51 A Construction Application 2016 Commonwealth of Massachusetts ,X716 — i
z, .€ City/Town of Northampton Number -
� '_ � Application for Disposal System
if $150.00
• ® Construction PermitISA Feeq ,010
Form 1A <9SB�
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 piing out Application is hereby made for a permit to:® Construct a new on-site sewage disposal system
forms on the ❑ Repair or replace an existing on-site sewage disposal system
computer,use ❑ Repair or replace an existing system component
only the tab key
to move your
cursor-do not 1. Location of Facility: S
Th
use the return
key. Assessor Map-21, Lot-4--- Lot on Sylvester Road (adjacent to House#567)
Address or Lot ti
�m O Northampton MA _ 01081 _
X City/Town State Zip Code
(Item O
2. Owner Information
Scott Keiter
Name
51 A Hatfield Street
Address(if different from above)
Northampton MA _ - 01060
City/Town State Zip Code
413-586-8600
Telephone Number
3. Installer Information
Name Name of Company
Address
City/Town - _. State Zip Code
Telephone Number
4. Designer Information
G. Newman Newman Environmental Engineering-
Name Name of Company
P.O. Box 395
Address
Worthington _ MA 01098
City/Town State Zip Code
413-238-5383 _
Telephone Number
t5fomr la.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
10City/Town of Northampton Number
''- a Application for Disposal System
$150.000-71
Construction Permit Fee
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 ❑ Cafeteria ❑ Other fixtures
Specify other fixtures: _ -- -- - —
440
6. Design Flow: Gallons per Day
440
Calculated Daily Flow: Gallons
7.
5/1112013
Plan:
Date of Original
one 5115/2013
Number of Sheets Revision Date
Sewage Disposal System at Lot onSylvester Road, Northampton, MA
Title of Plan
8. Description of Soil:
sandy loam of loamy sand—see soils report attached
9. Nature of Repairs or Alterations Of applicable):
New construction includes 1500-gallon septic tank, pipeline access boxes on steep slope,
D-box, 903-SF raised bed leach field and gravity connective piping.
10. Date last inspected: Date .
t51orml a.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
� Commonwealth of Massachusetts
07016 —I
g:.._=.7' City/Town of Northampton Number --
' Will ° Application for Disposal System $150.00
` _;� Construction Permit Fee
Form IA
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewa7- oisposa em in accordance with the provisions of Title 5 of the Environmental Code and
not • ce th em in operation until a Certificate of Compliance has been issued by this Board
of h.
3-/6 _r‘
• <ture Date
'pp kation Appro =- B -/1/25,1
— �
/ ..,tie .3//6
ame Date
Application Disapproved for the following reasons:
lilfi f
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
Conditions: NORTHAMPTON, MA 01060
1).System Designer must inspect and verify in writing
That the sewage disposal system was ins I al led
In accordance with the approved plans and Title 5.
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:
t5formta.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3