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341 Septic Application 4/15/14 Important:When filling out forms on the computer, use only the tab key to move your cursor-do not use the return key. 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