48 Application for Disposal System Permit Important:When
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matt
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
Number
DSO
Fee
DEP has provided this form for use by local Boards of Health it 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
❑ Repair or replace an existing on-site sewage disposal system
® Repair or replace an existing system component
1. Location of Facility:
48 Country Way
Address or Lot p
Florence
City/Town
2. Owner Information
Lisa Gibbs
Name
Address(if different from above)
City/Town
MA
State
01062
Zip Code
State Zip Code
Telephone Number
3. Installer Information
Tom Wanzcyk River Drive Excavating
Name Name of Company
Address
Hadley MA
City/Town State
413-584-1814
Telephone Number
01035
Zip Code
4. Designer Information
Alan Weiss Cold Spring Environmental Consultants Inc.
Name Name of Company
350 Old Enfield Road
Address
Belchertown MA 01007
City/Town State Zip Code
413-323-5957
Telephone Number
tsforml a.doc•06/03 Application for Disposal System Constmdion Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
;0/6-/3
Number
$ /50
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building 3 Bedroom Single Family Home
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
Number of showers
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
330+.
Gallons per Day
New 1500 gallon septic tank installed.
Gallons
07.19.16
Date of Original
01
Number of Sheets Revision Date
Septic Tank installation only due to corrosion of old 1000 gallon tank .
Title of Plan
8. Description of Soil:
9. Nature of Repairs or Alterations(if applicable):
New septic tank only as part of Title 5 inspection .
10. Date last inspected:
Date
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form to
20/6-73
Number
LSD
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] 17e
ro P
Signature
Application Approves'y
NaMe
Application Disapproved for the following reasons:
INa '',h .' , rill+
Date
D
t5fornl a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
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