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94 Septic Application & Forms 20007 N '4' e \'‘ T i . ''}I • .. f� FEE 5l00 COMMONWEALTH of MASSACHUSETTS Pd 4146 /iy» Board of Health, Aatifriffine4AL,. 1I 'ATI©N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT ❑Individual Components Location L)7/n ne/A2 /24 , Jd/ Owner's NamttiT/ikli 4 9fl4lA/Cal Map/Parcel# 99 C'//f,c.:%/yew,th€G:-00 40 Address V/�Ae--6�/�SZF/A-e /E Lot# //0/1-771/10-7,07-0.4/ 41.453 / f Telephone# am/ sey /c/0 Installers Name sticie I oav ai' Designer's Name £/a be m 5'7.�2� Address Address fie$3 /Ce -.ezn_ s% Telephone# Telephone# �/T/96 v� A cuiz 7 , i410Q Type of Building /2 -.S/.O ' t U/4nt //erfr2Eq q p Lot Sae 70 I,C [5 Dwelling-No.of Bedrooms i 4 Ste-40YQO�//S 1.-49 49.1.17765771- Garbage grinder(ry+d 5/X16Ct .P/%ten/=C7 No.of persons 47 Showers a Cafeteria hie, Other-Type of Building Other Fixtures �7 Design Flow (min.required) //o i 3 gpd Calculated design flow 1330 Design flow provided 3if gpd Plan: Date Jilt a576 d tuber of sheets / Revision Date Title s..FAwe 5 'fflE79-7 a /6 Ai Fort ,r. aiPd4-1.4 Loci 91 Description of Soil(s) €Q /2 rine//tea Gem Asr44 P/Ca Eah0 Soil Evaluator Form No. // Name of Soil Evaluatoradr Date of Evaluation 5,a1177Q AE a/a%7 DESCRIPTION OF REPAIRS ORAITERATIONS C0tr2A teTf cif:" MC_ s/S/ % ice/ //,l//4,O.t 11' c314 C/21/7 /S n The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree• o n. place di m in operation until a Certificate of Compliance has been issued by the Board of Health. Signed )( - Date /7/13 Inspecrior ptic System Permit Payment Record Date'. /03/47 Amount. $ 0e a Cash Check# /6 76 Property Owneretr-c- erfrigentetperi Property Address gQ et4a41 New Construction Repair k— JAMES P. DOPPMANN PATRICIA K. DOPPMANN 94 CHESTERFIELD ROAD LEEDS,MA 01053-9728 PAY TO THE ORDER OF ee: E7SA y� 1: f )„,.-75z_ r°N ri /J y 5 2LL 709 l• 52 50962 1670 5340�932118 14 DATE vaTE 5-25 a L670 ea" Woriltammeot, Wicadadadeted 212 ?naui Sewer 72ateetetOP tb€t, 7/2274 01060 fee. 413-587-1214 ?az 413-587-1221 Title V Certification of Compliance TO BE FILLED OUT BY THE DESIGNING ENGINEER AND THE SYSTEM INSTALL FR DESIGNER SIGN-OFF Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Designer and the Installer of a system are required to sign this form as a condition for issuance of a Board of Health Certificate of Compliance for the onsite septic system This is to certify that the onsite sewage disposal system that I desivned as: at94t Ch1/2577de fied,D — on /0/c$0, '7 (Address) (Date) has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the original approved plans have been reflected on an as-built plan that has been submitted to the Board of Health. new construction repair(existing system) DWCP number "CO 7 -/1 (Address) (Date) INSTALLER SIGN-OFF This is to certify that the onsite sewage disposal system that I installed on (Date) at the above-referenced address has been constructed in compliance with 310 CMR 15.00,and with the approved plan and all local requirements. (Print Installer's name) (Address) slnstalle's signature) (Date) NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site subsurface disposal system.Rather,the plan and installation are in compliance with all applicable rules and regulations as are in effect at the time of plan submittal. William J. Sieruta, P.E. 453 Federal Street Montague, MA. 01351 Board of Health City Hall Annex Main Street Northampton, MA. 01060 October 29, 2007 Subject: "As Built Inspection" J. Doppmann 94 Chesterfield Road Northampton, MA. An as built" inspection was completed for the subject septic system. This system is in compliance with 310 CMR 15.0 and local board of health regulations. If you have any questions or need any additional information, please do not hesitate to contact me. Very truly yours, Gi%�L Arn 'i LA"- William J. Sieruta, P.E. (i%?l>J Encl:Plan 2cc letter and plan: J. Doppmann WJS:mbs LaeitIon Address or Lot No. Method Used• FORM 11 - SOIL EV UATOR FORM Page 3 of 3 t; 114 %oe A74 , ��,, Dje �th observed standing in obseryetion hole �Li'6 h weeping from side of observation hole LSDepth to soil mottles ......_ .. Inches 0 Ground water adjustment .............. feet Index Well Number ....... Reading Date . . Adjustment factor Adjusted ground water level Ind Inches inches well lave Depth of Naturally Occurrina Pervkunvlaterlal Does at lest four feet of naturally occurring perviou.. material a let in ggij a s observed throughout the area proposed for the soil abs rption syst:m? yt�y If not, whet Is the depth of naturally occurring perviou materiel? Certification 95-; I certify that on (date) I have pass approved by the epartmento Emiro tat P was performed by fns consistent wit he req described in 310 CMR 15.017. Signature Oar APPROVED 7oRn.1(07/1! ed atta orandt h sitting, expertise e Data ee or examination above analysis nd experience D �/ FORM 12 - PERCOLATIO�J TEST 1% 'Location Address or Lot No. _..._ -_evhCii/rg%/fr—C-4 /IAD COMMONW^TALTH OF MASSACHUSETTS oz ii*. Massachusetts Percolation Test' Data (1/4(5 (J > Time: Observation Hole M Depth of Pere Start Pre-soak End Pre-soak Time at 12" Time at 9" - : 2_ _ 3 I 35- // 33- /4/ // . 4/6 3 5-, 33 Time at 6" - /2 07 �. Time 19"-6"I z1/3 = 7, 6Z I(-)n/ d Rate Min./Inch �/ U • A-0? Minimum of 1 percolation test must be performed in both the •rlmary eras •ND reserve area. Site Passed 0 Site Failed 0 Performed By: __ it_... WIMeased By: /14/9-72.71/Etta` 3 . e/1 7P . Cornmants: TI1 —% /2 /MJMy'f 62 d o' Pei Test No. /21I#t 65 Reeding ' Time Saturation ( 15 min) 02Y. 7)73,C Pet .olatlon 'feat 7 ;`k- 734 '21' /z- 0 9 Pere Rate Ground Elev . Depth of Dole 'East Pit Depth c / AZ - .7 on_�Nin/inch Teat No . qC: CQ l� Ilsnd.l np Time Saturhi on ( 15 min) 9 Pere . Rate Ground Elev . Depth of Ilolo Deep Teat Pitta Soil Description 'feat Pit Depth So! Crs u_/� Or5 — /a CCQ%kL, !C —!gc Cootie 71in inch Descrip on y. ?rc �J Groundwater Depth fGj.Elev. Croon. water D Bedrock Depth Elev .--' Bedrock V Ground Elev, /g/L/CUT Ground Elev, S .C.S Soil Peecription Seeeonsl high Water Dench Mark: Elev,-.1 _ IJescripllon E ev. 1ev. v CGMNESTS: \" 36 36 Ge/9 roof^ )cte : Client : mmmEmmd01WigTtgdUglPfft ►• _ is ��i� r�i iY/�� Table? Eng neer ;itnese : 'Petition w C FORM 11-SOIL EVALUATOR-FORM a Itiee 3 0 Sli •i . - Fake of • • ' Loutbn AddreN w Lot Na. . swim Addressor Lot He. . - - , On site Review /y//%J y / 7. /j . s��/1. // CU .4-a •: ..oe.V NO I.NUmbg—"te - 'P�!�TLM� w.., loci •ew Nau NYm y_. tl t __ 'l.n.:----- '.'w..te, /-144).. - tuc.tlgl(ld.ntlfY on sit., - A• sawn*kingly oli(a�h'a pi-4T r` , / . • . ... •// /J/usual' / tr sic I%10, svha stone. �� al•and Use, 5C4,..t2, tt I%i 41.."surl.a Ston.a �..Inez/77-�<i Go r! ./usual' • /.f� - 11•&1244-4"44:-14.-- ....... Pushkin an de:IaMwpe Isketeb.on eke back) • oa1Wa on landscape(sits eh on gm back) + - -- ! lamas bom /G ' /` _ t /) �{// DllUllue.l„om: �QO f d�.j SlL e C �c� (f Open W'xx Bo lax Malang c.? tat OPa Watx9odi , tt pWai.lvry tat $/,Le • .(P Possible Wet M _tat. Prawn tine.. Nat /6G r'641�J.. V...INa wx aal�.t" te.t Opel un. _CCt.Lt) y /r; Drinking�w;tefw�i -- , ...he ,v -._._-_� / Ci V.' �1�. (/•'V; Drinking W.ur e• tat Ow '. Fl P�j 4•. /. G �JLU•• I e •- DEEP.9BSERVATION HOLE LOGS • • - OEE1t OBSERVATION HOLE LOG' , • a. i .•.•. evI FWY. � Vi stti ".114".. 1at = ' mea ua..r4 Ranee.'ra cp.o Do./ma. r uxla. i+rai u. l.Nltit mM:M „lama ea•p.aoWw a e c..e v., � . : ' Ayl V�c loi .wiz• Alp s/ yz • • L —1 '�ll��'rz.</ 2G. C jAeop 2 S fCt/. • /a% Golri1SCS .20- •c, : •�uu , �y• ye J02 c).‘.�.4s • ' f CG4'7�5--ii `" f /. G I I . S- 13n�O J'izec . ,• /54/955.ct ilk • F/z.cam ce - 1, , -[wOe.Ga.iliW1L pbyYl[Ual[ EBYP YRPi1SaiINFA yt.A'f/7 v.r.M.IreY lr..xa' [N t..n teyr44a„ro� aU11�V�' / : i� / '1f .. talari ptp aala wMi".HS.% rct-' .v,#..we.e.e, a(% sIYWY WN/ww1 in• a/ %'• •Itw.xdP•anf 3 f/5 . r e.rrar Nd oew wen, skims a....r isms Gourd wise, 'L t e0/Jr.nnOnrW.Wla iW/.w.eYdlONr-IW.1.e , • • , 1 . • .. • . . • , • e • .. II • • • No. FORM 11 - SOIL EVALUATOR FORM e 1 of 3 Date: Commonwealth of Massachusetts , Massachusetts, Soil Assessment for On-site Sewage Dispels& Performed By: CI, Date: 64cA Witnessed By: A' • 4"7 11172-Zi---/efrL-) n»- Delp fit'/Viti 4c-Jci /t-c7,2 ny ./Zetc-i New Construction 0 Repair / lgicl /nein Air C/Le'510(1rX to / / /e AlcvznininA/oati friiw Office Review Published Soil Survey Available: No 0 Yes Year Published Publication Scale Drainage Class Soil Limitations 4,6 . LrefL /00/ Soil Map Unit Stu-finial Geologic Report Available: No 0 Yes Year Published Publication Scale . Geologic Material (Map Unit) Landform Flood Insurance Rate Map: Above 500 year flood boundary No EPIC Within 500 year flood boundary No Ellers Within 100 year flood boundary No 05[0 Wetland Area: National Wetland Inventory Map(map unit) Wetlands Conservancy Program Map(map-unit) Current Water Resource Conditions(USGS): Month Range :Above Normal LINenonil 0Below Normal 0 Other References Reviewed: DIM APPROVED FORM-12/1I7M