123 Disposal Construction Permit 2016 Commonwealth of Massachusetts 20.16. - 6
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Application for DisposalSystem $
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Construction Permit Fee Di I
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 New On-site Sewage Disposal
System.
1. Location of Facility:
Address: 123 Meadow Street
City/Town: Northampton, MA 01062
2. Owner Information
Name: Lance Kirley
Address: 123 Meadow Street
City/Town: Florence, MA 01062
Telephone: 413-335-1185 ; 413-341-3375
3. Installer Information
Name: Ben Goldberg
Address: PO Box 713
City/Town: Leverett, MA 01054
Telephone: 413-237-7060
4. 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
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•06/03 Application for Disposal System Construction Permit• Page 1 of 4
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Application for Disposal System $ pt / /�
Construction Permit Fee
A. Facility Information (continued)
6. Design Flow: 120 Gallons per Day
Calculated Daily Flow: 120 Gallons
7. Plan: 4/1/16 Date of Original
Number of Sheets 1 Revision Date
Title of Plan: Plan to Construct New Septic System
8. Description of Soil:
fine sandy loam
9. Nature of Repairs or Alterations (if applicable):
New compost toilet with urine separation and separate urine compost
system.
10. Date last inspected:
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed or
site sewage disposal system in accordance with the provisions of Title 5 of the Environmental
Code and n•t . .lace the system in operation until a Certificate of Compliance has been
issued by thi :o. t % Health.
Signature .� s V 0 2 '
Date /
Application A 'prove' By:
Name
Date
Application Disapproved for the following reasons:
t5formsla doc•06/03 Application for Disposal System Construction Permit• Page 2 of 4
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Construction Permit Fee
FORM 2A - DSCP
No. g0/6-‘. / O
Fee
COMMtO2setWEA.LT J4 OP WLSSACOUSE?}It
Board of Health, Northampton, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to: Construct New an individual sewage disposal system at
12 3 Meadow Street, Northampton as described in the application for Disposal System Construction
Permit No%'O/6-6 dated 1/019 .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Construction Permit
�. Fee
FORM 3A - CERTIFICATE OF COMPLIANCE
No.
Fee QCT,Z
COMMO?fWEAL1t-C OF MASSO CI-FI1SETtS
Board of Health, Northampton, MA
CERTIFICATE OF COMPLIANCE
Description of Work: ( X ) Complete System ( ) Individual Components
The undersigned hereby certify that the Sewage Disposal System: Construct New
by: Ben Goldberg
at: 123 Meadow Street, Northampton
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved
design plans/as built plans relating to application No. .9? "‘
dated
dated 4/1/16 . Approved Design Flow 120 (gpd).
Installer:
Date:
Designer: Thomas S. Leue, Homestead Inc . Date:
Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function
as designed.
t5formsla doc•06/03 Application for Disposal System Construction Permit • Page 4 of 4
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