21 Septic Application 2008 important:
When filing out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
m o
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form'IA
Number
Fee .
D-j
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:❑Consmict 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:
21 Cross Path Road
Address or Lot#
Northampton
City/Town
2. Owner Information
Elizabeth Parker Baird
Name
21 Cross Path Road
Address(if different from above)
Northampton
City/Town
MA
State
01060
Zip Code
3. Installer Information
Tom Wanczyk
Name
146 River Drive
Address
Hadley
City/Town
MA
State
413-586-007
Telephone Number
ttlecm
River Drive Excavating
Name of Company
4. Designer Information
Robert F. Sheehan
Name
146 Taylor Street
Address
Granby
City/Town
t5formla.d0c 06/03
MA
State
413-584-1814
Telephone Number
01035
Zip code
R. F. Sheehan Assnciates Inc.
Name of Company
MA 01033
State zip Code
413-467-7228
Telephone Number
Application for Disposal System Construdbn Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form to
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:
❑ Garbage Grinder(check if present)
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
330
Gallons per Day
336
Gallons
7. Plan: October 24, 2008
Dare of original
2
Number of Sheets Revision Date
Repair septic system design for Elizabeth Baird Parker
Title of Plan
8. Description of Soil.
Very fine silty sand
9. Nature of Repairs or Alterations(if applicable):
Complete new system, in 100 year floodplain, grades/contours will not be altered
10. Date last inspected:
Date
t5formla.00 06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form IA
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.
t5fonnla.doc•06/03
S'- Lure
Application Approved By:
PPS-D2 /of2-3IDE
A6wr Date
Name Date
Application Disapproved for the following reasons:
Application for Disposal System Construction Permit•Page 3 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Disposal System Construction Permit
Form 2A
Number
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.
Permission is hereby granted to:
Important Tom Wanczyk River Drive Excavating
When filling out Name Name of Company
forms on the
computer,use 146 River Drive
only the tab key Address
to move your Hadley MA
cursor-do not Cityfrown State
use the return
key to perform the following work on an on-site sewage disposal system:
oir
❑ Construction
® Repair or replacement
❑ Repair or replacement of system components
21 Cross Path Road
01035
zp Code
Facilely Address
Northampton MA 01060
City/Torn State Zip Code
Elizabeth Parker Baird 413-586-007
Owner Telephone Number
The work to be performed is further described in the Application for Disposal System Construction
Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions
or special conditions:
Conservation Commission approval required prior to the start of construction.
All coj., ction must be c within three years of the date below.
� . //—
App •ved by 6 Date
Title 77r 2
t5for2a.doc•06/03 Disposal System Construction Permit•Page 1 of 1