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ISOM
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
10/4-3
N mbar
$150.00
Fee
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
Application is hereby made for a permit to:® Construct a new on-site sewage disposal system
❑ Repair or replace an existing on-site sewage disposal system
❑ Repair or replace an existing system component
1. Location of Facility:
341 Audubon Road - Lot 1
Address or Lot#
Leeds(Northampton) MA
City/Town State
2. Owner Information
Elizabeth Vizentin and Barrett Newsome
01053
Zip Code
Name
195 Kennedy Road
Address(if different from above)
Leeds
City/Town
3. Installer Information
Craig Malanson
Name
4 Leadmine Road
MA
State
413-727-3835
01053
Zip Code
Telephone Number
Name of Company
Address
Southampton
City/Town
4. Designer Information
Richard P.Weisse
Name
241 College Highway &Clark Street
MA
State
413-297-4572
01073
Zip Code
Telephone Number
Heritage Surveys, Inc.
Name of Company
Address
Southampton
Cky/Town
MA
State
413-527-3600
01073-0001
Zip Code
Telephone Number
t5for1a.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
/0/9-3
Number
$150.00
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building Four bedroom single family dwelling
Number of Persons Served
❑ Showers Number of showers El Cafeteria El Other fixtures
Specify other fixtures.
6. Design Flow:
Calculated Daily Flow:
7. Plan:
2
660 (4 bedroom x 100 gallon x 1.5 Northampton
requirement)
440
Gallons
April 9, 2014
Date of Original
Number of Sheets Revision Date
341 Audubon Road-Lot 1, Plan of Proposed Sewage Disposal System
Title of Plan
8. Description of Soil:
See enclosed Soil Suitability Assessment for On-Site Disposal-9 series deep holes conducted
4-4-97, Performed by Matthew Sokop, Huntley&Associates, Inc.-5 series deep holes conducted
5-31-06, Performed by Thomas S. Leue, Homestead Inc.
9. Nature of Repairs or Alterations Of applicable):
10. Date last inspected:
Date
t5form1 a.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
aaN-3
Number
$150.00
Fee
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 piece the system in operation until a Certificate of Compliance has been issued by this Board of
Health./. l /i /
Signature) tL Date I tI
Application Approvedfy:
Application Disapproved for the following reasons:
y/64
Date
NDItTHAMF ION BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON, MA 01060
Conditions:
I}System Designer must inspect and verify to writing
That the sewage disposal system was installed
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:
tsformia.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
ELIZABETH VIZENTIN OR
BARRETT W NEWSOME
30 OSPREY LN (207)361-4876
YORK,ME 03909
IL
872
53-13/110 MA
26069
u:� Gil ] 6f Gu � 1 T 0/0 $ Iron'
R� �
BankofAmerica
/Lx M 011003130
1:O L LOGO L 381: 009454658174100872
•
Nn. a0/1-3 COMMONWEALTH OF MASSACHUSETTS
Board FEE /u�D
Board of Health, ladle (..aet/olr0/I/ , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: LI Individual Compovent(s) ,Complete System
The undersigned hereby certif that ti e Sewage Dis osal System; Constructed/Repaired ( ),Upgraded ( ),Abandoned ( )
by: tXZ44WA l e( a, �x✓irf'��e r.>.co n e
at 59/ .,W daps. GS- 1.
has been installed in accordance with the e-pr isi s f 310 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No._Y , dated # /� . Approved Design flow (gpd)
Installer --rm.!
Designee Inspector: _ % Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Nn. JEWS-3
COMMONWEALTH OF MASSACHUSETTS
FEE �6D
Board of Health, /(�p44,ear(J (J!✓ , MA_
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) /Complete System
The undersigned berth;ce/ru/fy_tat tZ Sewage DisJposaall System; Constructed/Repaired ( ),Upgraded ( ),Abandoned ( )
by: E/z46c, 4 Y{{ZltA lw/ 4MJ $✓ JJe scan t
at JV/ Aeieibo.,i raed- Lai- ..1.
has been installed in accordance with the-pr isi s f 310 CMR 15.00 (Tide 5) and_V proved design plans/as-built plans relating to
application No.22454"H 5 , dated j4/ /� . Approved Design Flow 4/ (gpd)
Installer �l /
Designer: Inspectort Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
HERITAGE SURVEYS, INC.
Professional Surveyors and Engineers
241 College Highway & Clark Street
Post Office Box 1
Southampton, Massachusetts 01073-0001
Bruce A Coombs, President
Professional Surveyor, MA, CT& VT
E-mail: bruce(aheritagesurveys.com
Telephone(413)527-3600
Facsimile(413) 527-8280
Website: heritagesurueys.com
LETTER OF TRANSMITTAL
To:
Northampton Board of Health
212 Main St.- City Hall
Northampton, MA 01060
RE: 341 Audubon Road
Leeds, MA
DATE:
December 30, 2014
OURJOB 7151-140212
NUMBER:
SUBJECT: Title V Certificate of Compliance-Designer & Installer Sign-Off
As-Built Plan for Septic System
NG YOU:
COPIES
DATE
HSI
Job#
DESCRIPTION
1
12/ 18/2014
7151-
140212
Title V Certificate of Compliance - Designer &
Installer Sign-Off
341 Audubon Road, Leeds, MA
1
12/ 18/2014
7151-
140212
As-Built Plan for Septic System
341 Audubon Road, Leeds, MA
1
4/15/2014
Signed Construction Permit Page 3 of 3
1
12/ 12/2014
Subgrade and Fiber Log Inspection Pictures
1
12/ 18/2014
System Installation Pictures-Final Inspection
Please contact this office if you should have any questions or comments relative
to the above enclosures.
Sincerely,
Mark P. Reed
cc Craig Malanson, Installer (with enclosures)
HERITAGE SURVEYS, INC.
Professional Surveyors and Engineers
241 College Highway & Clark Street
Post Office Box 1
Southampton, Massachusetts 01073-0001
Bruce A. Coombs, President Telephone (413) 527-3600
Professional Surveyor, MA, CT& VT Facsimile (413)527-8280
E-mail: bruce@heritagesurveys.com Website: heritagesurveys.com
Title V Certificate of Compliance
DESIGNER & INSTALLER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental code: Title V, Minimum Requirements for
the Subsurface Disposal of Sanitary Sewage, Section 15.021 (3), the Designer and Installer of a
system are required to sign this form as a condition for issuance of a Board of Health Certificate of
Compliance for the onsite septic system.
This is to certify that the onsite sewage disposal system that Heritage Surveys, Inc. designed as:
X new construction
_repair/upgrade (existing system)
SITE: 341 Audubon Road—Lot 1, Leed (Northampton)
FINAL INSPECTION DATE: ✓Z/i�
DWCP
OWNER: Elizabeth Vizentin& Barrett Newsome
has been constructed in compliance with 310 CMR 15.00, and all local requirements. Any changes
to the original approved plans have been reflected on an as-built plan that has been submitted to the
Board of Health.
DESIGNER
Heritage Surveys, Inc.
241 College Highway& Clark Street
P.O. Box 1
Southampton, MA 01073
(413) 527-3600
Signature
INSTALLER
Craig Malanson
4 Leadmine Road
Southampton, MA 01073
413-297-4572
NOTE: This certificate represents no warranty, expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system. Rather,the plan and installation are in compliance with all applicable rules and regulations as
are in effect at the time of plan submittal.
¥:PROJECT DOCUMENTS 7151 Seney\5331e5mdoe
DATE: 17--I8-t4 OWNER: Et .A86TH vt2ENTI,J it VAa3tW NEWstItie
JOB#:1 ICI-I4O21Z INSTALLER: CV-At4 Mh4MlsarJ
LOCATION: 341ACJDO nrJ ROAD Lat'S LOU eXPrM-jPlse1
AS-BUILT PLAN FOR SEPTIC SYSTEM
E • EXIST. WELL
11' FROM HOUSE
1500 GAL
SEPTIC TANK
#1 THRU #4=CORNERS OF
LEACH FIELD
C=CENTER COVER OF TANK
D=D—BOX (DISTRIBUTION BOX)
I.P.=INSPECTION PORT
LEACH FIELD
(40"x50')
4
VENT
SYSTEM TIES
A—C=20.0'
E—C=72.5'
A—D=220.0'
B—D=60.0'
A—LPORT=21 1.0'
B—I.PORT=75.0'
A—VENT=222.5'
B—VENT=84.8'
B—#1=44.0'
VENT—#1=50.0'
B—#2=78.5'
VENT—#2=63.5"
B—#3=107.0'
VENT—#3=41.0'
B—#4=85.0'
VENT—#4=12.0'
I.P
NOTE:
STONE RETAINING WALL & BARRIER
INSTALLED PER PLAN. SEE PICTURES.
PROPERTY LINE
NOT TO SCALE
241 College Highway &Clark Street
P.O. Box 1
Southampton, MA 01073
(413) 527-3600
!tillage *thugs, uc.
IRON PIPE
yeirApplication for Disposal System
Construction Permit
Form 1A
$150.00
Fee
B. Agreement
The undersigned sprees to ensure the construction and maintenance of the afontlseGibed on-Me
sewage disposal system in atxordance with the provisions of Title 5 of the Environmental Code and
not to the system al operation until a Certificate of Compliance has been issued by this Board of
a
tzfaml..doc 0e•03
ApDlicatbn-Geed By:
oats 4fril
Application Disapproved for the following reasons:
DIA ifirtr IORR NSTREETARD OF HEALTH
„ ; ,?1/ / /i / RTH1MPTON, MA 01060
Canadair
D.Syrian Deaasr swat See ad may Is Mesa
That to swap depsat ayM®was ine0ad
IN waadamwith the aypewd plar al lids 0.
7}
55 Wit e•"Maw with*.SAS.seeww.a
The s 510 We&Os Design;west sachet fat.
Speedos Odle aaard age.St tae ptseaat
dew EL
3).No Chalet oabeWeiehe ewmsda by do
Dute4wa PM. soma by both the lipase
sr
Deco ad di.de tend efliehbA/t
pothree lbws
Applbten lox DisppM System Combutlen Permit•Papa 3 of 3
BOARD OF HEALTH
DONNA C.SALLOOM.CHAIR
SUZANNE SMFTH.M.D.
JOANNE LEVIN,MD.
Swat Wood,MPH,DFador
Jewels Mir,MPH,Heed.Inspoctor
Praide Abbott,RN.Public Health Nose
Heather McBride.Clock
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587-1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON.MA 01060
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
SLaValley&D northampton ma.eov
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton,MA 01060
Property Owner:lc/re/1 W. nit"kJ.Same
Engineer.
ervatio Cott
Date: 11115 ki
Address: 45 /laci em.) r"' .
(x/e. CONS/ tocie;N)
Ratle
sion Conservation, Preservation and Land ILJse Planner