21 Lot 4 Application Disposal Construction 2013 Transmittal Cover Sheet
From: Greg Newman NEWMAN ENVIRONMENTAL
ENGINEERING
To: Northampton Health Department 21 Guard Road, P.D. Box 395
212 Main Street Worthington, MA 01098
Northampton, MA 01060
Tel: 413-238-5383
Fax: 413-238-4276
Date: May 13, 2013
Subject: Design of Septic System(Z1305-1) for S. Keifer
Lot on Sylvester Road, Northampton, MA
CONTENTS: Number of copies:
Design Plan(1 sheet) 2
Application for Disposal System Construction Permit 1
Site Evaluation Report(Forms 11 &12) 1
❑ Please reply ASAP ❑ Please send your comments ® Please review
Z Other -- If you should have any questions,please call.
Very truly yours,
Newman Environmental Engineering
Gregory J. Newman, P.E.
Commonwealth of Massachusetts 020/3-6
=._
) , ,-,,tt City/Town of Northampton Number
a - Application for Disposal System
` vgiftwpoi
_ Construction Permit Fees0 .00
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 ming 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. Assessor Map-21, Lot-4 --- Lot on Sylvester_ Road (adjacent to House#567)
�� I` Address or Lot#
Northampton MA 01081
City/Town State Zip Code
min X1
2. Owner Information
Scott Keiter
Name
51 A Hatfield Street
Address(if different from above)
Northampton MA 01060
Clty/Town State Zip Code
413-586-8600
Telephone Number
3. Installer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number
4. Designer Information
G. Newman Newman Environmental Engineering
Name Name of Company
P.O. Box 395
Address
Worthington MA 01098
City/Town 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 ,2oi3-6
City/Town of Northampton Number
MS Application for Disposal System
$150.00
s 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 LICafeteria 111Other fixtures
Specify other fixtures: --- ----- - -- - - -- ---
6. Design Flow: 440
Gallons per Day
Calculated Daily Flow: 440
Gallons
7. Plan: 5/11/2013
Date of Original
one 5/15/2013
Number of Sheets Revision Date
Sewage Disposal System at Lot onSylvester Road, Northampton, MA
Title of Plan
8. Description of Soil:
sandy loam of loamy sand-see soils report attached
9. Nature of Repairs or Alterations(if applicable):
New construction includes 1500-gallon septic tank, pipeline access boxes on steep slope,
D-box,903-SF raised bed leach field and gravity connective piping.
10. Date last inspected: ---- -Date
t5formia.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
. \ Commonwealth of Massachusetts 020/3.6
1 _=- -_1 City/Town of Northampton Number
' V 0 Application for Disposal System $150.00
�_� Construction Permit Fee
Form IA
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 Healtt ,
Signature Date
Ap }lon ApprowyddBy: /
la/.t..re/ /✓euth-' S/3 _/3
me Date
Apply ation Disapp oved for the following reasons: 0 R I!`
NORTHAMPTON BOAR OF HEALTH
212 MAIry STREET
NORTHAMPTON MA 01060 -
t5formla.tloc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
M>, CITY OF NORTHAMPTON, Mwac.._..
?Or- p ipe
DEPARTMENT OF PUBLIC WORKS
125 Locust Street
R
' '�; F Northampton, MA 01060
.
413-587-1570
Fax 413-587-1576
Edward S. Huntley, P.E.
Director
ASSIGNMENT OF HOUSE NUMBER
Street: Sylvester Road
Assessors Map: 21-004
House Number: 573
Date: July 2,2013
Remarks: This number was assigned by the Engineering Department on July 2, 2013.
The number assignment was requested by the owner, Scott Keiter, for
permitting purposes for the construction of a new, single family dwelling on
this vacant lot.
.44 s
le
Ilsr aurila,P.E.
Engineer
Central Dispatch Board of Health
Water Division Tax Collector
Sewer Division National Grid
Streets Division Verizon Telephone
Inspectors Comcast
Assessors Columbia Gas of Massachusetts
Police Department Post Office(Northampton)
James Thompson(GIS Coordinator) Post Office(Easthampton)
Registrar of Voters School Department(Joy Winnie)
Owner/Applicant: Scott Keiter
51A Hatfield Street
Northampton, MA 01060
K:\House Numbers\Sylvester Road4573 Sylvester Road.doc
BOARD OF HEALTH
CITY OF NORTHAMPTON
T
DONNA C.SALLOCM.CHAIR
.40111/11°.
SUZANNE SMITH.MD.
.JOANNE LEVIN.MD. MASSACHUSETTS 01060 1...14.•,171011,4
• OFFICE OF THE - "-;01
Brant Waod.MRL Dbticr BOARD OF HEALTH
Jaycee It MPH,Hera Ings.,
Palace.Abbott RN,Pubic el Nurse 212 MAIN STREET
Hatter McBrIM.Clark (413)587-1214 NORTHAMPTON.MA 01060
FAX(413)587-1221
Onsite Saone System Construction Permit: Conservation Commission Review
NOTE: As of 1/1/11, Septic System Permits will not be issued by the Northampton Board of Health
until we receive this form signed by the Northampton Conservation Commission Staff Member.
The Conservation Commission can be reached by contacting:
o Sarah laValley,Conservation,Preservation and Land Use Planner
5LaValleWanorthimptonma.gov _ #573
Office of Planning&Development �'
210 h In Street, Rm.11,City Hall Assessor 4 p yG
Northampton, MA 01060 / $ #9 - */�5 Y E"^�'
S > rt b [/`kcal```d -to 'loose #5567dd`
Property Owner: 54 r Add /)
Engineer CY'pci New ...r
t de ` Ux�-�an4- '2ev eta }Jbi- 14
Co ervation C mi n Conservation, Preservation and Land U Planner
Date:347f/6