232 Permits & Plans BOARD OF HEALTH
JOHN T.IOYCE.Chairman
Anne Bures, M.D.
MICHAEL R PARSONS
PETER I.McERLAIN.Health Agent
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
To: Mr.&Mrs. Randy Andrews
232 Haydenville Road,Northampton
From: Peter J.McErlain
Health Agent
Date:, June 30, 1993
Subject: Sewage Repair Permit Application
210 MAIN STEM
01060
14131 596-6950 Ext.213
The Northampton Board of Health is in receipt of your application for a permit to repair your septic
system at 232 faydenville Road.The setic system plan and application have been approved.The permit
to repair the system will be issued upon payment of the twenty dollar($20)permit fee,made payable to the
City of Northampton.
Also,I'm returning to you,Mr.Drake's bill for the engineering services which you had enclosed along
with the plans and application.
Please contact the Board of Health if you have any questions concerning the septic repair permit.
Thank you.
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C.E. Roberts Jr. & Sons Construction Inc.
#37 Berkshire Trail East
Williamsburg, MA 01096
(413) 268-3341
Monday, August 19, 2013
To Whom It May Concern:
This is a notice that the Disposal System Installer, C. E. Roberts Jr. & Sons
Construction Inc. certify that the septic tank at 232 Haydenville Road Northampton,MA.
01060,has been replaced with a new 1500 gallon tank,to the best of our knowledge in
compliance with 310 CMR 15.000, and all local requirements. I have enclosed an as-built
plan with this letter.
Thank you,
Sine r Richard C. Roberts
Secretary
C. E.Roberts Jr. & Sons Construction,Inc.
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Important:When
tilling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
t3 - 13
Number
$150.00
Fee 5v3 uJ /w Acck5
185— co-s\
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
Upepair or replace an existing on-site sewage disposal system
VRepair or replace an existing system component
Location of Facility: / ��
N%r�✓sin vim
Address or Lot
/1. / (Lerc's
City/Town
2. Owner Infor ation
Name
Address(if different from above)
Cityrrown
tt
State
oio4e3
Zip Code
3. Installer Information LiLJ r ^s 6-4 Lx
J t k oto_3
State Zip Code
V/3--s/9 -ice
Telephone Number
Name / / 1;--4,1/ _ Name of Company
l J Or r/sI;r+
Address , 3� K
r c�--• v
City/Town
4. Designer Information
Name
Address
CilyrTown
O9
State
'!^V,11 A Of
Zip Code
0 9/2-0267-3,14/
Telephone Number 6
Name of Company
State Zip Code
Telephone Number
tsfonnl a.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
2O0) - t3
Number
$150.00
Fee
A. Facility Information (continued)
5. Type Building.
Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
Number of showers
❑ Garbage Grinder(check if present)
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
Gallons per Day
Gallons
Date of Original
Number of Sheets Revision Date
Title of Plan
8. Description of Soil
9. Nature of Repairs or Alterations Of applicable):kr-
f^ K
10. Date last inspected:
Date
tbform.'a.doc•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 Fee
Form to
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 th ystem in pe�iuntil a Certificate of Compliance has been issued by this Board of
2-0 S - i3
Number
$150.00
Health
Signal
A lication Approved�By4:
ame i�
15form I a doc•06/03
Application Disapproved for the following reasons
Date
g711241"3
Date
Application for Disposal System Construction Permit•Page 3 of 3
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key
clt
t5form3 doe*06/03
Commonwealth of ( a9sachug�ts
City/Town of i w ,,p
,
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):
DSCP Date
DSCP Num
Papal
Street Sor Los d
A. � / L RI — --
9es —._
State
City/Town
Designer Info ation:
Name
Signature Installer Information //
a- �A el{
Signature
a/05
Zip Code
Name of Company
Date
_CCIA6140 041 .-4.16
Name of Compan{
Date
Use of this ystem is cond.Toned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed
-.140044-f I,LA4/'/ JO,
Approving Authority -
49/ i3
Date
Certificate of Compliance•Page 1 of 1