595 Permits & Cert. of Compliance Na.
FORM 1A - APPLICATION FOR DSCP
Fee
COMgvtoNtivEsLCIa-COT 21/449LSSACTilISEh s
Board of Health. Northampton. M
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to: air
() Complete System ( X ) Individual Components
Location 595 Haydenville ROa
Owner's Name Helen Symons
Map/Parcel
Address 9 High St.
Lot#
Haydenville, MA 01039-97190
Installer's name
Telephone# 268-8322
Address
Designer's Name Thomas Leue, Homestead Inc.
Address 1664 Cape St. , Williamsburg MA
Telephone#
Telephone 413 628-4533
Building Type: Dwelling
Lot Size (sq. ft.) 516 200
Bedrooms: 3
Garbage grinder (no 1
Other - Type of Building
No. of persons
Other Fixtures
Design Flow (min. required):
Calculated design flow:
Design flow provided:
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Soil Evaluation
Showers ( ), Cafeteria ( )
330 gpd
330 gpd
330 gpd
fine loamy sand soil
389
Thomas Leue
5/24/06
DESCRIPTION OF REPAIRS OR ALTERATIONS 2 new leach trenches using Leaching
Chambers.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with
...the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance
•has tire&issued by the Board of Health.
Date /0/5/6 4,
DEP APPROVED FORM 596
r
FORM 3A - CERTIFICATE OF COMPLIANCE
No. Fee
COM ■ O91WE91Llr9-I OP 91/4491SSACTITISf/r'rS
Board of Health, Northampton, MA
CERTIFICATE OF COMPLIANCE
Description of Work: ( X ) Complete System ( ) Individual Components
The undersigned hereby certify that the Sewage Disposal System: Repair
by: Rick Chaffee
at: 595 Haydenville Road Northampton
Homestead Inc. Project#: 38�
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 6/24/06 . Approved Design Flow 330 (gpd).
Installer
Designer: ' ' {,yjacad A—CR're--
Date: /Z��c.
Date: 11/29/06
Inspector: Date:
Local Approving Authority
Northampton Board of Health
This certification represents no warranty,' expressed or implied as to the functioning or
longevity of the onsite subsurface disposal system. Rather, the plan and installation are in
compliance with all applicable rules and regulations in effect at the time of plan submittal.
cc: Helen Symons, 9 High St., Haydenville, MA 01039-97190
DEP APPROVED FORM 5/96
FORM 3A - CERTIFICATE OF COMPLIANCE
No. Fee
CONNOIIINT LTVOT a LSS -PLISTIt'S
Board of Health, Northampton, MA
CERTIFICATE OF COMPLIANCE
Description of Work: ( X ) Complete System ( ) Individual Components
The undersigned hereby certify that the Sewage Disposal System: Repair
by: Rick Chaffee
at: 595 Haydenville Road, Northampton
Homestead Inc. Project#: 389
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 6/24/06
. Approved Design Flow 330 (gpd).
Installer
Designer:
Inspector:
s
Local Approving Authority
Northampton Board of Health
Date: /W4/O P,
Date: 11/29/06
Date:
This certification represents no warranty,' expressed or implied as to the functioning or
longevity of the onsite subsurface disposal system. Rather, the plan and installation are in
compliance with all applicable rules and regulations in effect at the time of plan submittal.
cc: Helen Symons, 9 High St., Haydenville, MA 01039-97190
DEP APPROVED FORM 5/95
No. 419°0
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
�p-t- sn+SPCO'i BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Individual Component(s)
D Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired IA)-Upgraded( ).Abandoned( )
bv: ice. _ & ss .. i / is T a7D6a
he provisions of 310 Cr 5.00 (Tile 5) and the approved design plans/as-built
dateda(E/24 et, Approved Design Flow 33 D (gpd)
L Inspector _�✓�'1 �� li Date /I/& 1 P6
FEE 1 ,odyS
at
has been insta
plans relatin
Installer
Designe
The issuance of this certificate shall not be construed as a guarantee that e system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
ed in acpordanc 'with
appl a on
bst
No. 2 :a
THE COMMONWEALTH OF MASSACHUSETTS
1� 1BOARD OF HEALTH
DISPOSAL SYSTEM CONSTTTTTTTT UCTION PERMIT
disposal system at I it- ' ' - .f (Q Z ((]as
in the application for Disposal System Construction Permit No.
��_ �� ,dated
hall be completed within three years of the date of this perm. • II local con Mons must be met.
Board of Health
FEE
,044D4 \
d yq
/Abandon ( ) individual sewage
Permission is hereby granted to Construct (u Repair ) Upgrade ( as described
Provided: Cons
Date
uct
FORM 2 - DSCP
FORM 1255 (REV 5/96)
DEP APPROVED FORM 5/96
f H; ] HOBBS&WMREN
PUBLISHERS- BOSTON
Called North 001 0
Garage
litek
well
Closeout Notes: I '
1. Septic tank is equipped with an outlet filter. This is a outline of 3 bedroom
\\ house
maintenance item. Filter must be cleaned whenever septic
tank is pumped, or every 3 years, whichever is sooner. ,\ 9g
Failure to maintain filter may lead to system failure.
2. Recommend pumping septic tank on a 3 to 5 year y \1 Note:No property lines appear on drawing at scale.
schedule, depending on house occupancy. \./\ Note: not within 100 foot wetland protection zone.
3. A copy of this document attached in the ;''\
basement/utility area will keep this information available in ; I \,\ ,"9:,
/1�
future years for maintenance. A I \ ° //
y,�...\4..A /y
, TBM:nail near base of triple tree
� �
Inspection ports:vertical per(.pipe _ Elevation:100.00'_ __/
from base of chambers to 6"from /
surface.Cap with removable cap- I — New 1500 gallon Title 5 septic tank
T/If' with outlet filter.Risers to within 6"
ffi of surface on all 3 access holes.
oil
37 2 / 1
Ong.Surf.Elev.:91.5'
Trench 1 / iY9i9�1 31 1�9, I' r
✓j ' Vanances Applied For:
Trench 2 ( ^ �Vikir�„� y 3 foot separation to groundwater.
` 1i r
``= -� '
Odg.Surf.Elev.:91.2' .-----”-- ..---.' i
e1 / 90 mil poly breakout barrier,3 downhill sides.
Use Title 5 sand between units and S feet surrounding units.1
As-Built Drawing Date: Owner:
/et
°' c. HOMESTEAD INC. •
Existing Septic System 6/24/06 Helen Symons e moo Thomas S. Leue R.S.
Revision Date: 595 Haydenville Rd. �° �e c , 1664 Cape St.
Scale: 1 : 30' Leeds, MA 01053 9E e`` - Williamsburg,MA 01096
Except as Noted 11/29/06 °494gEO stx�` 413]6284533 a
Important:When
filling 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
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):
20/5—S O /, 5-fro
r)
DSCP Number DSCP Dat€€
Helen Symons
Facility Owner
595 Haydenville Road
Street Address or Lot#
Leeds(Northampton) MA 01053
City/Town State Zip Code
Designer Information:
Alan Weiss, RS
None
Signature
Installer Information:
Cliff Clark Efe 3)24/ - 3572'7
Name
Cold Spring Environmental Consultants Inc
Name of Company
7.24.2015
Date
ame of Company
07.24.2015
Signature -1 foie) ?j 76 Date
Use of this system is conditioned on compliance with the provisions set forth below:
New Leacharea installed, recommended pumping tank every two years
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Approving Authority
Signature Date
t5form3.doc•06/03 Certificate of Compliance•Page 1 of 1
oT AN ACTUAL SLRVEV /' s "'"""san /
I7RAIN FCR SEPTIC
L LIN 1cN V sa�r #SBS EJOS11NG 3 BR
\ DW JJNG
��' \isisif \\1
PS BUILT \
07.24.2015 NN----,, ¢ \\\�
SCALE 1"=30 t,i I.N..,ti L.1._<
M 6 B: 10 L1
r rxw ra : n s
516,200+I-SF �� 11 g0 � + iI,ln i. iY Pn=n.u:,=
p. 101 _
—BM=1W
?T
u
®t e 97
Mr�l. / mvurat
LVE OLD SLS A
]ar
T ti
a _ ten 10(1 toveland
WETS INEF FEFES NIIH NEWSAS
GRAVITY SLOPE SEPTIC SYSTEM OPERATION AND
MAINTENANCE NOTES FOR HOMEOWNER.
1.)HAVE TPN(RINPED EVERY 2 YEARS POW 8C1-WvBFR CFECI®Pl`MNLLV.
2.)MA NIAINAREA OVER SEPTIC SYSTEMAS GRASSY
CRSMIAR GROUND COVER
3)DO NOT RPNFANY TREES CR DEEP ROOT1ND
SFRLUS WTHN 10 FEET OF SYSTEM
4)USF CNLY UOUID DETERGENTS 8 LCW FLON NASFERS. NU IL TO H]OEONERP C CCINTRACTCR
5)W PEAL_OIL AND GREASE FROM COC)MPRE:AND DIS a IN TRASH CON■ECTICNS FROM FEATING SYSTR4 AR2MJMUNI RS,
SIVY PILAFS WITFR\JELL F1LIRAI1CN LNTSPN )FEAT RI/FS
NOT SEPTIC. Axe NGI MAIMED.SANITARY NATOR CCMECIICNS CNLV PaR TIIED
6)All Toilets and Faucets must be conf rmed to not be leaking,because one leaking
fixture can fal a septic system in ONE DAY
Important When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
C
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form 1A
Number
Fee -yvz. 4•A t. E✓4l,
s- /7sC?
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:
595 Haydenville Road
Address or Lot#
Leeds(Northampton)
City/Town
2. Owner Information
Helen Symons
Name
MA
State
01053
Zip Code
9 NleHS
Address(if different from above)
HAyDEN vale
CityfrovOn State
M4Ss
237-7858
O/o37
Zip Code
Telephone Number
3. Installer Information
Ctl Fp CL•Aec/' CLRRK/S eXceJRT/n&G
t5forml a.doc•06/03
Name Name of Company
117E-Pot /CORD Pc dot aav
Address
10I4-0—IANISB1•1QG— MASS 01007
City/rown State Zip Code
abk - 796b
Designer Information
Alan Weiss
Name
350 Old Enfield Road
Telephone Number
Cold Spring Environmental Consultants Inc.
Name of Company
Address
Belchertown
City/Town
MA
State
413-323-5957
01007
Zip Code
Telephone Number
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
Number
$77-5=6
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
01
❑ Garbage Grinder(check if present)
3 Bedroom
Number of showers
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
330+.
Gallons per Day
378
Gallons
06.15.2015
Date of Original
Number of Sheets
Septic System Design Plan
Title of Plan
8. Description of Soil:
SL
Revision Date
9. Nature of Repairs or Alterations Of applicable):
New leachfeld.
10. Date last inspected:
Date
t5fomrl 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
Form 1A
20) s--8'
Number
$ 357)
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
Healtp. L` .S /a-c y/
Signature Date
pl icatioon Ap
iC� l/ZZ//r
Eurrec—C
�i i Date
C "Jcnt ' t o✓I Errs Tinfe ea-0j
Application Disapproved for the following reasons'
t5formla Coo•06/03 Application for Disposal System Construction Permit•Page 3 of 3
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 9B
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address
on the computer,
use only the tab
key to move your Name
cursor-do not
use the return Street Address
key.
.d City/Town State Zip Code
2. Owner Name and Address Of different from above)
Name
City/Town
Street Address
State
Zip Code Telephone Number
3. Type of Facility(check all that apply):
❑ Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15203:
gpd
5. System Designer. Name ❑ PE ❑ RS
Address
City/Town State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s)—specify:
❑ Reduction in SAS area of up to 25%1
SAS size,sq.fl. %reduction
t5form9b•rev.02/2014 Local Upgrade Approval Page 1 of 2
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater.
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well (explain):
ft.
min/inch
n.
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
❑ Use of only one deep hole in proposed disposal area
❑ Use of a sieve analysis as a substitute for a perc test
List local variances granted:
Approving Authority
Print or Type Name and Title
Signature Date
t5form9b•rev. 02/2014 Local Upgrade Approval Page 2 of 2