560 Application for Disposal System Permit 2012 ut
ey
Commonwealth of Massachusetts y0/a"/ 7
City/Town of Florence Number
Application for Disposal System $ /50 o0
Construction Permit Fee
Form 1A
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 6c tion of Facility:
:266.Sylvester Road
Address or Lot#
Florence MA
City/Town State
2. Owner Information
Estate of Irene Rivard-Susan Godard- Executrix
01062
Zip Code
Name
260 Sylvester Road
Address(if different from above)
Florence
City/Town
3. Installer Information
Mark Lavalley
Name
Sylvester Road
MA
State
(413) 586 2575
01062
Zip Code
Telephone Number
Lavalley&Sons
Name of Company
Address
Florence
City/Town
4. Designer Information
Timoth E. Ma•innis R.S
Name -
70 Montague Road
Address
Westhampton
City/Town
01062
MA
State
(413) 527 5291
01027
Zip Code
Telephone Number
oc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form IA
xf2-/ 7
Number
$
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
❑ Showers- Number of showers
Specify other fixtures:
6. Design Row:
Calculated Daily Flow:
7. Plan:
2
❑ Garbage Grinder(check if present)
8
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
440 gpd
Gallons per Day
440 gpd
Gallons
December 19, 2012
Date of Original
Number of Sheets
Subsurface sewage disposal system repair
Title of Plan
8. Description of Soil:
Sandy Loam, sand &grvl.
Revision Date
9. Nature of Repairs or Alterations Of applicable):
Replace a failing subsurface sewage disposal system. Install a new 1,500 gallon 2 compartment
septic tank, a new distribution box and a High Capacity Infiltrator trench system. Two trenches with
10 Infiltrators per trench, (40'L x 12'W) -20 Quick-4 Standard Infiltrators required.
10. Date last inspected:
December 16, 2011
Date
c•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
a City/Town of Florence
Application for Disposal System
Construction Permit
Form lA
Numbe /
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:
Name
Application Disapproved for the following reasons:
Date
2 1Z0) i a
Date
foc•06/03 Application for Disposal System Construction Permit•Page 3 of 3