97 Permit & Application & Certificate of Compliance Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System $
Construction Permit Fee
Form 1A
dots- I).
Number
50,00 Y-)1-IC
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: uoarade On-site Sewage Disposal System.
1. Location of Facility:
Address. 97 Mountain Street
City/Town: Northampton, MA 01062
2. Owner Information
Name: Jim Pratt
Address: PO Box 451
City/Town: Leeds, MA 01053
Telephone: 268-0316
3. Installer Information
Name:
Address:
City/Town:
Telephone:
Culver Enterprises
Designer Information
Name: Thomas S. Leue R.S.
Name of Company: Homestead Engineering Inc.
Address: 1664 Cane
City/Town: Williamsburg. MA 01096
Telephone: 413 628-4533
5. Type of Building:
Garbage Grinder(check if present)
Other: Type of Building Dwelling Number of Persons Served
Showers Number of showers
Cafeteria Other fixtures
Specify other fixtures:
t5formsla doc•O6/03
Application for Disposal System Construction Permit• Page 1 of 4
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
A. Facility Information (continued)
6. Design Flow: 440 Gallons per Day
Calculated Daily Flow: 440
Gallons
7. Plan: 8/16/15 Date of Original
Number of Sheets 14 Revision Date
Title of Plan Plan to Upgrade Septic System
D.VISrI)
8. Description of Soil:
lo. y sand
9. Nature of Repairs or Alterations Of applicable):
New septic tank and infiltration chamber style leachfield
10. Date last inspected: 7/21/15
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
Name
0 r
cation Approved By:
Date
Application Disapproved for the following reasons
Date
fZo— (5
� f5
15formsla doc•06/03
Application for Disposal System Construction Permit•Page 2 014
No a?/St la\
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit Fee
FORM 2A - DSCP
Number
$ Ih0.°0
zit-0
Fee
4 I Jgo eo
COM4.014W291LatfOT MASSAC fusePTS
Board of Health, Northampton, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to: Uparade an individual sewage disposal system at
97 Mountains Street, Northampton as described in the application for Disposal System Construction
Permit No. O/D"I dated £720b 5
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date gloZ7'i5 Board of Healt
AMIE
t5formsla doc•06/03 Application for Disposal System Construction Permit•Page 3 of 4
halfift
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
FORM 3A - CERTIFICATE OF COMPLIANCE
scrlption of Work:
e undersigned hereby certify that the Sewage Disposal System: oacrade
Culver Enterprises
Number
Fee
Fee
CO1vtivtQRf'WOf U1' T op m ssq '`USfE'fT'S
Board of Health, Northampton, MA
CERTIFICATE OF COMPLIANCE
( X ) Complete System ( ) Individual Components
7 Mount-i S -et N•rt, • . rto
is been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved
:sign plans/as built plans relating to application No.
ated ° /' 6 '15 Approved Design Flow 440 (gpd)
Date:
Istallec
)esigner:
$ Leue Homestead Inc• Date:
Date:
nspector:
The Issuance of this permit shall not be construed as a guarantee that the system will function
as designed.
Application for Disposal System Construction Permit•Page 4 of 4
t5formst a tloc•06703
OARD OF HEALTH
JNA C.SALLOOM,CHAIR
'SUZANNE SMITH,M.D.
JOANNE LEVIN,M.D.
ljamin Wood MPH,Director
del Wasiuk,Health Inspector
nund Smith,Health Inspector
Abbott,RN,Public Health Nurse
Heather McBride,Clerk
CITY OF NORTHAMPTON
MASSACHUSETTS oio60
OFFICE OF THE
BOARD OF HEALTH
(413)587-1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON,MA 01060
nsite Se .tic S stem Construction Permit: Conservation Commission Review
TE: As of 1 /11, Sepic System I we receive/1
th s form t signed by the Northalmpton Conservation Commission oStaff Member.
Conservation Commission Conservation,Preservation and Land
Sara Use Planner
o Sarah LaValley,
SLaValle v a.gov
587-1263
Office of Planning&Development
210 Main Street,Rm. 11,City Hall
Northampton, MA 01060
roperty Owner:
tz
ngineer.�ze—
,o
,P
on Conservation, Pre erva
Date:
Address:
Act (FAD rqui'd
ion and Land Use PlarUier
Closeout Notes:
1. Septic tank is equipped with an outlet filter. This is a maintenance item. Filter must be cleaned
whenever septic tank is pumped, or every 3 years, whichever is sooner. Failure to maintain filter
may lead to septic system backup and failure.
2. Recommend pumping septic tank on a 3 to 5 year schedule, depending on house occupancy.
3. A copy of this document attached in the basement/utility area will keep this information
available in future years for maintenance.
1
— --- — ---iii )
4-
Orig.Su .Ele..- 35.3
I
I
PL
Inspection Port and Vent
i
I
rig.Surf Elev.: 96.3
PL
1
Cleanout to surface at
mid-point of pipe run.
SDR-35 pipe.
TBM: nail at base of 24" maple tree.
Elevation: 100.00'
Schedule 40 se
PL
New 1500 gal.septic tank with outlet filter. Riser
to near surface over all three access covers
E t .LL
FORM 3A - CERTIFICATE OF COMPLIANCE
iS? Fee /50 as
/t/G)�/.h= COIvtT1.07f1VELL` OF RvtASS9t0-PUSETYS
Board of Health, Northampton, MA
CERTIFICATE OF COMPLIANCE
acription of Work: ( Y. ) Complete
System ( ) Individual Components
undersigned hereby certify that the Sewage Disposal System: uDQrade
F teIprlSeS
Imestead Inc. Project#: 66=0
s been i installed in accordance With the provisions or 310 41VIR 15.00 (Title 5) and the approved
sign plans/as built plans relating to application No.,?pZILl
dated / 6_ 1�-5 --= Approved
:sign Flow 4.40 (gpd).
ate of sub-grade inspection: 9/15/15
staller
resigner:
Date: t—
Date: 9/28/15
96
T
Date:
This certification represents no warranty, expressed or implied as to the functioning or
longevity a the all applicable licable subsurface iand regulations ons inn effect the at the time of installation are in submittal.
compliance with all app
cc: Jim Pratt, PO Box 451, Leeds, MA 01053
FILE COPY
DEP APPROVED FORM 5/96