97 Title 5 Failure Documents 2012 BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMITH, M.D.
JOANNE LEVIN, M.D.
Benjamin Wood.MPH, Director
Daniel Wasiuk,Health Inspector
Patricia Abbott, RN, Public Health Nurse
Heather McBride,Clerk
April 18, 2012
Donald and Dorcas Jepson
97 Marian Street
Northampton, MA 01060
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587-1214
FAX(413)587-1221
Re: Septic Inspection at 97 Marian Street, Northampton, MA
Dear Sir or Madam:
212 MAIN STREET
NORTHAMPTON,MA 01060
ta r
The Northampton Board of Health is in receipt of a report on the Subsurface Sewage Disposal System
Inspection conducted by Alan Weiss at 97 Marian Street Northampton, on April 12, 2011. That inspection
report indicates that the subsurface sewage disposal system at that address fails to protect the public health
and the environment as defined in Section 15.303 of CMR 15.000, State Environmental Code, Title 5.
Therefore, in accordance with the provisions of 310 CMR 15.000 of the State Environmental Code, Title 5, and
under authority of Massachusetts General Laws, Chapter 21A, Section 13, you (or the subsequent owners of
the property) are hereby ordered to repair the subsurface sewage disposal system at 97 Marian Street within
two (2)years of the date of the inspection, (by April 18, 2014). If further degradation of the sewage
disposal system occurs (e.g. sewage flowing to the surface of the ground), you may be required to complete
the repairs sooner.
All work to repair/upgrade the subsurface sewage disposal system must be performed by a licensed sewage
disposal system installer, in accordance with the requirements of 310 CMR 15.000, and with plans prepared by
a Registered Sanitarian or Registered Professional Engineer and approved by the Northampton Board of
Health.
Please be advised that you are entitled to a hearing on this order to upgrade your subsurface sewage disposal
system, provided that you file a written petition requesting such a hearing in the Board of health office within
seven (7) days of the receipt of this notice.
Please feel free to contact the Board of Health office, at 587-1214, if you have any questions concerning this
notice.
Thank you for your anticipated cooperation in this matter.
Sincerely,
Daniel Wasiuk
Health Inspector, Northampton Health Department
July 1, 2014
CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
BOARD OF HEALTH MEMBERS.:Donna Salloom, Chair—Joanne Levin, MD—Susanne Smith, MPH. MD
VYilliam Hargraves—Cynthia Suapis, PhD
STAFF: tlerridith O'Leary,RS, Director—Daniel Wasiuk Inspector pector—Edmund Smith, Inspector—Jennijer Brown, (UJ, Vurse
Donald and Dorcas Jepson
97 Marian Street
Northampton MA 01060
Dear Donald and Dorcas:
The reason for this letter is regarding the septic system located at 97 Marian Street. Pursuant to a Correction Order
dated 4/18/12 from the Northampton Health Department,two years was given to have a failed Title V Inspection
corrected. The failure date of the septic system was 4/6/12 and two years to correct would be a date of 4/6/14.
I understand that a connection of the house plumbing was made to the public wastewater system. Although,this is an
appropriate corrective action no documentation to substantiate this process was forwarded to the Northampton
Health Department. In addition,documentation regarding the removal or crush/fill of the septic tank must also be
provided to this department.
At this point in time, I am requesting you to provide all relevant documentation/information regarding the connection
to the public wastewater system and actions taken with the septic tank. Should this not be forwarded to the
Northampton Health Department,then the septic system will continue to be regarded as a failure and future
enforcement to ascertain compliance will be enacted.
I appreciate your anticipated cooperation with this matter. I can be reached at#413-587-1217 for questions and
concerns.
Sincerely,
Daniel Wasiuk
Health Inspector
Northampton Health Department
FILE COPY
212 Main Street,Northampton,MA 01060
Ph(413)587-1214 Fax(413)587-1221
July 1, 2014
CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
BOARD OF HEALTH MEMBERS: Donna Salloom, Chair—Joanne Levin, MD—Suzanne Smith, MPH, MD
William Hargraves—Cynthia.Suopis PhD
STAFF-Merridrth O'/Leary,RS Director—Daniel Wasiak Inspector—Edmund Smith. Inspector—./enniifer Brown, RA, Nurse
FILE NOTE
The septic system located at 97 Marian Street was connected to the city public waste water system following a Order
to Correct from the Northampton Health Dept.
A failed Title V Inspection report was submitted by Alan Weiss on 4/6/12. Order to Correct sent 4/18/12 by D.
Wasiuk.
Discussions following the letter were made with the owners and Alan Weiss. A connection was made to the city's
system. Unfortunately,no documentation was provided regarding the connection and the removal or crush/fill of the
septic system.
212 Main Street,Northampton,MA 01060
Ph (413)587-1214 Fax(413)587-1221
July 11, 2014
CITY of NORTHAMPTON
PUBLIC HEALTH DEPARTMENT
BOARD OF HEALTH MEMBERS: Donna Saltoom, Chair—Joanne Levin, MD—Suzanne Smith, MD
STAFF:Merridith O'Leary, RS,Director—Daniel Wasiuk, Inspector—Edmund Smith. Inspector-Jennifer Brown, RN,Nurse
FILE NOTE
RE: 97 Marian Street, Don Jepson
Septic system repair
The owner of 97 Marian Street, Don Jepson, had tied his plumbing of the house into the public sewer
system. He was given two years (2) to repair/replace a failed septic system-based on a failed Title V
Inspection in 2012.
Mr.Jepson forwarded the necessary information to substantiate the connection to the public sewer
system and the matter is deemed to be complete. The issue with the septic system has ended with the
connection into the public sewer system.
The septic tank was properly pumped,crushed,and filled. This and additional work was conducted by
Karl's Site Work.
Information submitted by Don Jepson is attached to this note.
Daniel Wasiuk
Health Inspector
212 Main Street,Northampton,MA 01060
Ph(413)587-1214 Fax(413)587-1221
Karl's Site Work Inc.
327 River Drive
Hadley, Ma. 01035
Ph. 413-549-5396
Fax 413-549-6115
May 2, 2012
Don &Dee Jepson
97 Marian Street
Northampton, Ma.01060
This proposal is submitted for work to be completed at 97 Marian Street and includes the following:
Obtain a trench permit from the DPW, ($250.00). Pump the 1000 gallon septic tank, crush and fill. Pump
an estimated 1500 gallons from the leach tanks, crush and fill. Due to the fact that I have no way of
knowing how much we will pump from the leach tanks any amount over this will be billed extra and any
amount under will be a credit Excavate to install a 4"sewer pipe with 6"clean-out at the stub from
outside the foundation to the stub as marked by the DPW Upon inspection the trench will be backfilled
and onsite topsoil will be re-spread An additional 15 cubic yards of screened topsoil will be provided and
spread Disturbed areas will be raked and seeded with the owner responsible for watering and
maintenance. Owner to move any landscaping that is to be saved. We will be close to a large oak tree
and the excavation will disrupt some of the root system- I do not know the effect this may have on the tree
and as I stated during our appointment we will attempt to stay away as far as practical and cannot be held
responsible for the tree.
The quote for the above-described work is:$4,083.00
This proposal does not include:
• Obtaining permits or paying fees other than the trench permit.
• Any other utility work.
• Any tree cutting.
"Note: Price assumes the measurements and marking by the DPW are accurate and the sewer stub will
be readily located.
Limitations: Latent subsurface conditions requiring soil stabilization, rock excavation,
dewatering or any other condition that prevents construction will be at extra costs and the
contract sum will be adjusted. Rock is described as bedrock or boulders exceeding one cubic
yard in size. Dewatering is defined as pumping or other drainage measures due to groundwater.
Karl's shall not be liable for any damage to structures, driveways,trees,plants, lawns or
underground pipes or systems due to construction activities.
The terms of the contract are: A 50%down payment prior to starting the work with the balance
to be invoiced and payments due within 30 days.Interest shall accrue at the rate of 1 9:%per
month on any amount past due. In any collection matter, Karl's shall be entitled to recover its
costs of collection, including legal fees. This proposal may be withdrawn by Karl's Site Work if
not accepted within 30 days.
Kar J:S Site o k rc. Date
it
Customer Date
(20120502)
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MUNICIPAL SEWER/AVAILABILITY APPLICATION
Northampton Streets Department
125 Locust Street
Northampton, MA 01060
587-1570
A Department of Public Works Trench Permit and Sewer Entry Permit shall be required
prior to any construction or connection activity associated with this application.
Location: 97 Marian Street, Northampton
Inquiry Made By.
Date of Inquiry:
Reason for
Request:
Donald Jepson 584-4318
4117112
Hook into City Sewer/Decommissioning Septic/ Betterment to
City Sewer ( See attached information )
Municipal Sewer Main in Front of Location: Yes X No
Municipal Storm Drain Available: 5 %deep Yes x No
Size of Sewer Main: 8 Material: 21 f.C . Age: f cl q3
Depth of Sewer Main:
Size of Service Connection 6 /Net/ Pv'C c (* DEEP AP.i2o X -
Type of Service Connection:
Tie-in to Sanitary Main Tie-in to Sanitary Stub
8-;A- ) N6&?6 7cPT Coo 1L rot (.0021C- SiI6&
Got / 7/ 's
Comments:
Note: If this availibility is for new construction, this form must be hand delivered to Building
Inspector.
A corresponding"sewer entrance fee"shall be paid prior to making any connection to the municipal sewer
system.Arrangements of such installation shall be madewith the Northampton Streets Department with a
minimum of 5 working days notification. All work shall conform to Northampton Streets Department
specifications.
i1 f ' %
John ohn Hall
Sewer Department
cc: Ned Huntley, Director DPW
Louis Hasbrouck, Building Commissioner
T;
Pcmnit No. 519-12
CITY OF NORTHAMPTON, MA
RESIDENTIAL OR COMMERCIAL BUILDING SEWER APPLICATION
A Department of Public Works Trench Permit shall be required
prior to any construction or connection activity associated with this application.
To the City of NORTHAMPTON, MASSACHUSETTS:
The undersigned, being the Owner 'of the property
(Owner. Owner's Agent)
located at 97 Marian Street � does hereby request a permit to install and
(Number) (Suter) _
connect a building sewer to serve the 1 Residence at said location.
(Residence,Commercial Bldg..sic.)
L The applicant and/or owner shall furnish upon request of the Superintendent the estimated
quantity and characteristics of waste to be discharged to the public sewer.
2. "Owner' shall mean the person holding title to the properly served or to be served by the
building sewer.
3. The person or firm NS ho will perform the proposed work is
Donald Jepson ,of 97 Marian St- Northampton, MA 01060
(Name) (Address)
4. Plans and specifications for the proposed building sewer are attached hereunto as Exhibit
In Consideration of the granting of this permit, the undersigned agrees:
To accept and abide by all provisions of the Code of Ordinances, City of Northampton,
Massachusetts, Sections 22-t1 through 22-52, and all other pertinent ordinances or
regulations that may he adopted in the future.
2_ To maintain the building sewer at no expense to the City.
3. To notify the Superintendent when the building sewer is ready for inspection and
connection to the public sewer, but before any portion of the work is covered.
\ win2\admin\Permits'\Sewer Entry\Penntts 2012 Sewer`,SI9-12 97 Malian Street.
Northampton.doc
%mot _ 7/6
4. The City shall not be held liable for any open plumbing fixtures below street level.
5. The applicant and/or owner hereby agree to pay to the City any sewer use assessments or
charges as may be established under city ordinance.
DATE! 04/23/12 SIGNED:
(Applicant)
Donald Jepson
97 Marian St, Northampton, M
01060
(Address of Applicant)
413-584-1318
S 200.00
(Telephone No.of Applicant)
inspection fee paid Check No. 1 C K1t33.12
Application approved and permit issued:
DATE: 04/23/12 ',, SIGNED:
(Director o Pub is 1V ks
,,Code of Ordinances Section 22-41 through 22-52 available upon request.
I le-in to sanitary mam
--_ .
it ie-into sanitary service at street line
Cie- in to storm drain
5200.0(] BETTERMENT FEE ...
5500.00 }— h1ARIAN STREET 5200.90
$100.00
'dwin2ladn»nyPermits).Sewer Entry'Permits 2012 Sewer,S19-12 97 Marian Street.
Northampton.doe
SEWER CONNECTION
INSPECTION REPORT
Northampton Sewer Department
125 Locust St.
Northampton,MA 01060
(413) 587-1570
Date: \-04/73/12 ingineei ing has taken ties to servic , ,a),l42
Signatur
Fyne of Service New X L Rener+ul Repair BETTERMENT
Pipe: Size 8" Material PVC AGE, 1998
Location of Installation: 97 Marian Street,Northampton,MA 01060
(Street and Number)
Permit Issued To: Donald Jepson
Contractor/Developer Installing Karls Excavating
Service Connection: 327 Ricer Drive Hadley, MA 01035
Telephone No.: (413)549-5396
The service connection at this location was inspect
by the undersigned on
�� In" and approved by:
at j./ (rime) - - — -- Sewer Supervisoi
I have instructed
installation can he haektiilled.
(D a
of J/A,?L,c c=1--/C that the
Measurements for all installation shall be listed on the hack of this form. ]he information shall
" be attached to the permit on tile at the Public Works Department office.
\Awin2)admin\PermitsASewer Entry\Permits 2012 SewerAS19-12 97 Marian Street.
Northampton doe
UV 311 A re
CITA OF NORTHAMPTON
DEPARTMEN[OF PUBLIC WORKS
125 IOLLL4t Street
Northampton.NIA 01060
Phone A13- 87-15]0
FAX 413-587-
Perrot No.
AB
fare Issued
By
L_
PENDING APPROVAL-9l MARION 51 REE':
6716
DISAPPROVED
50:2012
(It amuu:
No work test an
TRENCH PERMIT
Pursuant to C.L. e. 82.A 4 1 and 520 CMR 7.00 et seq. (as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
nits permit(Ticeetve for excavating, any public and private ppery)is Astrid under the prvs. s el M.4f.e S2 e and 520 CUR 1..00
and Section 28521 of d Revised Ordmanea of the City of Northampton subteen the Social:awns for thr Care of Street Cunt'approved and adopted
by the Department of Public Works on September 21 1991 I h tplteant bcrtb:agrees t iota an cos est.boneado and lung and to save the
City of Nonhampton homeless from it elatos for damages whatsoever an sing from he emanation e: II propeoRv affected by this pe n r,until sick
time as t work has been pp .ed and accepted by the Denenmene.of PEN:.Works ae provided fm beta and in the case of private nility,to pay it
charges fm restrfcinC Few$250.00 Chock (CO &G Cp Valid for 30 days from date of approval.Expiration Date. 17-/a—
Name of Applicant Phone Cali
,ASIRLSSITE WORK 413-549-53Y5
tot Address
City/Town
lit DLFY
327 R11'ER DRIVE
STATE
MA
ZIP
010:5
Name of Excavator(if riffle rent from applic
S45-1E
Street Address
Enyil'own SIRE /..1P
Phone Cell
Name of Owners)of Property
DONALD JET SUS
Street Address
97 AL5RUOX STREET
Cry.Town STATE ZIP
.N'OR IHArMPTON VIA 0060
Phone
I Location of proposed trench: 97 MARION STREET
Description and purpose of proposed ucnch:please describe t e exact location of the proposed tenet,
description of what is(or is intended Ito be laid in proposed trench(egg pipes-cable hoes etc_J
Estimated dates of oeeopa!ion of street:
NEW SEWER SERVICE LINE
d its purpose.Include a
Insurance Certificate E
Name and Contact Information of Insurer
ON FILE
ON FILE
?oho,Lpiranon Dam: ON FILE
Dtg Safer MS-ISO S330
ALL PERMITS ISSUED PURSUANT TO 520 CMR 1100 SHALL BE POSTED IN PIAIN VIEW ON I If SITE OF THE TRENCH
Note-Contractors will be charged her Inspections requested outside of regular working hours(7:00 a.m.-3:00 p.m.M-Ej
Contractor to notify DPW when job is in progress. ;NOTE:
Engineers need ties to this service for our records TEMPORARY
INFRARED SHALL BE REQUIRED AFTER TRENCH CUT IS MA DE 'PATCH REQEIRED
Wtia....1 coy .
S/91/ ..
E!5s02/201 1: 15 413549511J KAFLS
t Town z P:'^rrit.ine F'I;.N iPurtiltinri,
y Seal au tity) &treat
:M.se chusers 88828
There(i:)5554212&2123
r ' FAX(555)555-1212
Date T_55.12ed
E pLrat1C?i Date
TRENCH PERMIT
Pursuant to G.L. c. 82A §I and 520 CMR 7.00 et seq.(as amended)
THIS PERMIT MUST BE PALLY COMPI.F.TED PRIOR TO CONSIDERATION
Nrms of Applicant.(,r /S�/c `(JY/L
S eet:lddrsj3d7 /P/(/7✓ IC\
onCown MA 71P
YRc/Zio_d ,v174 CJ /C' —.
-5
Nsme of Exavat r(ffdifferent from applicant)
Street Address
Phone Cu
c f3 3-49.'S3YCe
64—t1 " �
(1/1? 6://2 2- . t&9(
PAGE 01/05
Phone
Ciry/;own I MA ZiT
Nsme of Owner(?)of Property
nano._ /d �f�v-�+,..
Street Addre s
77 /Pet re
CityTown ?�/- ti'tA I Z.nP
/Jd/ 'Ai/. 7�22:1( ewe .. Li(O rQ
other Costnct Parm@Fee Received No( ) Yes
Description,location and purpose of proposed trench:
PLase describe the exact location of the proposed trench end Its purpoe(include it disci-fp:lorl of what is(or is intended)to
be laid in proposed tr eu ch(en pipes/cable buts etc..)Pkase use reverse side If aiehttcnal spree Is needed-
.
reu
Phone Cell
-1/43 - t/3/t
Insurance Cert.tate k:
Name and Contact Information of Insure.:
Icv Lxptranon Date:.
Safop; 1St) ' k330
f Competent Ponion(as defined by c20 CM:I:Lee :
115132/2012 12:15 4135436112
}L,uatb tgiclIN HO Lctln E Liconsci
ARrs
d-:.ado• tptt Ucu Dam:
PAGE 02/03
TTY SIGNING TIUS FORM,THE APPLICANT, OWNER AND EXCAVATOR ALL ACKNOWLEDGE AND LERTWY
THAT THEY ARE FMCS-AR WITS,OR, 3 SPORE COMMENCEMENT OF THE WORK WILL BECOME FAIII.IAR
WITH.ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,TN CLE OIN(DSRA REGULATIONS,
81A, 520 CMR 700 et soq, AND ANY APPLICABLE MUNICIPAL ORDLNANCES BYLAWS 11ED
REGULATIONS AND'/HEY COVENANT AND ACREF.THAT ALL WORK DONE UNDER T HR PERMIT ISSUED TOR.
SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH TEE CONDITIONS SET FORT
BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE
EXCAVATOR TO UNDERTAKE SUCH WORX ON IRE PROPERTY DR THE OWNER, AND ALSO, FOR IZE..
DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO
ENTER UPQN THE PROPERTY TO MONITOR AND INSPECT THE WORK. FOR CONFORMITY WITH LITE
CONDII IONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERLNG SUCH WORK
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOLITLY AN)SEVERALLY TO
RZIM$TTRSE TIT&MUNICiC.MLITY FOR ANY AND ALL,COSTS AND EXPENSES INCURRED BY 7 HL
MUNICIPALITY EN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED'MERELTDRR,
GLCLUDIING BUT NOT LIMITED TO ENFORCING THE REQT5 RB.MENTS OP STATE LAW AND CONTIISONS OF
THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE TITERINSTPH,AND MEASURES TAIS,N BY THE
MUNICIPALITY TO PROTECT TIE PDBLIC WHERE THE APPLICANT OWNER.OR EXCAV ATORHAS TAILED TO
COMPLY THEREWFTIU ENCLUDING POLICE DETAILS AND OTHER REMEDIAL MTtA5VBtS DEEMED
NECESSARY BYTKE MLTNICU'ALI'IY.
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOIN PLY AND SEVERALLY TO DEFEAT?,
LNDEYLNIPY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM
ANY AO)) ALL LIABILFEY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT
OP ANY INJURY, DEATH, LASS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING TAE WORN
CONDUCTED UNDER THIS PERMIT.
APPLICANT YGNATURE
p D.#TE
(IF DIFFERENT)
DATE
OWNER'S SIGNATURE(WDIFFERLN1)
DATE:
< /a
FEND'NC APPROVAL-9/MARION STdULI
Ifl SIGNING T HIS FORM, THE APPLI( AVI,OWNER.AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAI
THEY ARE FAMILIAR WITH,OR,BEFORE COMMENCEMEN I OF THE WORK WILL BECOME FAMILIAR WITH,ALL
LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA RC(iCLA TIONS ( L.c$2A F1O CMR
7.00 seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENANT
AND AGREE TH.YF ALL WORK DONE UNDER THE,PERMIT ISSUED FOR SUCH WORK WILL COMPLY THERLWTTH IN
ALL RI.SPEC'IS AND WITH THE CONDI IIONS SET FORTH BELOW.
THE CNDERMUNED OWNER AUTHORIZES DIE APPIICANT TO APPLY FOR THE PURNII I AND THE LXCAV VI OR RI
UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER,AND ALSO.FOR THE DURATION OF CON STRI'C[ION.
AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO TITER UPON THE PROPERTY TO MONITOR
AND INSPECT TIM WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND ITIE LAWS AND
REGULATIONS GOVERNING STUB WORK
11IF t INDEP,SIGNFI) APPLICANT,OWNER ANT)EXCAVATOR AGREE JOIN FLY AND SEVERALLY TO REIMBURSE 1 H E
MUNI CTPALT FY FOR ANY AND AI.I COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNLCI ION WITI
TILTS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUI NOT LIMITED IO ENFORCING I I9F
REQUIREMENTS OF STA FE LAW AND CONDITIONS OF THIS PERMIT.INSPECTIONS MADE TO ASSURE COMPLIANCE
THERE VITH,AND MEASURES TAKEN BY IIIE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT
OWNER OR EXCAVA TOR HAS FAILED I O COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL
MEASURES DEEMED NECESSARY BY WE MUNICIPALITY.
DIE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY,AND HOLD HARMLESS TIM.MUNICIPALII Y AND AIL OF ITS AGENTS AND EMPLOYEES FROM ANY AND
ALL LIABILITY,CAUSES OR ACTION COSTS,AND EXPENSES RESUL TING PROM OR ARISING OUT DE ANY INJURY,
DEATH LOSS,OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED ENDER THIS PERMIT.
APPLICANT SIGNATURE
EXCAVATOR SIGNA I I RE OF DIFFERENT)
OWNERS SIGNA TURF ill'DIT FERENII
For
DAT
HAIL
DATE
Do not write in this section
WATER (1,1" 5 9 T� 1
SEWER tI .137/d//a_
NIREE FS /C r/-/Z -'
4-rot
Condition of roadBOad last pave
Siped+
Control Density Fill Required
Mug inSlall clemt o t(See Attached)
Refer to Engineering for plena
Subject m'-year pavement moratorium
,City Engineer
PENDING APPROVAL-97 MARION STREET
BY Sif,NING THIS FORM,THE APPLICAN I,OWNER_AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THA I
11ILI ARE FAMILIAR WITI I,OR,BLEORE COMMENCEMENT OF THE WORK.WILL BF COME FAMILIAR WIT H„11,V 1,
LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED. INCLUDING OSHA REGULATIONS G I c. ft1A.520 CYIR
7.90 t c 43D ANY APPLICABLE MUNICIPAL ORDINANCES BY LAWS AND RECULA IIONS AND THEY COVENANT
AND AGREE THAI ALL WORK DONE UNDER 1T IF.PERMIT ISSUED l OR SUCH WORK WILL COMPLY I'I IEREWII H IN
Al].RESPECTS AND AV FI H THE CONDITIONS SET FORTH BELOW.
THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TD APPLY 10R THE PERM F AND THE EX 10
INDERTAKF SIKH WORK ON THE PROPERTY OF THE OWNER,AND Al SO,FOR THE DURATION OF CJONSTRUCTION,
AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY [0 ENTER UPON THE PROPERTY TO MONITOR
AND INSPECT TAE WORK FOR CONFORMITY WI Iii THE CONDITIONS Al FACHED HERETO AND THE LAWS AND
RECiI!LATIONS GOVERNING SUCH WORK
THE(NORRSIGNED APPLICANT,OWNER ANT)EXCAVATOR AGREE 3OrN ICY AND SEV I,RA I.LY TO REIMBURSE THE
MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY TILE Ml NICH'ALII Y IN CONNECTION WITH
THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUI NOT LIMITED I0 ENH3RCINU IHE
REQUIREMENTS OF STA IF LAW AND CONDII IONS OF :HfS PERMIT,INSPEC1 IONS MADE TO ASSURE COMPLIANCE
THEREWITH,AND MEASURES TAKEN BY DIE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT
OWNER OR EXCAVATOR HAS FAILED TO COMPLY ['HEREWITH INCLUDING POLICE DE FAILS AND O-CHER REMEDIAL
MEASURES DEEMED NECESSARV BY THE MUNICIPALITY,
THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,
INDEMNIFY.AND HOLD HARMLESS .HE.MUNICIPAI_I FY AND ALI.OF ITS AGENTS AM)EMPLOYEES FROM ANY AND
ALT. lAH(1.11 Y,CAUSES OR ACTION COSTS,AND EXPENSES RESULTING FROM OR ARISING our OF ANY INJURY_
DEATH. LOSS.OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT.
APPLICANT 510A FURL
{ 44 DATE
Sl«i i3,
EXCAV A IOR SIGNA EL RE CIE DIFFERENT)
0%. R'S SIGNAIURF' T DIFFERENT
For City Town trw--Do no
WATER g
SEWER 7� Ja PQ-
STREET S /K L 1/—fa
Condition of road/Road last rya
Signed.
T - L /99S
ATF
DATE
is section
Control Density FiI Required
Must install clean-out(See gnashed)
I-
! Refer o Fnyneenng for plans
Subject to 5eyear pavement moratorium
,City Engineer
Karl's Site Work Inc.
327 River Drive
Hadley, Ma. 01035
Ph. 413-549-5396
Fax 413-549-6115
May 2, 2012
Don & Dee Jepson
97 Marian Street
Northampton, Ma.01060
This proposal is submitted for work to oe completed at 57 Marian Street and includes the following:
Obtain a trench permit from the DPW, ($250.00). Pump the 1000 gallon septic tank, crush and fill. Pump
an estimated 1500 gallons from the leach tanks, crush and fill. Due to the fact that I have no way of
knowing how much we will pump from the leach tanks any amount over this will be billed extra and any
amount under will be a credit. Excavate tc install a 4" sewer pipe with 6'clean-out at the stub from
outside the foundation to the stub as marked by the DPW. Upon inspection the trench will be backfil,ed
and onsite topsoil win be re spread. An additional 15 cubic yards of screened topsoil will be provided and
spread. Disturbed areas will be raked and seeded with the owner responsible for watering and
maintenance. Owner to move any landscaping that is to be saved. We will be close to a large oak tree
and the excavation will disrupt some of the root system. I do not krow the effect this may have on the tree
and as I stated during our appointment we will attempt to stay away as far as practical and cannot be held
responsible for the tree.
The quote for the above-described work is: 54,083.00
This proposal does not include'
• Obtaining permits or paying fees other than the trench permit.
• Any other utility work.
• Any tree cutting.
"Note: Price assumes the measurements and marking by the DPW are accurate and the sewer stub will
be readily located.
Limitations: Latent subsurface conditions requiring soil stabilization, rock excavation.
dewatering or any other condition that prevents construction will be at extra costs and the
contract sum will be adjusted.Rock is described as bedrock or boulders exceeding one cubic
yard in size. Dewatering is defined as pumping or other drainage measures due to groundwater.
Karl's shall not be liable for any damage to structures,driveways, trees, plants, lawns or
underground pipes or systems due to construction activities.
The terms of the contract are: A 50% down payment prior to starting the work with the balance
to he invoiced and payments due within 30 days. Interest shall accrue at the rate of I per
month on any amount past due. In any collection matter. Karl's shall be entitled to recover its
costs of collection. including legal fees. This proposal may be withdrawn by Karl's Site Work if
not accepted within 30 days.
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