DSCP Application - Childrens Island - North Facility Revised - Signed
t5form1a.doc• 06/03 Application for Disposal System Construction Permit • Page 1 of 3
Commonwealth of Massachusetts
City/Town of Salem
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
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
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use only the tab
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use the return
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Application is hereby made for a permit to: Construct a new on-site sewage disposal system
Repair or replace an existing on-site sewage disposal system
Repair or replace an existing system component
1. Location of Facility:
Children's Island - Up Island (North End)
Address or Lot #
Salem
City/Town
Massachusetts
State
01970
Zip Code
2. Owner Information
YMCA of the North Shore
Name
200 Cummings Center, Suite 173D
Address (if different from above)
Beverly
City/Town
Massachusetts
State
01915
Zip Code
(978) 922-0990
Telephone Number
3. Installer Information
Scott Faulkner (Building)
Name
Groom Construction (Building)
Name of Company
96 Swampscott Road
Address
Salem
City/Town
Massachusetts
State
01907
Zip Code
(781) 592-3135 ext. 204
Telephone Number
4. Designer Information
David S. Kelley, PE
Name
Meridian Associates, Inc.
Name of Company
500 CUmmings Center, Suite 5950
Address
Beverly
City/Town
Massachusetts
State
01915
Zip Code
(978) 299-0447
Telephone Number
t5form1a.doc• 06/03 Application for Disposal System Construction Permit • Page 2 of 3
Commonwealth of Massachusetts
City/Town of Salem
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
A. Facility Information (continued)
5. Type of Building:
Dwelling Garbage Grinder (check if present)
Other: Type of Building Self-Contained Composting Toilet Facility for
Day Camp
up to 200
Number of Persons Served
Showers
Number of showers Cafeteria Other fixtures
Specify other fixtures:
6. Design Flow:
Gallons per Day
Calculated Daily Flow:
Gallons
7. Plan: September 9, 2023
Date of Original
7
Number of Sheets
April 3, 2024
Revision Date
YMCA Children's Island Structures Up-Island Toilets: Cover, Proposed Plans, Proposed Elevations,
Proposed Sections, Proposed Wall Section (2), Foundation & Framing Plans;
8. Description of Soil:
The soils on the northern portion of the island are comprised of Udorthents which are comprised
primarily of man-made soils over top of loose sandy and fine sandy loam to bedrock at a depth of
around thirty-six (36) inches
9. Nature of Repairs or Alterations (if applicable):
Installation of Self-Contained Composting Toilet Facility
10. Date last inspected:
Date
t5form1a.doc• 06/03 Application for Disposal System Construction Permit • Page 3 of 3
Commonwealth of Massachusetts
City/Town of Salem
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
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
Health.
Signature
March 26, 2024
Date
Application Approved By:
Name
Date
Application Disapproved for the following reasons:
Doc ID: 41c31e0d115b3cfcf54296e410267061a8fcf9e7