7 Disposa Permit 2017 Commonwealth of Massachusetts
.4 City/Town of NORTHAMPTON Number
Application for Disposal System
Construction Permit Fee
Form 1 A iU
#135 7
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
Important:When
filling out forms Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system
on the computer, ® Repair or replace an existing on-site sewage disposal system
use only the tab
key to move your ❑ Repair or replace an existing system component
cursor-do not
use the return 1. Location of Facility:
key.
7 Shephards Hollow ROad (188 Chesterfield Road)
Address or Lot#
• Leeds (Northampton) MA 01053 _
City/Town State Zip Code
morn
2. Owner Information
Rachel Cartmell (C/O Hank Ross)
Name
Address(if different from above)
City/Town State Zip Code
413-584-1608
Telephone Number
3. Installer Information
Gene Tag)/
Name Name of Company
Address
Florence MA 01062
City/Town State Zip Code
413-626-3716
• Telephone Number
'•(-Nc MASS
••,\.2 �C
G 4. Designer Information
Q. a Alan Weiss Cold Spring Environmental Consultants Inc.
c Name Name of Company
350 Old Enfield Road
• Address
• '_, Belchertown MA 01007
City/Town State Zip Code
413-323-5957
Telephone Number
t5fomila.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts .20/7-4
�1=z ; . City/Town of NORTHAMPTON Number
(;i
! L !' Application for Disposal System
„� <• Construction Permit $ee
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building 4 Bedroom
Number of Persons Served
❑ Showers Number of showers 0 Cafeteria ElOther fixtures
Specify other fixtures:
440+.
6. Design Flow: Gallons per Day
Calculated Daily Flow: G66
Gallons
7. Plan: 07.16.2017
Date of Original
02
Number of Sheets Revision Date
Septic System Plan
Title of Plan
8. Description of Soil:
Sandy
9. Nature of Repairs or Alterations(if applicable):
New 1500 gallon septic tank, and 14' x 45' leachfield.
10. Date last inspected: Date
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts a0` 7../6
►-=_` ,-,i City/Town of NORTHAMPTON Number
C - ''-I.
Application for Disposal System $ Q
Construction Permit Fee
Form 1A
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed onsite
sewage disposal syst-• in accordance with the provisions of Title 5 of the Environmental Code and
not to place a-_ s •m in operation u til a Certificate of Compliance as been issued by this Board of
Health.i I, , _ _ 7 a / /-
Signatures .J ' Date
Application A i*roved By:
is.. ----------_.... -7/2 o I 7
NameDate
/ Ge...4.1/e--/ (.24-.51c)/
Application Disapproved for the following reasons:
ovnovoi
Conditions:
1).System Designer must inspect and verify in writing
That the sewage disposal system was installed
In accordance with the approved plans and Title S.
2).If this is a system with the S.A.S.constructed in
Title 5 fill the System Designer must conduct a bottom
inspection of the excavated area prior to the placement
of the fill.
3).No changes can be made during construction by The
Installer without prior approval by both the System
Designer and the Board of Health Agent.
4).Other conditions:
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