363 Application & Permit for Disposal System 2015 it out
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Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
,70/f/1
Number
Fee j 6/ �/0)
Av 47
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:
363 Westhampton Road
Address or Lot N
Northampton
City/Town
MA.
State
2. Owner Information
Melanie Gulow
Name
363 Westhampton Roas
Address Of different from above)
Northampton MA
City/Town State
(413)230-1972
Telephone Number
3. Installer Information
TBD
Name
01060
Zip Code
01060
Zip Code
Name of Company
Address
City/Town
4. Designer Information
Timothy E. Maginnis R.S., LSE
Name
70 Montague Road
Address
Westhampton
City/Town
State
Zip Code
Telephone Number
(413) 52 '
Telephone Number
ila.doc•06/03 Application for Disposal System Construction Pencil•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
Number
5
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
❑ Showers Number of showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
❑ Garbage Grinder(check if present)
6
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
330
Gallons per Day
330
Gallons
November 2, 2015
Date of Original
2
Number of Sheets Revision Date
Plan of REPAIR- Subsurface Sewage Disposal System design
Title of Plan
8. Description of Soil:
Sandy loam-Silt loam-Loamy sand- Lab analysis on file with Board of Health
9. Nature of Repairs or Alterations Of applicable):
Replace f subsurface sewage osal systInfiltrators gallon
distribution box and aInfltratorLea ingbed 5ows of with 6fill artorrs per row.
10. Date last inspected:
d a.doc•06/03
September 22, 2015
Date
Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Constructi • n Permit
Form 1A
,7075 /1
Number
21-g OD
Fee
B. Agreem
The ndersi'
sew ge disp
n t t place
off\H h.
J
tune
SIgAB
Applicatio
Name
/
•
a
e
agrees to ensure the construction and maintenance of the aforedescribed on-site
system in accordance with the provisions of Title 5 of the Environmental Code and
ys ern in operation until a Certificate gf Compliance has been issued by this Board
i _ rye r• 2 ?IS
Date
■ppro •
AMC.
By
Application Disapproved for the following reasons:
1 a.doc•06/03
Application for Disposal System Construction Permit•Page 3 of 3
BOARD OF HEALTH
DONNA C.SALLOOM.CHAR
SUZANNE SMITH.M.D.
JOANNE LEVIN,MD.
ar4mei Wood,MPH,Dracb
reels Mt,MPH,Noah iupecice
Ids Attar.RN,Pubic Hiet Nurse
Heather McSAM.Deer
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587-1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON.MA 01060
)nsite Septic System Construction Permit: Conservation Commission Review
TE: As of 1/1/11, Septic System Permits will not be issued by the Northampton Board of Health
it we receive this form signed by the Northampton Conservation Commission Staff Member.
Conservation Commission can be reached by contacting:
0 Sarah laVal ey,Conservation,Preservation and Land Use Planner
SL Vallev/anorthamotonma.ROV
Office of Planning&Development
210 Main Street, Rm.11,City Hall
Northampton,MA 01060 / /�
1perty Owner. /"/P/u ✓ C Kilo pi Address: So 3 �PsY�4, P
)ineer. /gym AlerviS
— )919 U: gi cia ft '
iservation Comm rn Conservation, Preservation Land U Planner
e: ii/asps