21 Lot 4 Conservation Commission Review 2013 BOARD OF HEALTH PT"
C.SALLOOM,CHAIR CITY OF NORTHAMPTON
DONNA1' .
SUZANNE SMITH,M.D. b "i
MASSACHUSETTS 01060
JOANNE LEVIN,M.D. 11
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Benjamin Wood,MPH,Director OFFICE OF THE _ _-
Daniel Wasiuk,Health Inspector BOARD OF HEALTH
Edmund Smith,Health Inspector 212 MAIN STREET
Patricia Abbott,RN,Public Health Nurse (413)587-1214 NORTHAMPTON,MA 01060
Heather McBride,Clerk FAX(413)587-1221
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE: As of 1/1/11, Septic System Permits will not be issued by the Northampton Health Department
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
SLaVallev@ northamptonma.gov
587-1263
Office of Planning&Development
210 Main Street, Rm. 11,City Hall / / L
Northampton, MA 01060 � /I/@W ST/rO ON
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Property Owner: Address:
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Qonservation Commission Conservation, Preservation and Lan Use Planner
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Checklist for Septic System Plan _ssor Avea Y^ter
Nett CLI-ri .,c-c-,oa
Application page attached to plan
PE or RS stamp, date,signature
Variances to property line setback distances must have Surveyor stamp
�77c Legal boundaries noted
Easements noted
Dwellings and buildings existing or proposed noted
Xi Location of driveway or parking areas,other impervious areas
❑ Location and dimensions of reserve area(new construction only)
y -• — ISystem design calculations 1.64P /_ /
(❑ Garbage grinder,y=- ,
r no 441:4
❑ Benchmark not disturbed during construction within 75ft of facility
/►tOrth arrow
trs�/ Contours
l( Deep hole location(s)and data
Perc hole location(s) and data
Elevations
Names of approving authority and soil evaluator X.FS Location of water supplies, public and private
/r o Within 400ft of system in case of surface water and gravel-packed public water supply
o Within 250ft of system in case of tubular public water supply �K
o Within 100ft of system in case of private wells(50k from tank)�--.,
ILWell statement, if applicable-
ocation of any surface waters, rivers,vegetated wetlands
Location of water lines and other subsurface utilities
A Obserrved and adjusted groundwater elevations in vicinity of system
A Profile of system
f Locus plan to show location of facility, including nearest street
/ ` Materials of construction and specs for system
Gas baffle
ipe in center line of tank
Dtr Double-washed stone
iffk/Schedule 40 PVC for trafficked areas, house to tank
_IVDistances noted from house to tank,etc.
O If dosing is proposed, design and specs of dosing system ` IN, /di
❑ When alternative technology is required,complete plan and sp cs including hydraulic profile
❑,v� eferred over beds
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:u.••ncy calculations for tanks or components partly below groundwater level
th 3:1 slope outside of mound,toe ending 5ft from property line
.� Local upgrade requests on the plan, all variances ,Q
Local upgrade forms attached to the application ' /
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