38 Application & Permit for Construction 2016 Commonwealth of Massachusetts
j- __ City/Town of Northampton
`'�'_- " Application for Disposal System
`� Construction Permit
Form 1A
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DEP has provided this form for use by local Boards of Health if they choose to do so. Before usimj
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:
38 North Farms Road
Address or Lot#
Northampton
City/Town
2. Owner Information
Gil Leblanc
Name
38 North Farms Road
MA
State
"4
01061
Zip Code
0i66.a
Address(i different from above)
City/Town
RE COPY
3. Installer Information
River Drive Excavating
State Zip Code
s3(9 -.n7?.
Telephone Number
c egatc- $ 9129
Name
Name of Company
Address
Hadley
City/Town /�
ea",s`u" - r IoM
4. Designer Information
Alan Weiss
Name
350 Old Enfield Road
forml a.doc•06/03
Slate Zip Code
413-584-1814
Telephone Number
Cold Spring Environmental Consultants Inc.
Name of Company
Address
Belchertown
City/Town
MA
State
413-323-5957
01007
Zip Code
Telephone Number
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
a-/8
Number
$ /✓27°
Fee
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:
01
❑ Garbage Grinder(check if present)
4 Bedroom
Number of showers
Number of Sheets
Septic System Plan
Title of Plan
8. Description of Soil:
Sand
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
440+.
Gallons per Day
445
Gallons
11.02.2016
Date of Original
Revision Date
9. Nature of Repairs or Alterations Of applicable):
New Septic Tank (1500 gal) and 14'x 43' Leachfield.
10. Date last inspected:
Date
rml a.doc•aS/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Northampton i Application for Disposal System
C onstruction Permit
Form 1A
x076
Number
$ /✓V r
OO
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.
ormla.tloc•06/D3
Signature
J fZ t Aera•0C
Application Approved By:
Date
Name etnC/ Date
Application Disappr ved for the following reasons:
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no
Application for Disposal System Construction Permit•Page 3 of 3
BOARD OF HEALTH
DONNA C.3ALLOOM,CHAR
SUZANNE SMITH,M.D.
JOWE LEVIN,MD.
8aip in Waad,SAM Din aor
Jowls Mr.MM,Haan aapa for
PRIMA Abbe,RN,Public HSIi Mn.
Hats MSC*,CJNt
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
212 MAN STREET
(413)587-1214 NORTHAMPTON,MA 01080
FAX(413)587-1221
Onsits Septic $vstem 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 readied by contacting:
O Sarah LaValky,Conservation, Preservation and Land Use Planner
SLa Valley llnorthamotonma,eov
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton, MA 01060
Property Ovmer:(%/ / LIZ& C
Engineer AL /!/€45 5
Address:3l/ 4 /2,s
Foa.1
Von Commas •nservation, Preservation and Land Use Planner
ate: I(7/10,
FILE COPY