308 Application Disposal System 2016 Commonwealth of Massachusetts //�crlserrl
AO/e-07
City/Town of Northampton Number
It- I Application for Disposal System •
Construction Permit Feerl
Form 1A
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 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:
use the return
key. 308 Chesterfield Road -Lot A
Address or Lot#
Leeds MA. 01053
City/Town State Zip Code
,rem X
2. Owner Information
Patrick Melnick Sr.
Name
311 Chesterfield Road
Address(if different from above)
Leeds MA 01053
City/Town State Zip Code
(413)584 1155
Telephone Number
3. Installer Information
TBD
Name Name of Company
Address
City/Town State Zip Code
oonnee\Number
TWINY ba,
4. Designer Information , a J_
Timoth E. Mae Innis R.S., LSE $ ! . - _''_
Name � 4,1.
6
I5).1, W•pany
70 Montague Road •-S4NIT AP\txAddress .._. ..
Westhampton MA. -__ 01027
City/Town State Zip Code
(413) 527-5291
FILE COPY Telephone Number
t5forml a doc•06103 Application for Disposal System Construction Pennk•Page 1 of 3
Commonwealth of Massachusetts ,70i6-�
i` City/Town of Northampton Number
WIT—; Application for Disposal System $
Construction Permit Fee
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
6
Other:Type of Building ---- - - - ---- Number of Persons Served
❑ Showers Number of showers Li Cafeteria ❑ Other fixtures
Specify other fixtures: -—
6. Design Flow: Ga0
Gallons per Day
Calculated Daily Flow: Ga ..__
Gallu ons
7. Plan: April 26, 2016
Date of Original
2 December 2, 2016
Number of Sheets Revision Date
Plan of Subsurface sewage disposal system design
Title of Plan
8. Description of Soil:
Sandy loam -Loamy sand _
9. Nature of Repairs or Alterations (if applicable):
N/A-This is new construction.
10. Date last inspected: NtA
Date
t5formtadoc•O6/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts /
nc City/Town of Northampton
Via— • Application for Disposal System $
Construction Permit Fee �'�
Form 7A
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 Comp- nce has been issued by this Board
of Health.
Signature Date
Application Approved By: 61/b
N: Date
Application Disapproved for the following reasons:
•
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