22 Application & Permits . . .
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BOARD OF HEALTH
DONNA C.$ALOOA.OHAIR
SUZANE SMmi.M.D.
JOANNE LEVIN.MD.
B>Vnd wood MPH.Descant
Jamie Mr.MPH.HaaM Impact
ebida Abbott NN,Pubic Nor Nina
Heather MdIrS.Clerk
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(417)587-1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON.MA 01060
Onsite Se• 'e S tem Con tru ion Permit: Conservation Comm' sio R =w
t Septic O r.aih
ntl we receiveth s ormsigned by he NorTampton Conservation Commission Staff Member.
he Conservation lava Commission can
Conservation,a reached by co t c ng:Planner
SLayallev(dnorthamotonma.¢0v
Office of Planning&Development
210 Main Street,Rm.11,City Hall
Northampton,MA 01060
'roperty Owner:
ingineer. S tadsp-SO^3
Address: .
o ad ' fel/fett)
servation, Preservation and Land Use Planner
Ri1
THE COMMONWEALTH OF MASSACHUSETTS
l
1 BOARD OF HEALTH
CITY OF No.' Y,v■mpi-DN
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE /r7i,°o
neon fork vermina Construct ( ) Repair f ) Upgrade (K) Abandon [ - FA Complete System ❑Individual Components
z� 01el In/ Isom Road
Rafe, i "Imp Lebheck;
c.,t;nfl
C„rcrsNa�ne oloGo
22 old Wisc., Rd, Net-41,464. 7 , MA-
.Address
(LH 3) 5E4 -1s65
rn nc 4
I-r��licwn F�t.v iro-„nwn 4-wl
Pio:Box 3141.6,4cf-Va kAnce,ciz
Address
3)256 -4499
,amt .m e
� 1 hLe/
Il0.NNy i� tin
)4'1 Erichie S4,Neijg^-p a.• MA OIO6O
dJtle.,
Type of Building' _ci -Y"Iinea∎1 1 1);p Ci\`^5
Dwelling—No.of Bedrooms
Other—Type of Building No.of persons
Other fixtures
Lot Size Sq.feet
Garbage Grinder (YG)
Showers ( ). Cafeteria ( )
Design Flow (min-required) 5 50 gpd Calculated design flow gpd Design flow provided 555 gpd
Plan; Date II/16124+14 Nungqer of sheets 1 Revision Date
Title 4e. :5 fe:4 Sysic UpyvaeL-
Description of Soil(s) .‘er-'GINA ‘‘
Soil Evaluator Form No. Name of Soil Evaluator f,. is Date of Evaluation IA/ulA
DESCREPTION OF REPAIRS OR ALTERAT10111 S
Replaccem$rz sysew, per Acp(cded 5a__
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TIRE 5 and rther agrees not to -lace the system in operation until a Certificate of Compliance ha been' ued by the Board of Health.
dry- is
Signed fir. r �- �� < Date
Inspections
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
vac,.�-1 iN BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) p Complete System
fhe undersigned hereby certify that the Sewage Disposal System:Constructed( I.Repaired F.Upgraded( ),Abandoned( )
tas been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
'tans relating to application No.�L1S' Y dated - 1+ . Approved Design Flow '�5 (gpd)
installer
fRJesiener: v
The is
Inspector -- Date
issuance Lh f this certificate shall be construed as a guarantee that the system will function as designed!
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. ,516 -Y
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
FEE / CT/)
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Constrict
disposal system at - - 1 -�
Repair ( ) Upgrade (x ) Abandon ( ) an individual sewage
d scribed
Provided: Construction shall he completed within three years of the date of this permit. All local conditi s s must be met.
in the application for Disposal System Construction Permit No.
dated
Date
FORM 2 - DSCP
FORM 1255 (REV 5/961
DEP APPROVED FORM 5/96
nsW> Hales n WARREN TM
Board of Health
PUBLISHERS- BOSTON