357 Septic Permits & Compliance 2014 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
212 MAIN STREET
(413)587—1214 NORTHAMPTON,MA 01060
FM(413)587-1221
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:
' O Sarah LaValley,Conservation,Preservation and Land Use Planner
5LaValley@northamptonma.gov
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton, MA 01060
Property Owner: CLA2PNCe-DEL%SL,E Address: 3570o6Ei 14840OU2a> •
1,..07- Os- 03•
Engineer: 1 c.i .eo Scmrr
Conservation Commission Conservation, Preservation and Land Use Planner
Date:
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CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
BOARD OF HEALTH MEMBERS: Donna Saloom, Chair Joanne Levin, MD—Suzanne Smith, MD, MPH
William Hargraves—Cynthia Suopis, PhD
STAFF.-Merridith O'Leary, RS,Director—Daniel Wasiuk Inspector—Edmund Smith, Inspector—Lisa Steinhock RN,Nurse
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE:As of 1/1/11,Septic System Permits will not be issued by the Northampton Health Department
until we receive this form signed by the Northampton Conservation Commission Staff Member.
The Conservation Commission can be reached by contacting:
O Sarah LaValley,Conservation,Preservation and Land Use Planner
S La Vallev0 northam oto nma.gov
587-1263
Office of Planning&Development
210 Main Street Rm. 11,City Hall
Northampton,MA 01060
Property Owner: (c4,CeA CC OLUStE Address: 2 3-7 Co-as /1e06-z-c) (avri
Engineer: r?tc1t Sry-r-r F'E r
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Conservation Commission'Eonservation, Preservation and Land Use Pl nner
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212 Main Street,Northampton,MA 01060
Ph (413)587-1214 Fax(413)587-1221
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Commonwealth of Massachusetts
City/Town of New Salem
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
® Repair or replacement of an existing system
❑ Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
8 Dot/7 et
OS Date
zntY - I )
DSCP Number
Clarence Delisle
Facility Owner
357 Coles Meadow Road
Street Address or Lot N
Northampton
City/Town
Designer Information:
Richard Scott, P.E
N
ture
Installer Information:
Dave Loven
Name
Signature
MA
State
01060
RM Scott&Associates
Zip Code
Name of Company
8-27-2014 •lb,„,i4
Date ��"7�
Loven Excavating
11-7S-t4
h.JR�=Nr?ethical
Name of Company
ii - 5--'a0x9
Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certific
des
Beyrig Authority
e sha I not be construed as a guarantee th t the system will function as
l(a_ r
Signal
Certificate of Compliance•Page 1 of 1