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Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
(er.& applcwi704)
a
Number n +1
$150.00 Q(�
Fee V
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
❑ Repair or replace an existing on-site sewage disposal system
❑ Repair or replace an existing system component
1. Location of Facility:
Lot#9-Sovereign Way
Address or Lot#
Northampton
City/Town
2. Owner Information
Todd Cellura
Name
hilt
fume i
�Ia I
IVV
1sf6,k
)41113
MA.
State
01060
Zip Code
135 Southampton Road
Address(if different from above)
Westhampton MA
City/Town State
413) 977-6608
Telephone Number
Installer Information
Todd Cellura
Name
135 Southampton Road
Address
Westhampton
cityrrown
01027
Zip Code
Cellura Constructuion Co.
Name of Company
4. Designer Information
Timothy E. Maqinnis R.S., LSE
Name
70 Montague Road
Address
Westhampton
City/Town
MA
State
k413) 977-6608
Teleph• ber
01027
Zip Code
MA.
State
(413) 527-5291
Telephone Number
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton
ri Application for Disposal System
Construction Permit
Form 1A
CL3
umber
$150.00
Fee
A. Facility Information (continued)
5. Type of Building:
Z Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
Number of showers
2
Number of Sheets
Plan for a Subsurface Sewage Disposal System
Title of Plan
❑ Garbage Grinder(check if present)
6
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
330
Gallons per Day
330
Gallons
October 9, 2013
Date of Original
Revision Date
8. Description of Soil:
Sandy loam-fine sandy bam -Medium sand - Official soil evaluation of file with Board of Health
9. Nature of Repairs or Alterations Of applicable):
N/A-This is new construction
10. Date last inspected:
N/A
Date
t5forml a.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 1A
,10134
Number
$150.00
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.
Signature Date
Application Approved By:
Name Date
Application Disapproved for the following reasons:
t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3