50 Certificate of Compliance/ Application for Disposal System Permit e 66' 1 icutioOK4, ?ttemaidadett4
212 Nag Street
lf4td4mfttoa, 9/M 01060
7e1 413-587-1214
lax 413-587-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE SYSTEM DESIGNER
DESIGNER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Designer of a system is required to sign
this form as a condition for issuance of a Board of Health Certificate of Compliance for the onsite septic
system.
This is to certify that the onsite sewage disposal system that I dedoned as: V new construction
_repair(existing system)
at cm OLD W (56+0 kap on S -.2 -06 DWCP number
(Armen) (Dan)
has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the
original approved plans ha e been reflected on an as-built plan that has boon submitted to the Board of Health
DO Mok/l Aave goono
T
Otky G. MAC-iOARS (APCH .J MA
t Designer's name) (Aar use
- 22 -ob
(Date)
NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the time of plan submittal.
Commonwealth of Massachusetts
City/Town of q,AcA2 mmel?nd
_" ' 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
Cant:
filling out
on the
ter,use
e tab key
e your
-do not
a return
m3.doc•06/03
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
Z 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
Joyce August
Facility Owner
50 0 Wi lson Road
Street Address or Lot#
Northampton
City/Town
DSCP Date
Ma.
State
01062
Designer Information:
Timothy E. Maginnis
Name Name of Company
( (.4.4,.. March 2, 2006
Signature Date
Installer Informa
James Dimos
Name Name of Company
Zip Code
J.C. & Company Inc.
Signature Date
Use of this system is conditioned on compliance with the provisions set forth below:
No garbage disposal is allowed
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Approving Authority
Signature Date
Certificate of Compliance•Page 1 of 1
\ \ \ \ \
\ N
0 \ Existing Infiltrator SAS
Existing
\ \ \ N'
\ 3 bedroom \
\ house \ Existing septic tank
\ ¢ ---_
N
0 \ 4' pvc solid pipe 1-; __\ m
•0 \ Existing \
\ garage
.0_s.
—
\ \ \ \ \ \ \ 4' pvc solid pipe
Existing
driveway Existing distribution box
O� / 4' pvc solid pipe
AS—BUILT DIMENSIONS
"A" to "C" = 19.0'
AS—built plan
"B" to "D" = 104' — 9" 25 Infiltrators
Joyce August
50 Wilson Road
tent:
filling out
on the
filer,use
e tab key
e your
-do not
return
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
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:X❑ 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:
50 Old Wilson Road
a Address or Lot#
Northampton
City/Town
2. Owner Information
Joyce August
Name
50 Old Wilson Road
MA.
State
01060
Zip Code
Address(if different from above)
Northampton
City/Town
3. Installer Information
James Dimos
Name
Fair Street Ext.
MA.
State
1413) 584 3245
01060
Zip Code
Telephone Number
J.C. & Company Inc.
Name of Company
Address
Northampton
City/Town
4. Designer Information
Timothy E. Magininis R.S.
mla.doc•06/03
Name
70 Montague Road
Ma.
State
013) 575 -2069
Telephone Number
01060
Zip Code
Timothy E. Maginnis&Associates
Name of Company
Address
Westhampton
City/Town
MA.
State
0131 527-5291
01027
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 IA
Number
Fee
A. Facility Information (continued)
5. Type of Building:
3
X❑ Dwelling 4 Bedrooms
Other: Type of Building
X❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
2
2
Number of showers
❑ Garbage Grinder(check if present)
6
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
330 qpd
Gallons per Day
330 qpd
Gallons
November 15 2005
Number of Sheets
Subsurface sewage disposal system design
Title of Plan
8. Description of Soil:
Sandy loam
Date of Original
N/A
Revision Date
9. Nature of Repairs or Alterations Of applicable):
Replace a failing SAS only. Install a new distribution box and a (30'L x17.5'W
Infiltrator leaching bed system
10. Date last inspected: N /A
Date
nla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Northampton Number
JrApplication for Disposal System
Construction Permit $
Fee
Form 1A
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore described on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
no . place the s stem in operation until a Certificate of Compliance has been issued by this Board
alb •• q( ' C- Go. —��—or
ature / Date
Application Approved By:
Name Date
Application Disapproved for the following reasons.
nl a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3