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Commonwealth of Massachu
City/Town of Northampton (Lee
Application for Disposal System
Construction Permit
Form 1A
f COPY
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
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:
107 Chesterfield Road
Address or Lot#
Leeds, Northampton MA 01053
City/Town State Zip Code
2. Owner Information
Virgina and Jack Parsons
Name
107 Chesterfield Road
Address(It different from above)
Leeds
City/Town
3. Installer Information
Karts Excav,
Name
River Drive
Address
Hadley
City/Town
MA
State
413-586-1899
01035
Zip Code
Telephone Number
Karls Excay.,
Name of Company
4. Designer Information
Alan Weiss, RS
MA
State
413-549-5396
01035
Zip Code
Telephone Number
Cold Spring Environmental Consultants Inc.
Name Name of Company
350 Old Enfield Road
Address
Belchertown
City/Town
MA
State
01007
Zip Code
tsformla doo•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton (Leeds)
j
Application for Disposal System
Construction Permit
Form IA
Number
$
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other:Type of Building 3 Bedroom Home
❑ Showers Number of showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
2
413-323-5957
Telephone Number
❑ Garbage Grinder(check if present)
❑ Cafeteria
Number of Persons Served
❑ Other fixtures
3 Bedrooms x 110gpd=330+
Gallons per Day
445
Gallons
04.01 2014
Date of Original
Number of Sheets
Septic System Design Plan
Title of Plan
8. Descfiption of Soil:
CS
Revision Date
9. Nature of Repairs or Alterations(if applicable):
New Septic Tank and 14 x 43'L. Field .
t5formla.dos.06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
_cm? City/Town of Northampton (Leeds)
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
10. Date last inspected:
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
Heatth.
Date
Signature
Application Approved By:
Date
Name Date
Application Disapproved for the following reasons:
[Storm is doe•06/03 Application for Disposal System Construction Permit•Page 3 of 3