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: