Lot 3 App Disposal System 2017 • Commonwealth of Massachusetts a0/7-/5
sn City/Town of Northampton Number
i Application for Disposal System $ /5L -0
Construction Permit Fee
-. Form0. 11
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:
Mien filling out Application is hereby made for a permit to: WI Construct a new on-site sewage disposal system
forms on the ❑ Repair or replace an existing on-site sewage disposal system
computer.use 0 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# 3 - Florence Road - former property of John Ewing
Vic 0 Address or Lola
Northampton MA _ 01060
City/Town State Zip Code
2. Owner Information
Prepared for Charles Arno
Name
g0x-1r_Gi9L, (y p
Address(if different from above)
Goshen MA 01032
City/Town State Zip Code
Cko t'C. So (au.? �J kkQi (413 ) 695-3500
tierTelephone Number
3. Installer Information FILE COPY
Charles Arno
Name Name of Company
Address
Goshen _._ _. MA 01032
City/Town State Zip Code
(413 ) 695-3500
Telephone N y.
•
1
•
4. Designer Information •
6-1---_
Timothy E. Maginnis RS 14.., — K.•. ;
NameIL
70 Montague Road
Address
Westhampton 01027
City/royal data zipcode
(413) 527-5291
Telephone Number
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
_S Commonwealth of Massachusetts 2017/5
City/Town of Northampton Number
Til $ /
[' Application for Disposal System
Imo.
Construction Permit Fee
Foran 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check a present)
Other: Type of Building Number of Persons Served
❑ Showers Number of showers ❑ Cafeteria ❑ Other fixtures
Specify other fixtures: yl�/b/�']'—//1---
6. Design Flow: - /,r(
�I ° Pd
Calculated Daily Flow: canons
July 5,2017
7. Plan: Date of Original
2
Number of Sheets _ _ _.. . -.. Re.rsion Date
SUBSURFACE SEWAGE DISPOSAL SYSTEM DESIGN
Title of Plan
8. Description of Soil:
Sandy loam - Fine silty sand
9. Nature of Repairs or Alterations(if applicable):
N/A - This is new construction
N/A
10. Date last inspected: -----
Date
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts a0/7-A6-
kk.,,
Or City/Town of Northampton Number
Ii- Application for Disposal System $
Construction Permit FFee
Form 4A
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
of
not tsi the system in or Certificate of Compliance has been issued by this Board
1 , -77et/xY7
Signature Date
Application Approved By:
-r � J 7� i 7
e Date
Nam --... --
Application Disapproved for the following reasons:
el J
Conditions:
I)'Syslem Designer must inspect and verify in writi
That the sewage disposal system was 6i‘:/oiled ng
2) In accordance with the approved pions and lige 5
.1f fins is a system with the S.A.S,c,ail Pratt I In .
Title 5 fill the System Desiencr moot umiIut l o I I"nm
Inspection of the excavated area prior to the p I:a .uN
of the fill.
3).No changes can he made daring coact-lit u.iii .,, ,
Installer without prior appv:d by built
Designer and the Board of llcallh&tic at
m
1).Other conditions:
t5fonnl a doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3