATION OF CONSTRUCTION,
MITE ICI RIZES PERSONS DULY.APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR
AND INSPECT THE WORK FOR CONFORMITF WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND
RF,CAJIAT[ONS GOVERNING SUCH WORK.
T HE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE
MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION W ITH
THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMI TED TO ENFORCING THE
REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PH RMTI,INSPECTIONS MADE I O ASSURE COMPLIANCE
THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT
OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREW'IIH INCLUDING POI ICE DETAILS AND OTTER REMEDIAL
MEASURES DEEMED NECESSARY BY THE MUNICIPALITY.
TEL UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOLD HARMLESS THE ML:S`ICIPALITY AND ALL OF ITS AGEN IR AND EMPLOYEES FROM ANY AND
ALL LIABIEIIY,CAUSES OR AC DON COSTS,AND EXTENSES RESULTING FROM OR ALIENING OUT OF ANY INJURY.
DEATH,LOSS,OR DAMAGE TO.ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT.
EXCAVATOR SIGNATURE(IF DIFFERENT)
OWNER'S SIGNATURE(IF DIFFERENT)
DA rE 1a zq-`o
DATE
DATE