50 Certificate of Compliance/ Well Construction Permit FORM 3A - CERTIFICATE OF COMPLIANCE
CERTIFICATE OF COMPLIANCE
Description of Work: _ Individual Component(s) X Complete System
The undersigned hereby certify that the Sewage Disposal System:
Constructed X Repaired X Upgraded_ Abandoned
by: Frank Leavens
at: 211 Westhampton Road - Florence, Massachusetts
*** This system has been installed in accordance with the provisions of 310 CMR
15.00(Title5) and the approved design plan / as-built plans relating to the
application No
dated: September 6, 2004
Installer: Karl Kuehner
Approved Design Flow: 550 god
So on Environmental Services Inc.
Designer: Timo
Date: November 6, 2
The issuance of this permit shall not be construed as a guarantee that the
system will function as designed.
LEGEND
=22 6„
A-D=35'9"
B-C=28'6" 1
' B-D=17'10"
211 WESTHAMPTON ROAD
1500 gallon
Septic Tank..-
6
40 unit Infiltrator system
SOUTHAMPTON ENVIRONMENTAL SERVICES INC.
Karl M.Kuehner Field Supervisor NO SCALE'
NUMBER
0
e r t
50
City of Northampton
3 BOARD OF HEALTH 1
i f y that \C P I -tA c i t s I
FEE$
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Z
This is to c
___V)(
`J NAME
O\ C\ 4)( Ro 7 I acke
For
ADDRESS
Is hereby granted a
Permit
ESTRONIMOrti
wren
This license
thereto and
or revoked.
I
is
expires
granted in co
ormi�y with the Statutes and ordinances
z3 201 \ unless sooner
relating
suspended
7 3 ,20
1O I I( &A`N
bA
I
Board of Health
r
BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
'ell Permit Number z&o-o3 (TO BE ASSIGNED BY BOARD OF HEALTH) Fee $50.00
its application must be accompanied by a scaled plot plan, produced by a civil engineer or registered
initarian showing the minimum distances required in Title 5 of the State Environmental Code. For new
instruction, requiring a septic system, the septic system plan submitted for the property in compliance
th Title 5 requirements will be acceptable if the proposed well location is included.
pplication is hereby made to construct( ) or repair( )a private well.
(-03 -
rd 5,23 - .i7fe- ?5( - Qe 6510
PPr Ad• ry ma Telephone Number
, State, Zip
e )
cation of Proposed Well
ifferent from address)
ell Driller (submit evidence of valtastate registration)
Tax Map # Parcel #
tr new construction:
Septic system plan complies with Title 5:
Septic system plan shows location of well:
yes >j,no( ) n/a( )
yes-igno ( ) n/a( )
tr new, repair or location to leach field, septic tank or city sewer:
A scaled well construction plan has been submitted:yes no ( ) n/a( )
na' e of Applicant
ease Mail Application to:
■rthampton Board of Health
2 Main Street
rthampton, MA 01060
Date
Ct MPLETED BY BOARD OF HI TH
Cita) Ol l7 Permit expires on: �7 2011 (One year from date of issuance)
rmit issue