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33 Septic Inspection 2015 Owner Information is required for every page. Important Wien filling out forms on the computer. use only the tab key to move your -do not cursor e return key. t5ms•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Properly Address Tim and Mary Ellen Dachas Owners Name Florence MA 01062 04.16.2015 City/Town Stale Zip Code pate of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. A. General Information Inspector: Alan Weiss Name of Inspector Cold Spring Environmental Consultants,Inc Company Name 350 Old Enfield Road Company Address Belchertown ciry/Twn 413--323-5957 MA 01007 State Zip Cede RS 933 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspectors Signature 4/16/2015 Dale The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. —"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. al Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachos Owner timers Name information is Florence MA 01062 04.16.2015 page required Ci Ram Stale Zip Code Date of Inspection Page. N P B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section 0 A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System at single family dwelling was inspected,Staining and Level in tank was good.Two persons had been using for last several years. A three line Leach trench System was installed about 23+/- years ago.The Distribution box and 12 feet of the upper line trench was bound up with root growth. The roots were cleared and pipe replaced and no failure conditions found.The 1500 gallon septic tank should be cleaned 8 pumped every two years The alarm(was repaired).The system now passes,reviewed with Health Department inspector. B) System Conditionally Passes: i] One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no°or not determined(Y,N,ND)for the following statements. If not determined,'please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Tilt 5(Mod I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachos Owner Owners Name information rs Florence required for evew page Citvnam MA 01062 04.16.2015 State Zip Code Date of Inspection B. Certification (Pont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ V ❑ N ❑ ND(Explain below) ❑ distribution box is leveled or replaced ❑ V ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Healthy. ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ V ❑ N ❑ ND(Explain below): ❑ V ❑ N ❑ ND(Explain below)'. C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh -ripe s pnaa InspecOon Fo,m.subsurface Sewage£spoaa Syn..•Pace 3 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachos Owner Owners Name information is Florence MA 01062 04.16.2015 qurred for every page City/Town State Zip Code Date of Inspection B. Certification (coot.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well . Method used to determine distance: "This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters • due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool • Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow .me s official Inspecton rmm.Subsurface Sewage Disposal sum.Pape 4 or 17 cV Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachos Owner Owners Name atonmation is required fc every Florence page- City/Town MA 01062 04.16 2015 State Zip Cede Dale of Inspection B. Certification (cant.) Yes No ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped'. ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal conform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure crfteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or no to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered'yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane property Address Tim and Mary Ellen Dachos Owner owners Name information for every is aw MA 01062 04.16.2015 r ry Florence Slate Zip Code Date of inspection Page. Ciryrtown C. Checklist Check if the following have been done.You must indicate"yes"or no as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as pan of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined as on Existing information.For example,a plan at the Board of Health. Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): d Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 700+ Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachos owners Name Florence MA 01062 04.162015 Clty(cwn state Zip Code Date of Inspection D. System Information Description: 1500 gallon,Septic Tank,pump(1000 gallon chamber),new D box and three(70't)line leaching trenches Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system?(Include laundry system inspe information in this report.) Laundry system inspected? Seasonal use? Water meter readings,if available(last 2 years usage(gpd)): Detail: 2 ❑ Yes Z No on ❑ Yes Z No ❑ yes ❑ No ❑ Yes Z No Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sq.ft.,etc.). Grease trap present? Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? Water meter readings,if available: Gallons per day(gpd) Z Yes ❑ No current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Thle 5 mroe Inspectors Form Subsurface sewage o-w=a swarm. a.ae t e Owner information is require for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and May Ellen Dachos wmers Name Florence MA 01062 04.16.2015 city/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use. Other(describe below): current Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes,volume pumped: How was quantity pumped determined? Reason for pumping'. Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool owner ® Yes ❑ No 2000+1-(tank and chamber) gallons measured Inspection and need. ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ® Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachas Owners Name Florence MA 01062 04.16.2015 City/Town Stare Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed Of known)and source of information 23+/-yrs Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan). Depth below grade: Material of construction'. ❑cast iron ®40 PVC ❑other(explain) Distance from private water supply well or suction line: 10'+ feel Comments(on condition of joints,venting,evidence of leakage,etc.): good condition Septic Tank(locate on site plan): Depth below grade: Material of construction: Z concrete ❑metal ❑fiberglass ❑ Yes E No reel ❑polyethylene ❑other(explain) 1500 gallon tank has baffles/tees in place,no high staining concrete competent. If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 105'x54.5'x 42' Dimensions: Sludge depth: pe PwCOY Page Ool Owner mromtationa required for every page Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Oachos Owners Name Florence MA 01062 04.16.2015 City/Town State Zip Code Date of inspection D. System Information (cant.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): good levels and staining,no corrosion. 8" meal. Grease Trap(locate on site plan)' Depth below grade' Material of construction. ❑concrete ❑metal feet ❑fiberglass ❑polyethylene ❑other(explain). Dimensions. Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Properly Address Tim and Mary Ellen Dachos Owner Owners Name information is Florence MA 01062 04.162015 required for every - - page. city/Town Stare Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on sae plan). Depth below grade. Material of construction: ❑concrete ❑metal Dimensions. Capacity: Design Flow: Alarm present Alarm level: ❑fiberglass ❑polyethylene ❑other(explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: pate Comments(condition of alarm and float switches,etc.): *Mach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Sums vu Tme 5 gfieinsp.ubm Furs Subsurface Seseue Dissusul SNsm'see=I I Of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachos Owner owners Name information required rO 5 Florence MA _ 01062 04162015 page.etl rw rvery City/Town State Zip Code Date or Inspection D. System Information (cont.) Distribution Box Of present must be opened)(locate on site plan): @ inv. Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Ater removing soil and roots, Levels and staining good,No staining liquid nor high staining observed above invert.No ponding noted. Box at 3"below grade(additional cover soil recommeneded)(Box was replaced due to cracking and roots,lines were clear and stone was clean upon completion. Pump Chamber(locate on site plan): Pumps in working order. Alarms in working order: ® Yes ❑ No ® Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump cycled and working,Alarm switch neeed replacement and was completed. If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS)(locate on sae plan,excavation not required). If SAS not located,explain why: Title 5 Ofloal Far Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachos Owner owners Name Information is Florence required for every MA 01062 04.162015 Page. City/Town State Zip tole Date of Inspection D. System Information (cant.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length_ ❑ leaching fields number,dimensions ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): No signs of ponding,nor high staining or wetness indicative of failure noted once roots were removed and reinspected with City Health Inspector. 3'.70'x2'Wx1.5'H Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Trim.5 onciai haven=Fa. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachas Owner Owners Name informationia Florence MA 01062 04.162015 repmred tor even page cnyrtown state zip code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of pending,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Title eman In s.�., sa„ae•Disposal msm•Pepe 14 m„ Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property assess Tim and May Ellen Dachos Owner Owes Nine information Ls Florence required Mevery cMrtw.n MA 01082 04.162015 State Zip code Date of Inspection D. System Information (cont,) Sketch Of Sewage Disposal System.Provide a view of the sewage drsposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below. ❑ hand-sketch in the area below (Si drawing attached separately a 5 cea i.w.em.erm staken s..we awe.. rm 1:a 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen Dachos Owner Owner's Nane reromiadf for very Florence MA 01062 04.16.2015 Page. for r e Ciry?ovm State Zip code Date of Inspection D. System Information (cant.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 4•+ feet Please indicate all methods used to determine the high ground water elevation ® Obtained from system design plans on record If checked,date of design plan reviewed. attached. Dare ❑ Observed site(abutting property/observation hole within 150 feet of SAS) O Checked with local Board of Health-explain: record attached, 1992 ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: From records from BOH attached Before filing this Inspection Report,please see Report Completeness Checklist on next page. Owner information is Florence required for every Flor n page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 33 Birch Lane Property Address Tim and Mary Ellen nachos owners Name MA 01062 04.16 2015 State np Cede Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A,B,C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 9Y 5 09as imce000v Form.Subsurface Sewage Disposal System•Pape 17 of 17 Prior to root removal 33 Birch Lane Florence, MA 04,152015 Roots in leach pipe 33 Birch Lane Florence, MA 04.15.2015 Upper Trench after Roots Cleared 33 Birch Lane Florence, MA 04.16.2015 Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Form IA Number $ 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 Important When filling out forms Application is hereby made for a permit to:❑Construct a new on-site sewage disposal system on the computer. ❑Repair or replace an existing on-site sewage disposal system use only the tab ®Repair or replace an evsting system component key to move your cursor do not use the return 1. Location of Facility: key 33 Birch Lane --JUj— Address or Lot It Florence(Northamptor6 MA 01062 Cityfoan State Zip Code JAM 2. Owner Information Tim and Mary Ellen Dachos Name Address(l different from above) chyrrown State Zip Code 413-330-8620 Telephone Number 3. Installer Information Mike Meadows Karls Site Work Name Name of Company River Drive Address Hadley MA 01035 City/Town State Zip Code 549-5396 Telephone Number 4. Designer Information Alan Weiss Cold Spring Environmental Consultants Inc. Name Name of Company 350 Old Enfield Road Address Belchertown MA Cby?own State 413-323-5957 01007 Zip code Telephone Number t51wmta doc•06103 Application for Disposal System Construction Permit•Page I of 3 Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Form 1A Number $ Fee A. Facility Information (continued) 5. Type of Building. ® Dwelling ❑ Garbage Grinder(check if present) Other:Type of Building 4 Bedroom Single Family Number of Persons Serves ❑ Showers Numberushowers ❑ Cafeteria ❑ Other fixtures Specify other fixtures: 6 Design Flow: Calculated Daily Flow: 7. Plan: 01 440+. Gallons per Day 700+(1992) Gallons Date of Original Number of Sheets Revision Dale Part of Title 5,D box replacement and section of leach trench pipe with roots. Title of Plan 8. Description of Soil: Fine sand Nature of Repairs or Alterations Of applicable): D box replacement and section of leach trench pipe with roots. 10. Date last inspected. Date t5fom,I odor 05103 Application for Disposal System Construction Petmil Page 2 Of Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Form 1A Number $ 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 place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signature Date Application Approved By: Name Date Application Disapproved for the following reasons: t5tomlla dom D6103 Application for Disposal System Construction Permit•Page 3 of Original Plan 33 Birch Lane Florence, MA 04,17 2015 A g 1111114411114 1 p .. pO Z° w C1 al . .. • s vip li o ., g Sn n .,AA 'flity n - a sski ■ TisTPN�y�ysx5 te a e"..p r 1'r.WA:nu al s,∎IHl . "AZ: • r. a t'flr%14 JP *r' ass u .m,...w.ar. .1 "Qi4 .>4av 7wv7 Ouginal permit 33 Birch Lane Florence, MA 04.17.2015