324 Disposal System Permit 2016 I
Commonwealth of Massachusetts ,,XAc- a
_' ,=> City/Town of Northampton
t P 'A� Number
' m Application for Disposal System
�;;__=t; $150.00
Construction Permit Fee
Form1A /94
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
Important:
When filling out Application is hereby made for a permit to: ® Construct a new on-site sewage disposal system
forms on the ❑ Repair or replace an existing on-site sewage disposal system
computer,use ❑ Repair or replace an existing system component
only the tab key
to move your
cursor-do not 1. Location of Facility:
use the return
key. _Lot_adjacent to 324 Audubon Road, Leeds, MA
r� Address or Lot# — —
Leeds MA 01053
City/Town State Zip Code
IMPAI
2. Owner Information
Jod1r Cutter& Lisa Tikkala //L, . `,
Name lt .-
324 Audubon Road /
Address(if different from above) —Leeds __ MA 01053
City/Town State Zip Code
301-908-6543
Telephone Number
3. Installer Information, �• a � to/JGcaJ ait�5 �� S �u M ec.UO t,J , MA-
NapoI -r Name of Company 3
i s hc....c d tic,.I Z
Ira - —
City/Town if State Zip Code
X113-636.- ,)g6,
Telephone Number
4. Designer Information
Gregory J. Newman, P.E. __ _ Newman Envinronmental Engineering _
Name Name of Company
P.O. Box 395
Address
Worthington` _ MA 01098
City/Town State Zip Code
413-238-5383
f; ,. . - Telephone Number
ip
t5form'I a.doc•06/03 . ` �
E , r Application for Disposal System Construction Permit•Page 1 of 3
L. il
Commonwealth of Massachusetts X/C-/6
• City/Town of Northampton
Number
=`� = l Application for Disposal System
$150.00
=! pp p y
VM
' Construction Permit Fee
Form 1A
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
Important:
When filling out Application is hereby made for a permit to: ® Construct a new on-site sewage disposal system
forms on the ❑ Repair or replace an existing on-site sewage disposal system
computer. use
only the tab key Repair or replace an existing system component
to move your
cursor-do not 1. Location of Facility:
use the return
key. Lot adjacent to 324 Audubon Road, Leeds, MA
Address or Lot#
% :4 ` Leeds MA 01053
City,?own State Zip Code
reem
/
2. Owner Information
Jody Culter& Lisa Tikkala 4/ A' (‘"(1
Name / I
324 Audubon Road
Address(if different from above)
Leeds _ MA 01053
City/Town State Zip Code
301-908-6543
Telephone Number
3. Installer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number
4. Designer Information
Gregory J. Newman. P.E. Newman Envinronmental Engineering
Name Name of Company
P.O. Box 395
Address ---_-- ---------- ------- —
Worthington MA 01098
CitylTown State Zip Code
413-238-5383
Telephone Number
t5formla.doc•06;03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
-4=j7 /Town of Northampton 101‘-g101‘-gCit
c y�` y p Number
_' 'c) Application for Disposal System
? $150.00
Construction Permit Fee
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other Type of Building
Number of Persons Served
❑ Showers Number of showers ❑ Cafeteria ElOther fixtures
Specify other fixtures:
6. Design Flow: 440
Gallons per Day
Calculated Daily Flow
Gallons
7. Plan: 10/8/2015
Date of Original
1
Number of Sheets Revision Date
Sewage Disposal System at Lot on Audubon Road, Leeds, MA
Title of Plan
8. Description of Soil:
Sandy loam -see plan
9. Nature of Repairs or Alterations (if applicable):
New Construction - includes 1500-gallon septic tank, D-box, 1200-SF raised bed leach field, and
gravity connective piping
10. Date last inspected: Date
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3