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Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
201 14
(-4944
Number ✓
Fee
-
I L4 ZuG'
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:❑ Construct a new on-site sewage disposal system
Z Repair or replace an existing on-site sewage disposal system
❑ Repair or replace an existing system component
Location of Facility.
310 Old Wilson Road
Address or Lot#
Northampton (Florence)
City/Town
2. Owner Information
Ian and Brooke Breen
Name
310 Old Wilson Road
MA
State
01062
Zip Code
Address Of different from above)
Florence
City/Town
3. Installer Information
Rob Adair
Name
Potwine ST
Address
Amherst
City/Town
t5form1a doc•06103
MA
State
01062
Zip Code
Telephone Number
Adair Const
Name of Company
Designer Information
Alan Weiss, RS
Name
350 Old Enfield Road
Address
Belchertown
City/Town
MA
State
531-7921
01002
Zip Code
Telephone Number
Cold Spring Environmental Consultants Inc.
Name of Company
MA 01007
State Zip Code
413-323-5957
Telephone Number
Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
7 City/Town of Northampton
! L Application for Disposal System
Construction Permit
Form 1A
Number
$
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:
1
❑ Garbage Grinder(check if present)
4 BR Home
Number of showers
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
Number of Sheets
Septic System Repair Plan
Title of Plan
8. Description of Soil:
Sand
440+
Gallons per Day
518
Gallons
06.03.2014
Date of Original
Revision Date
9. Nature of Repairs or Alterations(if applicable):
New each area
10. Date last inspected:
Date
t5formia.cloc•D6/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
zot4 -`1
Number
$ iSt
Fee
B. Agreement
The undersigned agrees to ensure the .•"ruction and maintenance of the aforedescribed on-site
sewage disposal system in accord with the provisions of Title 5 of the Environmental Code and
to place the system in ope n.-. until a Certificate of Comp'am has been issued by this Board of
Application Disapproved for the following reasons:
t5formta.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3