140 Grow Food Northampton Applications & Permits COMMONWEALTH Of MASSACHUSETTS
Board of Health, D2
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
)licauon for a Permit to Constrncty Repair( ) Upgrade( ) Abandon( ) - ❑Complete System O Individual Components
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CLV.I/Xi /44 Owner's Name
etstaller's Name ti.940F �L>< YI'1 t-i“)t
i.ere iailt uF/.address
Telephone
0057-tut
Addres
ID3
Telephone# 413— ys
Designer's Name — S /HOE
Address
Telephone
0b
low
,pe of Building
welling-No. of Bedrooms
her-Type of Building
Sher Fixtures
esign Flow (min.rem red)
Ian: Date
lescription of Soils)
/(f /¢
loll Evaluator Form No, Name of Soil Evaluator��—
lot Sire 17 RG bgefte
Garbage grinder( )
No.of persons L_Showers( ),Cafeteria( )
gpd Calcul
Number of sheet
esign flo
3
)ESCRIPTION OF REPAIRS OR ALTERATIONS
e
Design flow provided
Y7)Revision Date
Date of Evaluation
ei —
gpd
9,'»'
The undersigned agrees to - above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nql p ' s- :tem in oper. ' until a Certificate of Com lance has been issued by the Board of Health.
Signed �� Date
r -�
Inspections
COMMON\\TEAITEI OF MASSACHUSETTS
Board of Health, /t(1/✓1// // ,ff./l/ MA.
CERTIFICATE OE COMPLIANCE
)escription of Work: ❑Individual Component(s) ,Complete System
Me undei undersigned hereby certify that the Sewage Disposal System', Constructed (.Repaired ( ),Upgraded ( ),Abandoned ( )
it t--r- f a ,
tas been installed in accyrdance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
tpplicationNo. ( - y dated, . Apprbvedbe3rgn Flow (gpd) -
Install cr .-__ __ _ _"-
Designer: Inspector _ Date: - ;
the issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACQ-IUSETTS
Board of Health, .,. �ct/.� .. bA1A.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE .
Permission is hereby granted m, Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 7Z ./ -/r r / f ,/ �i / ''.!P /)1`/(t A 21 - 1 as described in the application for
Disposal System Construction Permit No. I( / dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev 5r96 AM.Sullen co.C'adeYtwnuA Date //.//a Board of Health
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Commonwealth of Massachusetts
City/Town of
Application for Disposal System
Construction Permit
Form IA
070/q-?
Number pp
$.fa?N ftO/
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
1. Location of Facility:
Lf0 6/1 eoi oyt
Address or Lot#
FLY*
own
City/rown
417
State
2. Owner Information
Grp 1—rod AA/CH 41cf l 1V-1-0v
Name
ass N1a Sfez # 9D7
Address(if different from above)
1 �a
City/Town
3. Installer Information
u e1 { wti
Name
Address
City/Town
4. Designer Information
LLy/fdo 1"�1 " SP12 (h'11u5 eGu
Name Name of Company
14111
State
Telephone Number
Name of Company
Zip Code
G/oG o
Zip Code
State Zip Code
Telephone Number
Address
City/Town
State Zip Code
Telephone Number
t5forml a doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
NIL
Commonwealth of Massachusetts
City/Town of
Application for Disposal System
Construction Permit
Form 1A
020/Y-q
Number
A. Facility Information (continued)
5- Type of Building:
❑ Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan: 5_€, q.{
Number of Sheets
❑ Garbage Grinder(check if present)
Uninio S +)a.¢1- 1-1/10,45
Number of showers ❑ Cafeteria
Title of Plan
8. Description of Soil:
ALA
Gallons per Day
Gallons
b)r raPs4 Date of Original
Revision Date
Number of Persons Served
❑ Other fixtures
9. Nature of Repairs or Alterations (if applicable): �)
4v4 w-fmcJ(�1 dnur=4. eq.) rA jzv rj, 121161-�%nsi ec1-
-� cPrvn st /n-site oyt�67am\.rot l e acc Cif tors (Je-v-
to a S6 U
10. Date last inspected:
uvice —s 2w0.
Date
t5formta.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of
Application for Disposal System
Construction Permit
Form 7A
umbe-� //� /
$_129/11O/ 1'
Fee //
B. Agreement Tke ihnchzel p,meiosr..Q +D peP IY -Fw as exes69 -' 1- ti4L 5
The undersi• ed a• ees to ensure the construction and maintenance of the aforedescribed on-site
sewage dispo , ystem in accordance with the provisions of Title 5 of the Environmental Code and
not to place 'e stem in operation until a Certificate of Compliance has been issued by this Board of
Health_
Signature
Application Approved By
FY/14th //b/d
Date
Name Date
Application Disapproved for the following reas s:
,cekie; 194/ Q��O�c_4 , ,d__
:5formla doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
has provided this form for use by local Boards of Health if they choose to do so. Before using the form,
ocal Board of Health to make sure that they will accept it.
ioiN-/e/
Fee
Number ,
53
check th
Facility Information
lication is hereby made for a permit to: construct New On-site Sewage Disposal
System.
Location of Facility:
Address: 140 Meadow Street, Florence
City/Town: Northampton, MA 01060
Owner Information
Name:
Address'
City/Town:
Telephone:
Installer Information
Name:
Address:
City/Town:
Telephone:
Grow Food Northampton
245 Main St.
Northampton, MA 01060
413-207-5899
Grow Food Northampton
245 Main St.
Northampton, MA 01060
413-207-5899
Designer Information
Name: Thomas S. Leue R.S.
Name of Company: Homestead Engineering Inc.
Address: 1664 Cape Street
City/Town: Williamsburg MA 01096
Telephone: 413 628-4533
Type of Building:
Other:Type of Building Compost toilet
Showers
Cafeteria
Specify other fixtures:
xmsla doc•06/03 Application for Disposal System Construction Permit• Page 1 of 4
Garbage Grinder(check if present)
Number of Persons Served:II
Number of showers
Other fixtures
Commonwealth of Massachusetts 076/1//V
City/Town of Northampton Number
i�n - Application for Disposal System $ /✓r0
Construction Permit Fee
:acility Information (continued)
Design Flow:
Calculated Daily Flow:
1 Gallons per Day
200 Gallons per growing season
Plan: 9/8/14 Date of Original 9/0/2014
Number of Sheets 10 Revision Date
TitleofPlan Draft Proposal to Compost Human Urine at the Florence
snit Community Garden in Florence Massachusetts
Description of Soil:
fine sandy loam
Nature of Repairs or Alterations Of applicable):
Compost of separated urine that has been collected from the compost
toilet facility on site. Urine to be composted on site utilizing a
method outline in the plan.
Date last inspected:
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 Healthy
amre Oij iiJ J Date /77 7I II
PY�Zte� / Gvw4--' iU4/11A-vihn
Application Approved By:
oe
Date
Application Disapproved for the following reasons:
W:1%/1711777
n
ft
ormsl a doc•06/03
Application for Disposal System Construction Permit• Page 2 of 4
Commonwealth of Massachusetts
City/Town of Northampton Number
Application for Disposal System $ /50
Construction Permit Fee
FORM 2A - DSCP
Fee 12
COMuOrM'Wmwriiuf Of antsy cgfuSE*S
Board of Health, Northampton, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
;slot) is hereby granted to: Construct New an individual sewage disposal system at
ea.ow Street lore c- No. tham.t. as described in the application for Disposal System
action Permit No AO IL dated 'WS •
led: Construction shah be completed within three years of the date of this permit. All local conditions must be met.
Board of Health
)rmsla doc•06/03
Application for Disposal System Construction Permit• Page 3 014
Commonwealth of Massachusetts AWN
City/Town of Northampton Number
Application for Disposal System s /0
Construction Permit Fee
FORM 3A - CERTIFICATE OF COMPLIANCE /
Fee 7 f
/
cornotOT(WEALT7(or MASS9{C?(RlSErlYS
Board of Health, Northampton, MA
CERTIFICATE OF COMPLIANCE
:ription of Work: ( X ) Complete System ( ) Individual Components
indersigned hereby certify that the Sewage Disposal System: Construct New
Florence Oroanic Community Garden
140 Meadow Street, Florence, Northampton
Seen installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved
3n plans/as built plans relating to application No.
d 9/8/14 . Approved Design Flow 1 (gpd).
alley:
igner:
lector:
Thomas S. Leue, Homestead Inc.
Date:
Date:
Date:
issuance of this permit shall not be construed as a guarantee that the system will function
designed.
rtmsl a doc•06/03 Application for Disposal System Construction Permit•Page 4 of 4