140 Septic Application & Permit 2011 No.
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COMMONWWSOF MASSACHUSETTS
Board of Health,' /V✓/%/%i it/)i//I /IL/MA
PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
kermit to Construct <j Repair Opgrade,P4 Abandon( ) - 4Complete System O Individual Components
Location ✓Zyrl L/2k"
Owner's Name .%Gt/CL_ LA/4
Map/Parcel# //r C.0(/S /'-Lc,/rl(/(/J ,' ''
Address /yL' (GL 7 ; 7`I/-i/U/u//�U
Lot# /'//: , /../ •/J b I . .. --J
Telephone# .' .
13 5-(5/— a33/9
Installer's Name Cu-'- (.>( 7t, ( (_ci
Designer's Name i/j/LC. //L// ,J >l * '7/)
Address . . r r.
Address /G ///frill- / /- U
5
/ , Ir/ /2(.1 7 r 7 /NG
Telephone# 1 I PI'
Telephone# ///5 Syy /3'/7 //3 (:27 77 V
Type of Building R1'//i7 /L 7//I( y/-i/ :F
Dwelling-No.of Bedrooms 3 3/ D///.Si: I /V/ O/5/-'GS//C
Other Type of Building ,S/LJ L E /-,H/ J//r
Other Fixtures 'rd_ C/7 //j /7///;/.
Design How (min.required) //lJ / X igpd Calculated design flow L/Q-
Plan: Date ,j(/✓% 6 0'6// Number of sheets /
«Z //!/2.
tot Size sq.ft.
Garbage grinder(4/0
No of persons Showers(/),Cafeteria(4G
/, O L / / (/ r J/��/ / //I(L /ice ‘-'/E- /1-
Tide `s- »7'! 5V577: /l) /)r5/7.,(/ /2-J4_C x( i/C<' (ki
Description of Soil(s) ✓i / /%i 7/1;j71/ /)
Soil Evaluator Form No. // Name of Soil Evaluator/V' 596k//5 Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS C6'Lr)/// /r %T 5/»r/( ,S /57-//1 ) /7r
Design flow provided 17/g 7 gpd
Revision Date
/yU (/oc/TS A)FM)/ GC) k/)
/6//2 fr6 /0
3//JGlz9/Z /5 , G .4xi/9 /96,A77//>/22v7 4J /30H /2&601/)/764 /
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of place the m in operation until a Certificate of Coympliance has been issued by the Board of Health.
Signed i� ,�itii �, JW' •fl tCe Uare .9 C- /mo o/.
Inspections
No.2*// 7
COMMONWEALTH OF MASSACHUSETTS
Board ofHeakh, ✓f I w "j/(r/v A{.
CERTIFICATE OF COMPLIANCE
Description of Work: U Individual Component(s) XComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ),Repaired ( ),Upgraded- Abandoned ( )
by:
FEE
/J(i `O
at
has been installedUn accordance with the prdsiyionsyof 810 CMR 15.00 (Title 5) and thy approved design plans/as-built plans relating to
application—No. / dated / t/i I . Approved Design flow " t —' (gpd)
:
Installer Y "-
IA/ `T'
Designer. I Inspector Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construcy ) Repair(,) Upgrade(A/) Abandon( )an individual sewage disposal system
at / '/G^ (, j-,. / Y-/ nCc✓ Ili • //(v >i• %L/✓ as described in the application for
Disposal System Construction Permit No. ./76// 7 dated / / '/i/ .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions-must be met.
Form 1255 Fee.5/95 un.suam Co.G swnuA Date'/_2 // Board of Health
BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMITH,M.D.
JOANNE LEVIN,M.D.
Benjamin Wood,MPH,Director
Javeria Mir,MPH,Health Inspector
Patacia Abbott,RN,Public Health Nurse
Heather McBride,Clerk
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:
O Sarah LaValley,Conservation, Preservation and Land Use Planner
SLaValley@northamptonma.gov
Office of Planning&Development
210 Main Street, Rm. U,City Hall
Northampton, MA 01060
Property Owner: --,/c/YGL /C c /
Engineer h2 J ., ,Siert.A74, Rb
ervation Comm
Date: b/a t/k
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Address: /10 Cobs /4.1w AY
Conservation, Preservation and Land Use Planner