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994 Construction Permit 2019 s o d Commonwealth of Massachusetts rut �� It City own of Northampton Number (�6 Apolication for Disposal System s Co struction Permit Fee 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 E oard of Health to make sure that they will accept it. A. Facility Information Application is herey made for a permit to: Repair on-site Sewa a Disposal System. 1. Location of acility: Address: Florence Rd.-lot City/Town: Northampton, MA 01062 2. Owner Information Name: Mathias Raindi. Address: c/o Mike John, 33. Hillside Rd. City/Town: Montague, MA 01351 Telephone: 416-834-3000 3. Installer Infoi mation Name: Mike John S4- Address: �n¢D,' 4 City/Town: C-' , M © 1 3 Telephone: 413 -$3�- 30o0 4. Designer Inf rmation Name: Thomas S. Leue R.S. Name of Comp ny: Homestead Engineering Inc. Address: 1664 Cage Street City/Town: Williamsburg, MA 01096 Telephone: 413 628-4533 5. Type of Building: Garbage Grinder(check if present) Other:Type of Building Single family:hcfine Number of Persons Served Showers a`` Number of showem, Cafeteria Other fixtures Specify other fixtur s: t5formsIa doc•06/03 Application for Disposal System Construction Permit•Page 1 of 4 _tx Commonwealth of Massachusetts City own of Northampton Number a Ap lication for Disposal System Construction Permit Fee A. Facility Inormation (continued) 6. Design Flow 33 6 Gallons per Day Calculated ally Flow: 330 Gallons i. Man: 4/16/19 Date of Original Number of She is 1 Revision Date Title of Plan: Plan to Repair Septic System S. Description of Soil: siltysand 9. Nature of Repairs or Alterations (if applicable): New septic to k. pump tnk andi t at'on chamber ac fie 10. Date last ins ected: B. Agreement The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage dis osal system in accordance with the provisions of Title 5 of the Environmental Coc a and not to place the system in operation until a Certificate of Compliance has be �e issued b this Board of Health. j" n I SignatureM ,� ��'' Date Application Approved By: Name Date Application Disap roved for the following reasons: t5formsl a doc•06/03 Application for Disposal System Construction Permit•Page 2 of 4 Commonwealth of Massachusetts City own of Northampton Number Application for Disposal System s 5••�''r Co struction Permit Fee FORM 2A - DSCP No. Fee C0MM0M WT%LT!W OF *I.ASS_tCgfVSxgtjS Board of Health, Northampton, MA ISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to: epair,an individual sewage disposa[system at Florence Rd.—lot. Northa o as described in the application for Disposal System Construction Permit N dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Date Board of Health t5forms1a doe-06/03 Application for Disposal System Construction Permit•Page 3 of 4 Commonwealth of Massachusetts City own of Northampton Number o Application for Disposal System s ,•• Construction Permit Fee FORM 3A - CERTIFICATE OF COMPLIANCE No. Fee CO!VI.ON'W!E%. ?qCOf W SSA.CgfVS!FTVS Board of Health, Northampton, MA CERTIFICATE OF COMPLIANCE Description of Work: ( X ) Complete System ( } Individual Components The undersigned hereby certify that the Sewage Disposal System: Repair by: M ke John at: F orence Rd.-lot, Northampton has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design p ans/as built plans relating to application No. dated 4/16/19 Approved Design Flow 336 (gpd). Installer: Date: Designer: Thomas S. Leue, Homestead Inc. Date: Inspector: Date: The issuance of tl ils permit shall not be construed as a guarantee that the system will function as desig ied. t5formsla doc•06/03 Application for Disposal System Construction Permit•Page 4 of 4