79 Construction Permit 2017 Commonwealth of Massachusetts W0/7-`7
iw.yiitwl City/Town of Northampton Number
't1 ,� Application for Disposal System $ /5Q
GConstruction Permit
Fee
' ~ Form 1A
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 s stem in operation until a Certificate of Compliance has been issued by this Board of
git / //
Signature Date
Application Approved By:
7///7
Name Date
Application Disapproved for the following reasons:
Ap-poryricifi
•
Conditions:
1).Sv<tcm 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:
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3