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288 Applications & Pemits Commonwealth of Massachusetts City/Town of NORTHAMPTON Application for Disposal System Construction Permit Fee Form 1A A. Facility Information (continued) 5. Type of Building: Dwelling Other: Type of Building ❑ Showers Specify other fixtures: 6. Design Flow: Calculated Daily Flow: 7. Plan: Number of showers Number of Sheets SEWAGE DISPOSAL SYSTEM UPGRADE Title of Plan 8. Description of Soil: SEE FORM 11 ❑ Garbage Grinder(check if present) ❑ Cafeteria 381 Gallons per Day 330 Gallons JULY 14, 2014 Date of Original Revision Date 9 Nature of Repairs or Alterations Of applicable): REPLACE ENTIRE SYSTEM PER APPROVED DESIGN 10. Date last inspected: t5forml a doc•06/03 Date Number of Persons Served ❑ Other fixtures 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 aoptja Number $ee /60 f1 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 a_ A. Facility Information 'pedant then filling out Application is hereby made for a permit to ❑ Construct a new on-site sewage disposal system on the ® Repair or replace an existing on-site sewage disposal system >nputer,use ❑ Repair or replace an existing system component Fly the tab key Hove your r-do not 1. Location of Facility: se the return .y_ 288 WEST FARMS ROAD _. n Address or Lot# e FLORENCE MA 01062 City/Town State Zip Cade 2 Owner Information KATHY DUTEAU Name Address(if different from above) City/Town State Zip Code 413-585-0625 Telephone Number 3. Installer Information CLIFF CLARK CLARKS EXCAVATING Name Name of Company P_ O. BOX 224 Address WILLIAMSBURG - _ Cily/rown State (413)268-7968 Telephone Number 4. Designer Information MARK THOMPSON Name P. O. BOX 314 Address CHESTERFIELD City/Town 01012 Zip Code HILLTOWN ENVIRONMENTAL Name of Company MA State (413)296-4499 Telephone Number 01012 Zip Code t5formla doc•06/03 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 � 4Lde? NumEer /10 Fee B. Agreement The undersigned agrees to ensure the construction and maintenance of the atoredescribed on-site sewage disposal system in accordance with the provisions of Title 5 t the Environmental Code and not to place the system in pe do7y until aCertificate of Compli ' Date haseeen issued by this Board of Health., /G jLdLf� ---- f -- Signature �r Application Approved By: Application Disapproved tor the tollowing reasons: t5formt a cloc•06/03 Application for Disposal System Construction Permit Page 3 of 3 atant: filling out on the outer.use the tab key Dve your x-do not the return Commonwealth of Massachusetts City/Town of NORTHAMPTON Certificate of Compliance Form 3 DEP has provided this form for use by local Boards of Health.Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. This is to Certify that the following work on an On-Site Sewage Disposal System ❑ Construction of a new system ® Repair or replacement of an existing system ❑ Repair or replacement of an existing system component Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): DSCP Number DSCP Date KATHY DUTEAU — ----. —_ Facility Owner 288 WEST FARMS ROAD — .—.— — — --� Street Address or Lot# 01082 MA FLORENCE —.—. - -.------ Sate - - - -- 01 Zip Code City/Town Designer Information: Mark Thompson t5form3 dos.06/03 Signs Insta Hilttown Environmental_ Name of Company Dade 1- raatiorno n/4 L,f ✓4 1/4 l.'/t`W L V� — _ Name of C /`ny Date Rit Signat0(e — —. — Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be coned as a guarantee that the system will function as Approving Authors Signature Certificate of Compliance•Page 1 of 1 Commonwealth of Massachusetts City/Town of NORTHAMPTON Disposal System Construction Permit Form 2A ams Nuber DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use Permission is hereby granted to: ,rant: CLIFF CLARK CLARK'S EXCAVATING 11 filling out Name Name of Company p use the heta P. 0. BOX 224 the key tab key Address ove your WILLIAMSBURG MA 01096 or-do not City/Town State Zip Code the return to perform the following work on an on-site sewage disposal system: ❑ Construction ® Repair or replacement ❑ Repair or replacement of system components 288 WEST FARMS ROAD Facility Address FLORENCE MA 01062 City/Town State Zip Code KATHY DUTEAU 413-585-0625 Owner Telephone Number The work to be performed is further described in the Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions: All construction must be completed within three years of the date below. Approved by Tale Date 5form2a.doc•06/03 Disposal System Construction Permit•Page 1 of 1 BOARD OF HEALTH DONNA C.SALLOOM,CHAIR SUZANNE SMITH,M.D. JOANNE LEVIN.M.D. Benjamin Wood,MPH,Director rveda Mir,MPH,Health Inspector ma Abbott RN,PubbhCHe4th Nurse CITY OF NORTHAMPTON MASSACHUSETTS 01060 OFFICE OF THE BOARD OF HEALTH (413)587-1214 FAX(413)5E17-1221 212 MAIN STREET NORTHAMPTON.MA 01080 Onsite Se•tic S stem Con truction Permit: Conservation Commi-sion R view OTE: As of System Permits I we receivelth s ormtsigned by the Northaimpton Conservation Commission oStaff Member. na Conservation Commission can be reached by contacting: o Sa ah LaVal e Conservation,Preservation and Land Use Planner a v Ilevi y (al n .go_v Office of Planning&Development no Main Street,Rm. 11,City Hall Northampton,MA 01060 'roperty Owner: ngineer: M, /__ _ 0 oA/ '��� �. Co- servation Corn icetIon Conservation, Preservation and Land Use Planner Address:A Date: