414 Application Disposal System 2017 Commonwealth of Massachusetts P0i7-17
�- �c City/Town of Northampton
Number
Application for Disposal System
1.-,1 l- P Y -1.IR $ Sp QO
_,, Construction Permit Fee 34
Form IA
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 Application is hereby made for a permit to:❑ Construct a new on-site sewage disposal system
on the computer,
use only the tab ® Repair or replace an existing on-site sewage disposal system
key to move your ❑ Repair or replace an existing system component
cursor-do not
use the return 1. Location of Facility:
key.
xr414 Coles Meadow Road
Address or Lot
-l� Northampton MA 01060
D� YO City/Town State Zip Code
IA- 2. Owner Information
Mark Rejniak / 0.v k D ip J�k K�
Name
Address(if different from above)
City/Town
State Zip Code
527-7433 or 860654-4152
Telephone Number
3. Installer Information
Karls
Name Name of Company
Address
Ho° Hadley
(-----
`Sqe ity/rawn State 01054
Zip Code
MA
, ^ m 549-5396
» m,
. a Telephone Number
: 5
• a if co
/i . . Designer Information
Alan Weiss Cold S.rin. Environmental Consultants Inc.
Name Name of Company
350 Old Enfield Road
Address
Belchertown MA 01007
City/Town State Zip Code
413-323-5957
Telephone Number
t5fonnla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
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Location Address LN
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On-site
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Deep Hole Number_AL Date: -�-
Location (identity on site plant r T. . . Weather_ S�-
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Land Use . ..
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Position on landscape (sketch on .he back) _..
Distances from: ..--- .. . _..
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DID APPROVED FOAM-12 0:195 f
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Location Address or Lot No. 4 4 ! al 5•
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Determination . or Seasonal Hili Water Table
Method Used:
C _Depth observed standing in observation hole._._... . inches
n�Depth weeping from side of observation hole..:.. . inches
Uepth to soil mottles . 48,,. inches
Ground water adjustment _______ feet
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Index We!! Number .____
Reading Date __
-'a index well level
Adjustment factor
Adjusted around water level __
Depth of Naturally Occurring Pervious Materia!
Does at least four feet faapronaturally
oc ening pervious material exist in sl areas
observed throughout
or the soil absorption systems u-LS
!f not, what is the depth of naturally occurring pervious material?
- Certification
! certify that on qS
Icethe Department of(date) I have passed the soil evaluator examination
was ovapprovedy bywrrOm-rental Protection and that the above analysis
described in 31CMR with the required Training, expertise and experience
Signature 4_4_
Date
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6/27/2017 10:09 AM