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Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form IA
.020/5 /6
Number h/
$ /6 00
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:® 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
Location of Facility:
Lot#9 Sovereign Way
Address or Lot#
Florence MA
City/Town State
2. Owner Information
Sovereign Builders, Inc.
Name
Lot#9 Sovereign Way
Address(ft different from above)
Florence MA
City/Town State
01062
Zip Code
Telephone Number
01062
Zip Code
3. Installer Information
Todd Cellura Cellura Construction, Inc.
Name Name of Company
135 Southampton Road
Address
Westhampton MA
City/Town State
413-527-8153
Telephone Number
Designer Information
James A. Gracia
Name
99 Glendale Street
Address
Easthampton
City/Town
t5forml a.doc•06/03
James A. Gracia, PE
Name of Company
MA
State
413-527-8318
Telephone Number
01027
Zip Code
01027
Zip Code
Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form 1A
420/k7k
Number
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
Number of showers
Z Garbage Grinder(check if present)
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
501 GPD
6. Design Flow: Gallons per Day
495 GPD
Calculated Daily Flow: Gallons
8/20/2013
7 Plan: Date of Original
2
Number of Sheets Revision Date
Septic System Design
Title of Plan
8. Description of Soil:
Sand (see Soil Logs on Plan)
9. Nature of Repairs or Alterations (if applicable):.
10. Date last inspected'.
Date
t5forml a.dac•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
iCity/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form 1A
X20/3 76
Number
$ee / r/
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
_ance with the provisions of Title 5 of the Environmental Code and
on until a Certificate of Compliapce has been issued by this Board of
t5form1 a doc•06/03
sewage disposal system in acc
not to place th Mstem in op
Sig Lure Date
Application Appro
Name //
knl/e //f/ "✓
t
y
Application Disapproved for the following reasons:
9A,3/3
Date
vut
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON. MA 01060
Application far Disposal System Construction Permit•Page 3 of 3
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Commonwealth of Massachusetts aQ,3/6_
City/Town of NORTHAMPTON Number
Disposal System Construction Permit
Form 2A
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
the local ma n mu He ealth to st b sub determine the ee am form they pr o tided here. Before using this form, check with
Permission is hereby granted to:
Cellura Construction
Todd Cellura Name of Company
__---_
Name --— - - - - -
135 Southampton Road. . - - - - ---- 01027_
Address MA _ _. - ---
_ Zip Code
Westhampton _- - - - - - - State
City/Town
to perform the following work on an on-site sewage disposal system:
® Construction
❑ Repair or replacement
❑ Repair or replacement of system components
Lot#9 Sovereign Way
Facility Address
Florence_
cityRown
Sovereign_Builders___
Owner
MA
State
413-527-6153.
Telephone Number
01062
Zip Code
The work to be performed is further described in the Application
Title f 5 and the following System local provisions
n for Disposal System Construction
Permit. The applicant recognizes his/her duty to comply
or special conditions.
t5form2a.doc•06/03
All construction must be completed within three years 3at/e low.
Approvei ,�/ est /_r
jt//"r L777���///
Title
NORTHAMP ON BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON, MA 01060
Date
Disposal System Construction Permit•Page 1 of 1
BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMITH.M.D.
JOANNE LEVIN,MD.
Benjamin Wood,MPH,DYector
Jamie Mr.MPH,Health Inspector
Panicle Abbott,RN,Public Her Nurse
Heaa,a McBride,Clerk
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587-1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON,MA 01060
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE:As of 1/1/11, Septic System Permits will not be issued by the Northampton Board of Health
until we receive this form signed by the Northampton Conservation Commission Staff Member,
The Conservation Commission can be reached by contacting:
0 Sarah LaValley,Conservation, Preservation and Land Use Planner
S La V a l ley@ no rth a m Dto n m a.eov
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton, MA 01060
Property Owner: /0e../.1 67/4,
Engineer _/e< .'nes
;orhservation Corn
)ate: `y?-6//S
Address. Li -#9
Se//et 44/
(Net) Grim, /a0 01,1
Conservation, Preservation and Land Use Planner
) od weeackr 'ett) orarted