7 Septic Permit 2017 /oil—//
Commonwealth of Massachusetts
.-r City/Town of NORTHAMPTON
'r� Number I 111 I
_ ; Application for Disposal System
61)-2,S1
p
Construction Permit Fee $ 1 •
�
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
forms on the
computer,use
only the tab key
to move your
cursor-do not Application is hereby made for a permit to: Construct a new on-site sewage disposal system
use the return
key. Repair or replace an existing on-site sewage disposal system
Repair or replace an existing system component
D��O
1. Location of Facility:
7 Shephards Hollow ROad (188 Chesterfield Road)
Address or Lot#
Leeds (Northampton) MA 01053
City/Town State
Zip Code
2. Owner Information
Rachel Cartmell (C/O Hank Ross)
Name
e-mail address(optional)
Address(if different from above)
L
State
City/Town
State
Zip Code
413-584-1608
Telephone Number
3. Installer Information
Gene Tacy
Name Name of Company
Address
•
S
State
Florence State MA 01062
City/Town Zip Code
413-626-3716
Telephone Number
4. Designer Information
Alan Weiss Cold Spring Environmental
Name Consultants Inc.
Name of Company
350 Old Enfield Road
Address
State
Belchertown MA 01007
City/Town State Zip Code
413-323-5957
Telephone Number
A. Facility Information (continued)
5. Type of Building:
Garbage Grinder (check if
Dwelling present)
Other: Type of 4 Bedroom Number of Persons
Building Served
Cafete Other
Showers Number of showers ria fixtures
Specify other fixtures:
440+.
6. Design Flow: Gallons per Day
Calculated Daily Flow: 466
'saltons
7. Plan: 07.16.2017
Date of Original
02
Number of Sheets Revision Date
Septic System Plan
Title of Plan
8. Description of Soil:
Sandy
9. Nature of Repairs or Alterations (if applicable):
New 1500 gallon septic tank, and 14' x 45' leachfield.
10. Date last inspected: -
Date
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the
aforedescribed on-site sewage disposal system in accordance with the provisions of
Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Heat.
Signature Date
Application Approved By:
Name uate
Application Disapproved for the following reasons:
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3