308 Application Disposal System 2016 (2) Commonwealth of Massachusetts 020/6- a
City/Town of Northampton Number
CAllt ° Application for Disposal System $ ��
/ Construction Permit Fee
4-(27-16S
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
only the tab key ❑ Repair or replace an existing system component
to move your
cursor-do not 1. Location of Facility:
use the return
key. 308 Chesterfield Road
S Address or Lot#
Leeds MA. 01053
City/Town State Zip Code
MP 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
Telephone Number
t
4. Designer Informationp
i ua
Timothy E. Maginnis R.S., LSE �� oiwms
Name A iAK m y
70 Montague RoadG: i
Address ,a..'14%\`'J �
Westhampton 01027
City/Town State Zip Code
14131 52 7-52 91
Telephone Number
t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts X0/6
./ City/Town of Northampton Number
tSApplication for Disposal System $
*051_,-7!
Construction Permit Fee
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building - --- ---- 6
Number of Persons Served
❑ ShowersNumber or showers ❑ Cafeteria ElOther fixtures
Specify other fixtures: ---
6. Design Flow: 330
Gallons per Day
Calculated Daily Flow: 330
Gallons
7. Plan: April 26, 2016
Date of Original
2
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: D t A
Date
t5fonnia.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
. . Commonwealth of Massachusetts 6
re � City/Town of Northampton
Number
t _rApplication for Disposal System
` 'LL�° _ Construction Permit Fe
Form 1A
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage • posal system in accordance with the provisions of Title 5 of the Environmental Code and
not to pl - the system in operation until a Certificate of Compliance has been issued by this Board
of H
r / w/ i 1 6
ignatur - - _— Date
Application Approved B
) c/3//6
Name _atoe-/ 4. 4„ S rd Date
Application Disapproved for the following reasons:
i--..r
1 liWVL
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON, MA 010E0
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