21 Conservation and Application 2016 BOARD OF HEALTH
CITY OF NORTHAMPTON
GONNA C.SMLOOM.CPoVRUZANNE q .�1'a�
a N •_ -
Jo wE LSME N.�uco. MASSACHUSETTS 01060 •-z!�.,,1 Pari
swan Woad.MPH,floor
• OFFlCE OF THE �' -1
Jeans W.MPH./MOM arpamr BOARD OF HEALTH
POW MOM RN,Pubic Ha1M Num 212 MAIN STREET
Sane McBride.Geek (413)587-1214 NORTIAMPTON.MA 01080
FAX(413)587-1121
Onsite Septic System 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 reached by contacting:
0 Sarah LaValley,Conservation,Preservation and Land Use Planner
$LaVallevtn onhamotonma.QOv
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton,MA 01060
Property Owner: SRS LLC Address: 21 /14.tI1-re Ii Po`..af
Engineer u �L4� Caw tiln+e�0'a)
///
Con s rvedon Corn Is't Conservation. Preservation and Land Use Planner
Date: 7//3//6
I Fri 7r_.r,7 ' 11i
it
Commonwealth of Massachusetts (20/6`1/
• -LS' •.i City/Town of NORTHAMPTON umber
"= Application for Disposal System 0U -
tl $ ll1'�
141/4,
Construction Permit NOTE Feed
Form 1A pAto 0
V W P�"4- review
DEP has provided this form for use by local Boards of Health if they choose to do so. Bef a 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 0 Repair or replace an existing system component
cursor-do not
use the return 1. Location of Facility:
key.
21 HATFIELD ROAD
y Address or Lot# -- --
NORTHAMPTON _._ MA 0
City/Town State Zipp Code
WA
2. Owner Information
SRS LLC
Name
9 VALEY STREET
Address(if different from above) - - --
HATFIELD _ MA _ 01038
City/Town _ - State - Zip Code
• c6�� / 54P/y 413-247-0246 9799
Telephone Number
Cate 9/3-5-63-7LV
3. Installer Information
W.R. THAYER _ _ W.R. THAYER&SON
Name Name of Company
84 KING STREET
Address
HATFIELD _ _ MA 01038
Cdy/Town State Zip Code
413-247-5564
Telephone Number
4. Designer Information
DOUGLAS MacLEAY MacLEAY ENGINEERING
Name - Name of Company
221 THOMPSON ROAD
Address
COLRAIN MA _ 01340
City/Town - _.. State Zip Code.... _
413-624-3718
Telephone Number
t5fornl a.doc•08/03 FILE Copy Application for Disposal System Construction Permit•Page, of 3
Commonwealth of Massachusetts 20/6.17
f Cit /Town of NORTHAMPTON
Y Number
ski= s Application for Disposal System
/
=_ Construction Permit Fees
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building
Number of Persons Served
❑ ShowersNumber of showers — IDCafeteria ❑ Other fixtures
Specify other fixtures:
6. Design Flow: 330
Gallons per Day
Calculated Daily Flow: 330
Gallons — —
7. Plan: JULY 9, 2016
Date of Original1 - —
NONE
Number of Sheets - —
Revision Date
SEPTIC REPAIR PLAN FOR SRS LLC 21 HATFIELD ROAD NORTHAMPTON
Title of Plan
8. Description of Soil:
SAND
9. Nature of Repairs or Alterations(if applicable):
10. Date last inspected _.
Date
15forml a.doc•06/03
Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts 0,49/6-//
-, City/Town
_ I, of NORTHAMPTON
Number
, `'—= 0 Application for Disposal System $ X50
T ,
Construction Permit Fee
Form IA
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.
Signature -. - _ — Date
Application Approved By:
7 //40/6
Name • Date
to/ fs51:4
Application Disapproved for the following reasons:
AIPPRI�i
t5formta.tloc•06/03 Application for Disposal System Construction Permit
•Page 3 of 3