231 Application for Disposal System Permit 2013 Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
,2013-.2l
Number
$150
Fee r4
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
mt:
ling out Application is hereby made for a permit to:® Construct a new on-site sewage disposal system
n the ❑ Repair or replace an existing on-site sewage disposal system
er,use ❑ Repair or replace an existing system component
tab key
r your
•do not 1. Location of Facility:
return
Lot#4-Sylvester Road
Address or Lot#
Florence
City/Town
2. Owner Information
Jeff Lavalley
Name
23 Hayes Ave
MA.
State
01062
Zip Code
Address Of different from above)
Northampton MA
City/Town State
(413)250-2267
01060
Zip Code
Telephone Number
3. Installer Information
Mark Lavalley Lavalley Construction
Name Name of Company
Sylvester Road
Address
Florence
City/Town
MA
State
(413) 586-3779
01062
Zip Code
Telephone Number
4. Designer Information
Timothy E. Maginnis R.S., LSE
Name
70 Montague Road
Address
Westhampton
City/Town S ate Zip Code
1413) 527-5291
Telephone Number
ml a.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
01027
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
Number
$150
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other:Type of Building
❑ Showers Number of showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7, Plan:
2
Number of Sheets
Title of Plan
❑ Garbage Grinder(check if present)
8
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
440
Gallons per Day
440
Gallons
November 11, 2013
Date of Original
Revision Date
8. Description of Soil:
Sandy loam-Loamy sand -sand and gravel with large stones and boulders
9. Nature of Repairs or Alterations Of applicable):
N/A-This is new construction
10. Date last inspected:
nla.doc 06/03
N/A
Date
Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
.?0/9-02/
Number
$150
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
Application Approved By:
nia.doc•06/03
Name
Application Disapproved for the following reasons:
Date
///Y/I3
Date
Conditions:
1),System Designer must inspect mid verify in writing
Thal the sewage disposal system was installed
In accordance with the approved plans and Title 5,
2).If this is a system with the S.A.S.constructed in
Tine 5 fill the System Designer must conduct a bottom
inspection of the excavated area prior to the placement
of the fill.
3).No changes can be made during conatmction by the
Installer without prior approval by both the System
Designer and the Board of Health Agent
4).Other conditions:
Application for Disposal System Construction Permit•Page 3 of 3