417 Application Disposal 2018 Commonwealth of Massachusetts/g lit
®- City/Town of Northampton Number
� ��, . Application for Disposal System $159.00
"t / Construction Permit 44 r )Fee
Form 1A \5)0,\
DEP has provided this form for use by local Boards of Health if they c Yirto do so. Before using
the form, check with your local Board of Health to make sure that they r 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 e • t on-site sewage disposal system
computer,use �nJ
❑
only the tab key Repair or replace an 's&§sy6tem Lpmponent
to move your p h._. A. 13
cursor-do not 1. Location of Facility:
use the return
'
key. 417 Westhampton Road
Address or Lot N
m Northampton - _ _ _ MA 01060
X City/Town State Zip code
IEWI? 0
2. Owner Information
Mary Cadorette
Name
417 Westhapton Road _
Address(if different from above) - - - - - - - - - - -
Northafton MA 01060
City/Town _ - _—-. _- - - - - --_.
State Zip Code
413-588-8462
Telephone Number
3. Inst- - formation
zov
r1Gmi.
Name of Company --
4. ' at eteitie7A,
City/Town
State Zip Code
Telephone Number
4. Designer Information
Edward T. Berry, P.L.S. & Paul HadseI, P_E. _ Edward T. Berry, P.L.S., Residential
Name Development Consultant
113 Main Street - - -
Address -- — - - - -
Athol _ MA 01331
City/Town State Zip Code
978-249-8811
Telephone Number - -- - --
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page I of 3
Commonwealth of Massachusetts
q City/Town of Northampton t --�
6 Application mbar
��_/. pp ation for Disposal System
Construction Permit Fee 000
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling 0 Garbage Grinder(check if present)
Other: Type of Building -- ---- --- -- _
Number of Persons Served
❑ ShowersNumber oishowers ❑ Cafeteria ❑ Other fixtures
Specify other fixtures:
6. Design Flow: 770
Gallons per Day --_
Calculated Daily Flow: 770
Gallons - - --
7. Plan: August.13, 2018
Date of Original - -
1
Number of Sheets Revision Date
Septic System Upgrade
Title of Plan ---
8. Description of Son:
0-2" disturbed (fil� 2"-72" C/fSL Eshwt @ 12" 15 mpi
9. Nature of Repairs or Alterations (if applicable):
install complete new system with 2000 gallon septic tank, effluent filter, 1000 gallon pump chamber
and 25' x 55' stone& pp_e leach field
10. Date last inspected:
Date
t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts 210/
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