776 Title 5 Construction Permits, Conservation Comission DOcuments, Soil Survey, Alternate System Document ii
2014 000 8 2
Bk 1156 Pg: Page 1 12
Re riled 01/17/2014 02:10 PM
Notice of Alternative Sewage Disposal System
M.G.L. c.21A, § 13 and 310 CMR 15.0287(10)
[This Notice to be recorded and/or filed for registration in the chain of title of the Property served by an Alternative
Sewage Disposal System("Alternative System ).l
NAME(S)OF OWNER OF PROPERTY SERVED BY ALTERNATVE SYSTEM:
SANDRI REALTY INC.
AD EM:
TITLE REFERENCE FOR PROPERTY SERVED BY ALTERNATIVE SYSTEM[check and
complete each that applies]:
X Deed recorded with the HAMPSHIRE COUNTY Registry of Deeds in Book 1995 Page 286
_Certificate of Title No. issued by the Land Registration Office of the Registry District
_Source of title other than by deed
[If Alternative System Owner(s)is other than Property Owner(s),complete the following:]
Alternative System Owner Name:
Alternative System Owner Address:
WHEREAS, Section 15.280 of Title 5 of the State Environmental Code("Approval of
Alternative Systems"),provides for the Massachusetts Department of Environmental Protection(the
"Department")to approve or certify,as appropriate,all proposals to construct,upgrade or replace on-site
sewage disposal systems using alternative systems;
WHEREAS,owners and/or operators of approved or certified altemative systems are subject to
general conditions,as specified in Section 15.287 of Title 5 of the State Environmental Code, 310 CMR
15.287,and may be subject to special conditions,as specified in the Department's approvals or
certifications;such general and special conditions potentially including,without limitation,requirements
relating to the use of trained operators,periodic inspections,maintenance, sampling,reporting and/or
recordkeeping;
WHEREAS, Section 15.287(10)of Title 5 of the State Environmental Code, 310 CMR
15.287(10),requires that"prior to obtaining a Certificate of Compliance for installation of a new or
upgraded system,the system owner shall record in the chain of title for the property served by the
alterative system in the Registry of Deeds and/or Land Registration Office,as applicable, a Notice
disclosing both the existence of the alternative on-site system and the Department's approval of the
system. The system owner shall also provide evidence of such recording to the Local Approving
Authority[;]"and
WHEREAS,the Property is served by an altemative sewage disposal system.
NOW,THEREFORE,Notice of an altemative sewage disposal system is hereby given for the
above-referenced Property,as follows:
1. Existence. An altemative system has been installed as a new or upgraded altemative sewage disposal
system, on or adjacent to the Property, and serves the Property. The trade name and model number(s) of
the altemative system are as follows:
Trade name of technology: GEO-FLOW PIPE LEACHING
SYSTEM
Manufacturer Name: ADVANCED DRAINAGE SYSTEMS
Modelnumber(s):
Page 1 of 2
2. Approval/Certification. On March 19 2013 [date) the Department,pursuant to its authority
under the section of Title 5 as specified below,approved or certified the technology used in the above-
referenced alternative system,under MassDEP Transmittal Number W088685 [Transmittal Number
of approval or certification].
[Check one of the following,as applicable:]
X Approved for remedial use under 310 CMR 15.284
_Approved for piloting under 310 CMR 15.285
_Provisionally approved under 310 CMR 15286
Certified for general use under 310 CMR 15.288
A copy of the Department's ApprovaUCertification is available from the Department in person or on-
line at the Department's website: http.//www.mass.gov/dep
WITNESS the execution hereof under seal this (`� day of c)6,7 a r,y ,20 ) / made by
the above-named Alternative System Owner(s). /
[Alternative System Owner(s)]
Print Name(s): Michael V.Behn, C.O.O. Sandri Realty, Inc.
frank-1k Quad
s
COMMONWEALTH OF MASSACHUSETTS
On this It day of 20)1,before me,the undersigned notary public,personally
appearedW7tJio \J. 1.Gtn (name of document signer),proved to me through satisfactory
evidence of identification,which were fcrennelt�Kno„9n to be the person whose name is
signed on the preceding or attached document, and acknowledged to me that(he)(she)signed it
voluntarily for its stated propose.
(official signature and seal of no y)
/h.�. Comm/55rrn CC/"/"CS /-1/441/44/9
[Complete the following Property Owner(s)Consent if Alternative System Owner(s)is other than the Property
Owner(s):]
CONSENTED TO:
[Property Owner(s)]
PrintName(s):
Date:
COMMONWEALTH OF MASSACHUSETTS
, ss
On this da of 20 before me the undersigned notary public,personally
appeared (name of document signer),proved to me through satisfactory
evidence of identification, which were to be the person whose name is
signed on the preceding or attached document, and acknowledged to me that(he)(she)signed it
voluntarily for its stated purpose.
(official signature and seal of notary)
Upon recording,return to:
[Name and address of Property Owner(s)]
.A.TT ____.__
i/Application page attached to plan
Lily€or RS stamp, date, signature
EY Variances to property line setback distances must have Surveyor stamp
I Legal boundaries noted
E' Easements noted
("i Dwellings and buildings existing or proposed noted
V location of driveway or parking areas,other impervious areas
E✓ Location and dimensions of reserve area(new construction only)
PY System design calculations
garbage grinder,yes or no
@ Benchmark not disturbed during construction within 75ft of facility
'/North arrow
2�5ntours
yz Deep hole location(s) and data
I' Perc hole location(s) and data
G Elevations
• Names of approving authority and soil evaluator
• Location of water supplies, public and private
o Within 400ft of system in case of surface water and gravel-Packed public water supply
o Within 250ft of system in case of tubular public water supply
o Within SOOft of system in case of private wells(50ft from tank)
ET Well statement, if applicable
• Location of any surface waters, rivers,vegetated wetlands
u Location of water lines and other subsurface utilities
EE Obserrved and adjusted groundwater elevations in vicinity of system
El, Profile of system
/Locus plan to show location of facility, including nearest street
6 aterials of construction and specs for system
baffle
ipe in center line of tank
�! $ouble-washed stone
�-J.' edule 40 PVC for trafficked areas, house to tank
y, Distances noted from house to tank,etc.
• If dosing is proposed, design and specs of dosing system
T. When alternative technology is required,complete plan and specs including hydraulic profile
LE Inches preferred over beds
d.,/Buoyancy calculations for tanks or components partly below groundwater level '�
42 3:1 slope outside of mound,toe ending 5ft from property line
LT Local upgrade requests on the plan,all variances
• Local upgrade forms attached to the application
• Sy$tem Plan Rev{ew
1
BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMITH, M.D.
JOANNE LEVIN,M.D.
Benjamin Wood,MPH,Director
Javeria Mir,MPH,Health Inspector
atdcia Abbott, RN,Public Health Nurse
Heather McBride,Clerk
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587-1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON,MA 01060
Onsite Septic System Construction Permit: Conservation Commission Review
JOTE: As of 1/1/11, Septic System Permits will not be issued by the Northampton Board of Health
intil we receive this form signed by the Northampton Conservation Commission Staff Member.
he Conservation Commission can be reached by contacting:
0 Sarah LaValley, Conservation, Preservation and Land Use Planner
SLaValley@northamptonma.gov
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton, MA 01060
ss: 776 // A iee
Engineer: ad. Az, (Pa i/ —$V
II`7? No G thba we e14-- ((/■eu,
oilserva Ion om Is Ion Conservation, Preservation and Land Use Planner
Date: I I i5 /I5
Commonwealth of Massachusetts
Nziret City/Town of NORTHAMPTON
n= • Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
MassDEP has provided this farm for use by on-site professionals and local Boards of Health. Other forms may be used,but the
information must be substantially the same as provided here. Before using this form, check with your local Board of Health to
determine the form they use.
A. Facility Information
A.RSANDRI
Owner Name
776 NORTH KING STREET - -. 8/19 - - - -- --
MaptLol#
Street Address
NORTHAMPTON MA 01060
City sate by Code
B. Site Information
1. (Check one) ❑ New Construction ❑ Upgrade ® Repair
WEB _ VARIES 253A
2. Published Soil Survey Available? ® Yes ❑ No If yes: year Published - Publication Scale Sall Map Unit
HINCKLEY FEW -- ----
Sole Name __-- _ Solt Limitations
3. Surf clal Geological Report Available?❑ Yes ® No If yes. Year Published Publication Scale Map Unit
Geologic MaleaN Lantlfann
4. Flood Rate Insurance Map
Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ® No
Within the 500-year flood boundary? ❑ Yes ® No Within a velocity zone? ❑ Yes 0 No
5. Wetland Area: National Wetland Inventory Map reap Unit Name
Wetlands Conservancy Program Map Map Unit-- -- ---- Name
macrot5form11-1.doc•rev.10/07 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8
Commonwealth of Massachusetts
• *_- City/Town of NORTHAMPTON
q„ Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
B. Site Information (Continued)
6. Current Water Resource Conditions(USGS): Mwit vas— Range: ® Above Normal ❑ Normal ❑ Below Normal
7. Other references reviewed: _- --- - --- -_--- --
C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area)
Deep Observation Hole Number: 1 10/9!1.3 a30 AM CLEAR COOL
P ___ Data Time -.. weather
1. Location
194+1-
Ground Elevation at Surface of Hole: -- - - Location(identify on plan): - -
LAWN FEW _ 8
2. Land Use -
(e.g.,woodland.agricultural field.vacant lot,em.) Surface Stones slope(^c)
GRASSES
Vegetation La
ralbrm Posaon on Landscape(attach sheep
52
3. Distances from: Open Water Body feel +— Drainage Way net - Possible Wet Area ,
Property Line )SeOei i Drinking Water Well CITY- Other teat
4. Parent Material: RIVERENE DEPOSIT --- Unsuitable Materials Present: ❑ Yes 0 No
If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
NONE NONE
5. Groundwater Observed: ❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water In Hole
183.5+1-
Estimated Depth to High Groundwater: i1n2c6 n - elevation
macrol5fonn11-1.doc•rev. 10/07 Form 11-Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 0
;?\ Commonwealth of Massachusetts
a:14 City/Town of NORTHAMPTON
. 114 Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (Continued)
Deep Observation Hole Number: 1
—r
Redasimoryhlc Features Cowes Fragments Soll
Sell Herl.ont Soll Matrix:Color- (mottles) Soll Teatun %by Volume Soll Consistence Other
Depth(In.) Layer Moist(Mansell) (USDA) Cobbles 6 Structure
(Moist)
Depth Color Paccent Gravel Stones
0-19 A 10YR3/3 - - - LOAM SANDY 0 0 SINGLE
GRAIN FRIABLE
19-32 B 10YR3/4 - - - SANDY
0 0 SINGLE FRIABLE
LOAM GRAIN
COARSE 15 0 SINGLE FRIABLE
32-84 C1 10YR416 - - SAND GRAIN
V FINE SINGLE FRIABLE
84-88 C2 10YR3/3 - - - SILTY 0 0 GRAIN
FINE SINGLE
8 8-126 C3 7.5YR4/4 - .. - SAND 0 0
GRAIN FRIABLE
I
Additional Notes:
macrol5tmml1-1 eoc•rev. 10/07 Farm 11-Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 6
•
Commonwealth of Massachusetts
cq •iron; City/Town of NORTHAMPTON
a -1 Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (Continued)
2 10/9/13 11AM _ CLEAR
Deep Observation Hale Number: -- - Date Time - weather
1. Location
Ground Elevation at Surface of Hole: 191- - Location(identify on plan):-
LAWN FEW 8 --
2. Land Use _ --- - - Surface Stones Slope(%)
(e.g..woodbnd,ag4wlNml field vacant lot,etc.)
GRASSES _. - ----- - -- - - -- Position on Landscape(attach sheet)
-. --
Vegetation n Landfortn 52+/-
100+ 52+1- Possible Wet Area -
3. Distances from: Open Water Body - feel Drainage Way reel feSt
45+/- CITY- Other _ ---
Property Line (eel -- Drinking Water Well feel feel
RIVERENE DEPOSIT -
4. Parent Material: Unsuitable Materials Present: ❑ Yes El No
-
If Yes: ❑ Disturbed Soil 0 R Material ❑ Impervious Layers) ❑
Weathered/Fractured Rock ❑ Bedrock
NONE NONE
5. Groundwater Observed: ❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water In Hole
94 183+/-
Estimated Depth to High Groundwaler: Indies -- --- -- &ovation
macrol5form11-1.doc•rev.10107 Form 11-Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of B
Commonwealth of Massachusetts
w,; g. City/Town of NORTHAMPTON
_r 4, Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (Continued)
2
Deep Observation Hole Number --- - _ - _
esduslmorphlcFeatures Coarse Fragment Sall
(mottles) Solt Texture %by Volume Solt Consistence Other
Depth(ln.) Soli ayer Soil Matrix:Cola- Structure
Layer Moist(Mensal!) Depth Color Percent (USDA) Gravel Cobbles IS (Nola[)
Stones
SANDY SINGLE FRIABLE
0-20 A 10VR313 - - LOAM _ 0 .. 0 GRAIN
20-32 B SANDY 10YR4/6 - - - LOAM 0 0 SINGLE FRIABLE
GRAIN
COARSE SINGLE FRIABLE
32-44 C1 2.5Y3/3 - - - SAND _ 15 _ 0 GRAIN
MED 0 0 SINGLE FRIABLE
44-98 C2 10YR4/8 94 2.5Y312 8 SAND _ GRAIN
SILT 0 0 massive compact
96-132 C3 5Y3/2 - - - LOAM
Additional Notes:
maool5form11-1.doc•rev. 10/07 Form 11—Soli Suitability Assessment for On•S5e Sewage Disposal •Page 5 of 8
•
Commonwealth of Massachusetts
"* , City/Town of NORTHAMPTON
e°■' i Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
D. Determination of High Groundwater Elevation
1. Method Used:
l Depth observed standing water in observation hole Inches - - - Inches
❑ Depth weeping from side of observation hole Inches -_-- Inches
A. _. _._ B. 94
❑ Depth to soil redoximorphic features (mottles) Inches Inches
A. a.
El Groundwater adjustment(USGS methodology) lathes —_-- Inches
2.
Index Wall Number Reading Dale _ _ —.._- Index Wall Leval
Mtustrnent Factor Adjusted Groundwater Level
E. Depth of Pervious Material
1. Depth of Naturally Occurring Pervious Material
a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
jYes ❑ No
20 96
b. If yes,at what depth was it observed? Upper boundary: hems Lower boundary: fiches
macrol5fomt11-1.doc•rev.10107 Form 11—Soli Suitability Assessment for On.Slle Sewage Disposal •Page 6 of e
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
7'_ Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
U
F. Certification
I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil
evaluations and that the above analysis has been performed by me consistent with the required training,expertise and experience
described In 310 CMR 15.017. I further certify that the results of my soil evaluation,as Indicated In the attached Soil Evaluation Form,
are accurate and in accordance with 310 CMR 15.100 through 15.107.
Signature of Soll Evaluator Date
DOUGLAS MacLEAY P.E. SE1441 10/95 -- --
Typed or Printed Name of Soil Evaluator/License# Date of Soll Evaluator Exam
DANIEL WASIUK NORTHAMPTON
Name of Board of Health Witness---- — _ --— Board of Health
Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing,and
to the designer and the property owner with PercolaUon Test Form 12.
macrotSfumm11-1.doc•rev. 10/07 Form 11-Soll Suitability Assessment for On-Silo Sewage Disposal •Page 7 of e
A / - _____ ___ _
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Name:EASTHAMPTON
Date: 10/30/2013
Scale: 1 inch equals 2000 feet
Location: 042°21'43.7 14 072°36'04.7° W
Caption:A.R.Sendd
776 No King Street
Northampton,MA 01060
Canada(C)1%1.Wated,.Inc
--Groundwater Watch
http://groundwatenyateh.usgs.goWSlateMapsiMA.html
USGS Nome
Contact USGS
Search USGS
Groundwater Watch Latest News...
Massachusetts Active Water Level Network
Hover mouse ayet site for Intormation.
Click Site to open page with county Inlormaton and sae selection.
Explanation-Percentile rlasseshwaele Seeenal teet...u-.nl '°alas WW2*
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Interactive map
Massachusetts Counties depicted on the state location map with active wells
Counties Well Count Real-Time Cant) PeHadic
Barnstaple County 9 10 - 49
Berkshire County 1 - 5
Bristol County 1 - B
Dukes County - - 9
Essex County 1 2 6
Franklin County - - 6
Hampden County 1 - - 15
Hampshire County 1 - 6
Middlesex County 1 4 - 11
Nantucket County 1 - - 10
Norfolk County 2 - 4
Plymouth County 7 2 - l5
Worcester County 1 2 - 9
Number of active MA wells: 1 9 29 2 153
10/30/2013 1:48 PM
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Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Percolation Test
Form 12
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. 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.
A. Site Information
A.RT.SANDRI
Owner Name
776 NORTH KING STREET
Street Address or Lot#
NORTHAMPTON
City/Town
MA
Stale
Contact Person(11 afferent ham Owner) Telephone Number
01060
Zip Code
B. Test Results
Observation Hole#
Depth of Perc
Start Pre-Soak
End Pre-Soak
Time at 12'
Time at 9"
Time at 6°
Time(9°•6°)
Rate(Min./Inch)
DOUGLAS MacLEAY
Test Performed By:
DANIEL WASIUK
Witnessed By.
Comments:
15form12.doc•06/03
10/9/13
Date
54
10:24
10:39
10:39
11:02
11:32
30
10
Test Passed:
Test Failed:
10 AM
Time Dale Time
Test Passed: ❑
❑ Test Failed: ❑
Pero Test•Page 1 of 1
St�
4)
Adjustment factor Adjusted ground water level
Depth of Naturally Occulting Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
If yes,what is the depth of naturally occurring pervious material?
If not,what is the depth of naturally occurring pervious material?
Deep Hole Number: Date:
Location(identify on s
Land Use/Vegetation
Landform:
Position of Landscape:
Distance from.
Open Water Body
Possible Wet Area
Drinking Water Well
On-Site Review
Time://A,isit Weather:Cool rcast
Slope(%): Surface Stones:
Feet
Feet
Feet
T.P.# 1-1
DrainagewaL Feet
Property Lineyry(/ r{O 3(10 Feet
Other Feet
DEEP OBSERVATION HOLE LOG
Depth from
Surface
(Inches)
Soil
Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other(Structure,Stones,Bouldei
Consistency,% Gravel)
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.54
la
r trt,,
toY' 3
tOY' y
7;6/4
CO4r• /
?5y3/,
11"
3 3.-/
r
Parent Material(geologic)
Depth to Groundwater: Standing Water in the Hole:Nonce
Estimated Seasonal High Ground Water: >
Depth to Bedrock: >
Weeping from Pit Face:/o,
BOARD OF HEALTH
MEMBERS
Y FLEITMAN,M.D.,ACTING CHAIR
SUZANNE SMITH,M.D.
DONNA C.SALLOOM
DIRECTOR OF PUBLIC HEALTH
NTHI SCRIMGEOUR,MHEd,CHES, BOARD OF HEALTH
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
(413)587-1214
FAX(413)587-1221
T.P.11 1-1
212 MAIN STREET
NORTHAMPTON,MA 01060
ow./C7a/,o/Ia/14 Ia./14.W
Site Suitability for On-Site Sewage Disposal (' fA/e.ss
Or/ Date: 0�4�,-3
oject Number:
:rformed b y: .j A %/ a y`/
Equipment Operator:4 77A-tern
ralth Inspector: /
Yt A. 4.5•4
Site
Address
SNOLU X/ is<7 $1,e
New Construction 1
Client Name& Address
Repair
X •
•er
Office Review
'Wished Soil Survey Available: No O Yes
Published Publication Scale Soil/hlap Unit Drainage Class Soil Limitations.
trfrcial Geologic Report Available: No ❑ Yes 7
Year Published Publication Scale Geologic Material(Map Unit) Landform
ood Insurance Rate Map:
Above 500 year flood boundary❑ Within 500 year flood boundary ❑ Within 100 year flood boundary ❑
'etland Area:
National Wetland Invetory Map(Map Unit) Wetlands Conservacy Program Map(Map Unit)
urrent Water Resource Conditions(USGS): Month
Range: Above Normal ❑ Normal ❑
ther References Reviewed: -
Below Normal 1
t ; 27 Percolation-rest stemma
're 1-1
Time
Measurement
Time
Measurement
egin Saturation
0 911
Begin Saturation
rid Saturation
/0131
/01'39e i2
End Saturation
depth
leasurement
1)•Q pt
9"depth
Measurement
depth
feasurement
/l:3^
6"depth
Measurement
lapsed Time
3Q �jfiis 1r.Ni
Time
9"to6"
ercolation Rate <2 min. in
ottom of Percolation Test Hole:
ercorauon nave:
Bottom of Percolation Test Hole:
-Determination Wale. Tablr
fethod Used
Depth observed standing on observation hole>
1 Depth to soil mottles inches
rdex Well Number
❑ Depth weeping from side of observation hole inches
❑ Ground water adjustment inches.
Reading Date Index well level
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
m! Application for Disposal System
Construction Permit
Form 1A
)0/3-10 _
Number
/"ID
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:
776 NORTH KING STREET
Address or Lot#
NORTHAMPTON MA
City/Town State
2. Owner Information
SANDRI LLC
Name
400 CHAPMAN STREET
Address Of different from above)
GREENFIELD MA
City/Town State
800-628-1900
Telephone Number
3. Installer Information
Name Name of Company
Address
City/Town
4. Designer Information
Douglas J. MacLeay
Name
377 Main Street
Address
Greenfield
City/Town
01060
Zip Code
01301
Zip Code
State Zip Code
Telephone Number
SVE Associates
Name of Company
MA
State —- -
(413) 774-6698
Telephone Number
01301
Zip Code
tsfonnla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
?\ Commonwealth of Massachusetts
9 City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form 1A
;0/30
Number
$ /50
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:
2
Number of Sheets
SEPTIC REPAIR PLAN
Title of Plan
8. Description of Soil:
❑ Garbage Grinder(check if present)
GASOLINE STATION/CONVENIENCE
STORE Number of Persons Served
❑ Cafeteria ❑ Other fixtures
Number of showers
500
Gallons per Day
500
Gallons
10/30/13
Date of Original
Revision Date
Parent material: RIVERENE DEPOSIT See plan for detailed test pit descriptions.
E.S.H.W.T.: 94 Percolation rate: 10 MIN/IN
9. Nature of Repairs or Alterations Of applicable):
REPLACEMENT OF AN EXISTING SEPTIC SYSTEM.
10. Date last inspected:
Date
iforml a.doc•06/03 Application for Disposal System Construction Perme•Page 2 of 3
Commonwealth of Massachusetts
ra City/Town of NORTHAMPTON
\ Application for Disposal System
Construction Permit
Form 1A
av
Number
$ /f0
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.
Signature
Application Approved By:
Date
Name Date
Application Disapproved for the following reasons:
t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Disposal System Construction Permit
Form 2A
/0/3-D
Number
Permission is hereby granted to:
, C
Name Name of Company
gOD hs.JJmi.al gS.
Address �C�1 /n /2 _0430/City/Town iJ� State Zip Code
to perform the following work on an on-site sewage disposal system:
❑ Construction
® Repair or replacement
❑ Repair or replacement of system components
776 NORTH KING STREET
Facility Address
NORTHAMPTON MA
City/Town State
SANDRI LLC 800-628-1900
Owner Telephone Number
01060
Zip Code
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:
All construction must be completed within three years of the date below.
Approved by
Title
Date
:5fom2a.doc•06/03 Disposal System Construction Permit•Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Certificate of Compliance
Form 3
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 Number DSCP Date
SANDRI LLC
Facility Owner
776 NORTH KING STREET
Street Address or Lot#
NORTHAMPTON MA 01060
City/Town State Zip Code
Designer Information:
DOUGLAS MacLEAY P.E. SVE ASSOCIATES INC.
Name Name of Company
Designer's issuance of System Installation Observation
Report shall constitute certification of work performed.
Inst Information: "
v1 Yacativ,5 kr
Soma .
Signature
H.0 KOCJ
Name of Company
Date jai i3 \ ��
Use of thiscyistem is conditioned on compliance with the provisions set forth below:
f11i•m I tt
The issuance of this certificate hall not be c tru d as a guarantee that the system will function as
desjo d
A�p�ro w�n�g�AU[h
Signature\
/y
Me AA"
Date
5form3.doc•06/03 Certificate of Compliance•Page 1 of 1