259 Well Application & Plans Commonwealth of Massachusetts
City/Town of Leeds
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
Important:
When filling out Z Construction of a new system
forms on the ❑ Repair or replacement of an existing system
computer, use ❑ Repair or replacement of an existing system component
only the tab key
to move your
cursor-do not Has been done in accordance with Title 5 and the Disposal System C strt/motion Permit(DSCP):
use the return OD�J O— ' j 9 /3
key. f
t5form3.doc•06/03
DSCP Number
Patrick Melnik
Facility Owner
259 Chesterfield Road
Street Address or Lot#
Leeds
City/Town
DSCP Date
Designer Information:
Timothy E. Maqinnis R.S.
Name
Signature Da
Installer Information:
Randy Baker Randy Baker " onstruction
Name Name of Company
July 7, 2014
Date
Signature
Use of this system is conditioned on compliance with the provisions set forth below:
No garbage disposal allowed
The issuance of this certificate shall not be cfnstrued as a guarantee that the system will function as
desi G.nedla d /Y` R.
Approving AUth M1y
Signat
7/01
Certificate of Compliance•Page 1 of 1
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
Commonwealth of Massachusetts
City/Town of Northampton
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
® Repair or replacement of an existing system
❑ Repair or replacement of an existing system component
use the return Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP).
key
2013-8
DSCP Number
Patrick Melnik Sr.
Facility Owner
259 chesterfield Road
Street Address or Lot*
Florence
City/Town
Designer Information:
Timothy E. Maginnis R.S., LSE
Name
Signature
Installer Information:
Randy Baker 8 Cous
Name Name f�pany
j. g,/ !S WAaf I lu 7 ry
Signature Dat
5/28/2013
DSCP Date
MA
State
Name of Company
Date
01062
Zip Code
Use of this system is conditioned on compliance with the provisions set forth below:
7125 — ?i{18-±rt9-k )ACCT-- S ^ (Inf. iteurl Y.3 Ct,VE1> ..„„
7 N0%/ - Come z K ✓c-w
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Northampton Health Department
Approving Authority
Signatu
-7//D4 '
Date
t5form3 doc•06/03 Certificate of Compliance•Page 1 of 1
Commonwealth of Massachusetts
City/Town of Northampton
Certificate of Compliance
Form 3
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the return
key.
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
Z Repair or replacement of an existing system
❑ Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
2013-8
DSCP Number
Patrick Melnik Sr.
Facility Owner
259 chesterfield Road
Street Address or Lot#
Florence
City/Town
Designer Information:
Timothy E. Maginnis R.S., LSE
Name
Signature
Installer Information:
Randy Baker
Name
5/28/2013
DSCP Date
MA
State
Name of Company
Date
Name of Company
01062
Zip Code
Signature Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Northampton Health Department
Approving Authority
Signature Date
t5fonn3.doc•06/03 Certificate of Compliance•Page 1 of 1
1.1
• I
City of Northampton
BOARD OF HEALTH
PERMIT NUMBER: Z0121 " 01
This is to certify that
FEES 50
CHECK#O A 5q
CASH
M
NAME
11 ctlestiezp PA- (aS noS3
ADDRESS
Is Hereby Granted a Permit to Install an
Individual Private Drinking Well: 2c/
LOCATION: OR 59 cllE5-Wt +- 1f� '
DATE:
jID , 21) 13
This license is granted in conformity with s and ordinances relating
thereto and expires (n, unless sooner suspended
or revoked.
BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION P
Well Permit NumberpO!3"0/ (TO BE ASSIGNED BY BOARD OF HEALTH)
F
CLt4
This application must be accompanied by a scaled plot plan, produced by a cm eflneer or registered
sanitarian showing the minimum distances required in Title 5 of the State Environmental Code. For new
construction, requiring a septic system, the septic system plan submitted for the property in compliance
with Title 5 requirements will be acceptable if the proposed well location is included.
Application is hereby made to construct( )or repair a private well.
4.t4 7 .n$Cr)'ii
Owner's Name ee
311 Cdo+TG.erf,el, a y krail4
Styyeect Address
La/r Ana 01 0 r-.?
City, State, Zip Code
ar9 cu>rc ft, nQ
Location of Proposed Well
(if different from address)
0.-/.14 414
Jo) i2
Date,S.n1_ 6 -7 S'D
Telephone Number
/ S' F
Tax Map#
Well Driller(submit evidence of valid state registration)
1.19
Parcel #
Conserva r n Commiss n Approval
oCK (SLaValleyienorthamptonma.gov)
For new construction: — S tot
Septic system plan complies with Title 5: yes 4 no ( ) n/a( ) --pea) cy/ 40 6t
Septic system plan shows location of well: yes ( )no ( ) n/a( ) desibpled by
For new, re:air or location to leach field, septic tank or city sewer: U
A sc.j, well construction plan has been submitted:yes ( ) no() n/a( )
JO
Signatu f.f Applicant Dat
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
TM MC1iM Js
TO BE COMPLETED BY BOARD OF HEALTH
Permit expires on: (One year from date of issuance)
Permit issued (date)
AS—BUILT DIMENSIONS Existing distribution box ("D")
40 mil poly barrier
•
/ (3 sides)
Title-5 sand
/
/ . . ._
Existing /
/ 3 bedroom / ' ''ii®®���®ii•
/ / Reserve area
/ / Inspection
1 / ®����A��®®®6 '.., Ports
Reserve area
/ Existing 2 / - '
Existing / garage / / 'A. 1`'y iiiiiiiiiiii
well location / D'1®
• - - / / Porch l
�/ J \ '8ft.
3 5R 4" pvc solid pipe
4"pvc solid pip
/ c
Driveway Existing septic tank
Pump out man—hale ("C)
INFILTRATOR LEACHING TRENCH SYSTEM
3 Trenches with 12 Infiltrators/trench
b / \ b C AS 3UILT PAL\
259 CHESTERFIELD ROAD
FLORINCE, MASSACHUSETTS
CHESTERFILELD ROAD — NORTHAMPTON, MASSACHUSETTS
CITY OF NORTHAMPTON,
DEPARTMENT OF PUBLIC
125 Locust Street
Northampton,MA 01060
413-587-1570
Fax 413-587-1576
PENDING APPROVAL
MASSACHUSETTS 259 CHESTERFIELD ROAD
WORKS
Trench Permit Number
Date Approved:
Expiration Date:
2013-083
(for City Use Only)
EXCAVATION/TRENCH PERMIT
Pursuant to G.L. c. 82A and 520 CMR 1400 et seq. (as amended)
This permit must be fully completed prior to consideration. Submit completed form with permit fee to
Northampton Department of Public Works, 125 Locust Street,Northampton,MA 01060.
This permit is issued under the provisions of M.G.L.c. 82A,520 CMR 14.00 and applicable sections of the
Revised Ordinances of the City of Northampton, including,but not limited to,Section 285-21.
Fee: $250 Check#: 5013
Date Issued: 5/8/13
seaum ui nppucaut
PATRICK MELNIK
Primary Phone#
584-6750
Street Address
259 CHESTERFIELD ROAD
Emergency Phone#
537-0219
City/Town
NORTHAMPTON
State
MA
Zip
01060
Email
Name of Excavator
BRANDY BAKER
Primary Phone #
348-6991
Street Address
149 BRIDGE ROAD
Emergency Phone#
City/Town
NORTHAMPTON
State
MA
Zip
01060
Email
Name of Property Owner(s)
PATRICK&ALICE MELNIK
Primary Phone#
584-6750
Street Address
311 CHESTERFIELD ROAD
Emergency Phone#
City/Town
NORTHAMPTON
State
MA
Zip
01060
Email
Insurance Certificate#
ON FILE
Policy Expiration Date
g-/-/3
Name& Contact Information of Insurer
ON FILE
Dig Safe#
2013-190-2081
(D2L-13)
Pg.u4,Excavation/Trench Perm.'.
To be completed when approved permit is picked up.
By signing below, the applicant acknowledges and agrees to all the conditions of approval stated below
and validates this permit.
J7
Date
For City Use-Do not write in this section
Department Approvals/Comment Other Referenced Permits
Water .Y S' ri-/3 NO �SEZirS
Sewer j%�7�S7(3/73
Streets
Condition of road:
Road last paved:
point
1Q97
Conditions of Approval
❑ Control Density Fill Required ❑ Refer to Engineering for plans
❑ Must install clean-out(See Attached) ❑ Subject to 5-yr.pavement moratorium
❑ Other requirements(See Attached) C Water/Sewer/Drain Entry Permit
Fee
❑ $250 Permit Application Fee received(Check payable to the City of Northampton)
• Fee Waived. Reason:
Permit Approval
Director of Public Works
Date
Pgie/1a
L'
Permit No. D26-13
CITY OF NORTHAMPTON, MA
DRIVEWAY PERMIT
FEE: 5250.00
THE BOARD OF PUBLIC WORKS
Date: 5/2/13
Check 4: SON
Driveway must be staked and house& lo.-rre:;aka.pos,-ed
The undersigned respectfully petitions your honorable b*t p for. A new Curb Cut
Permission to install a driveway at: 259 Cr esterfield R.,ad
Fifteen (15)foot maximum width from street tin_ to propel ty line. Gutter drainage not to be
disturbed. All drainage shall be directed off:he driveway surtae- to adjacent land and not on the
existing roadway. The first one hundred(100) feet of the driveway surface shall be paved as
soon as possible if the grade of the proposed driveway exceeds 3% at any point in the first one
hundred (100) feet. Homeowners will be held responsible for pry costs to the City of
Northampton in the event of a washout of this driveway. City is not responsible for cul verts
installed under driveways in City layout. Code of Ordinances §350-8.8 providing standards for
private, individual driveways as most recently amended,must be followed.
Proposed Location htspection By:
Gravel Base Grade Inspected By:
Final Approval:
Teleph�,iz:
satire:
auick Melnik Sr
584-6750
. c57- -i 3
THE BOARD OF PUBLIC WORKS voted that petition be granted.
Edward S. Huntley, P.E.
Director of Public Works
Cc: Building Inspector
S
a-!
(SUBJECT TO ATTACHED CONDITIONS 1 &2)
Permit No. D26-13
Conditions: Driveway Permit
In lieu of plan approved by the City Engineer I agree to the following added conditions:
I. I will contact the Department of Public Works and have an inspector check and approve
the graded gravel base prior to paving to insure compliance with slope and location;
2. I further agree that if in the inspections, any of the permit conditions are not met that I
will at no expense to the City remove and replace the driveway as directed by the City
Engineer.
By:
Name:
Address:
Petitioner Signature
Patrick Melnik Sr.
311 Chesterfield Road
Leeds, MA 01053
Note: The Public Works Department recommends that you provide a plan showing the
proposed driveway with grades and location in the future to avoid possible expense
which you will incur by not getting approval of actual plans in advance.
For Commercial and Industrial applicants, a plan showing the proposed driveway with
grades, location and Planning Board permits are required.
Cc: Building Inspector
N FB adq 12L s3 4 7gl2a3
ti neummpe5 servo or IWO
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un
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kl
\ 61.7115 50.ET
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e
FI:mon
s,
�.
5 55 o e
.e — 2„T'.
CHESTERFIELD ROA D y el 1 es Do esex vrienELI) - -
PATRICK J. MELNI(i
ALICE E. MEINIK
a A APLI i be al n I e 3,
..:. - 7< .5,5
BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMITH,M.D.
JOANNE LEVIN,M.D.
Benjamin Wood,MPH,Director
Daniel Wasiuk,Health Inspector
Edmund Smith,Health Inspector
Patricia Abbott,RN,Public Health Nurse
Heather McBride,Cleric
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
212 MAIN STREET
(413)587-1214 NORTHAMPTON,MA 01060
FAX(413)587-1221
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE: As of 1/1/11, Septic System Permits will not be issued by the Northampton Health Department
until we receive this form signed by the Northampton Conservation Commission Staff Member.
The Conservation Commission can be reached by contacting:
0 Sarah LaValley, Conservation, Preservation and Land Use Planner
SLaVallev@northamptonma.gov
587-1263
Office of Planning& Development
210 Main Street, Rm. 11, City Hall
Northampton, MA 01060
Property Owner: 2--IrIc.K Re_
Engineer: /im /14ct etieL S
Address: 2S9 d es4 4P/�'/ a11
(Aleu) s/ JC�Div)
o servation Common Conservation, Preservation and Land Use Planner
Date: 67L1/13
F3` SQ7 e t CWtd IliV y -- 2e
(ecotAAMAPht&ci 4911 1400 se calla( dJUVeLf cola ycnbti
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the ret rn
key.
IOW
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
020/3 -8
Number
r N
Fee
` Vb / N
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
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:
259 Chesterfield Road
Address or Lot#
Florence
City/Town
2. Owner Information
Patrick Melnik Sr.
MA.
State
01062
Name
259 Chesterfield Road
Zip Code
Address(if different from above)
Florence
City/Town
3. Installer Information
Randy Baker
Name
149 Bridge Street
Address
NorthampRton
City/Town
MA
State
(413) 586-4825
01062
Zip Code
Telephone Number
Name of Company
4. Designer Information
Timothy E. Maginnis R.S., LSE
t5formla.doe-06/03
Name
70 Montague Road
Address
Westhampton
City/Town
MA.
State
(413) 527-5291
01027
Zip Code
Telephone Number
Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 'IA
.9-O/3-g
Number
$ /50
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
2
❑ Garbage Grinder(check if present)
6
Number of showers
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
Number of Sheets
330
Gallons per Day
330
Gallons
May 28, 2013
Date of Original
Revision Date
Title of Plan
8. Description of Soil:
Sandy loam- Fine sandy loam with lg. stones and boulders
9. Nature of Repairs or Alterations Of applicable):
N/A-This is new construction
10. Date last inspected:
N/A
Date
t5fornla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Florence
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 th system in operation until a Certificate of omplia ce has been issued by this Board
pf Health.
Signature
Application Approved By:
//ec.(44 X spu-cr
Application Disapproved for the following reasons:
Date
Date
t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
02013 0259' CLesIerf'Jc �l
Checklist for Septic System Plan Review
Application page attached to plan
PE or RS stamp,date, signature
Variances to property line setback distances must have Surveyor stamp
Legal boundaries noted
Easements noted
Dwellings and buildings existing or proposed noted
Location of driveway or parking areas,other impervious areas
Location and dimensions of reserve area new construction only)
System design calculations
Garbage grinder,yes
Benchmark not disturbed during construction within 75ft of facility
North arrow
Contours
Deep hole location(s)and data
Perc hole location(s) and data
Elevations
Names of approving authority and soil evaluator
Location of water supplies, public and private
o Within 400ft of system in case of surface water and gravel-packed public water supply
o Within 250k of system in case of tubular public water supply
o Within 100ft of system in case of private wells(50ft from tank)
Well statement, if applicable
Location of any surface waters, rivers,vegetated wetlands
Location of water lines and other subsurface utilities
Obserrved and adjusted groundwater elevations in vicinity of system
Profile of system
Locus plan to show location of facility, including nearest street
Materials of construction and specs for system
Gas baffle
Pipe in center line of tank
Schede Double-washed 0 PV stone
trafficked / / / 36)
Schedule 40 PVC for t areas, house to tan ,$ ✓(�°
Distances noted from house to tank,etc.
❑ If dosing is proposed, design and specs of dosing system
❑ When alternative technology is required, complete plan and specs including hydraulic profile
XTrenches preferred over beds
Buoyancy calculations for tanks or components partly below groundwater level
<3:1 slope outside of mound,toe ending 5ft from property line s /Q�
❑❑\ Local upgrade requests on the plan, all variances i //Rr {7
❑ Local upgrade forms attached to the application N
.cl b< ,, t,,vc4
BOARD OF HEALTH
City of Northampton
APPLICATION FOR A GROUND SOURCE HEAT PUMP WELL
CONSTRUCTION PERMIT
GSHP Well Permit Number (to be assigned by board of health) Fee: $
Fee: $50.00 minimum for first well
$25.00 for each additional well
Total# of GSHP Well(s) I
This application must be accompanied by a scaled plot plan,produced by a civil engineer or
registered sanitarian showing adherence to the Underground Injection Control (UIC)
requirements (attached).
Application is hereby made to construct( ) or repair(qj a GSHP well.
4-4:t4 "-ate' 4(
Owner's Name ew /W Date
311 C Wire-A-76 7 ft
Street AcWress
Lt• 1 C I/e,Lt I
City, State,Zip Code
AT
Telephone Number
}S 5 C N.4 r-0 --re A44
w fa. 4a71 8
Location of Proposed Well(s)
(longitude and latitude)
/s -e
Tax Map#
, y„
Sign e of Applicant to
Y9
Parcel #
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
Final approval to be issued with UIC approval paperwork.
TO BE COMPLETED BY BOARD OF HEALTH
Permit issued(date) Permit to operate(date)
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Howard Laboratories
62 Main Street- Hatfield, MA 01038 Tel (413) 247-5533 Fax (413).247-9599
Henshaw Well Drilling
Client: Pat MelnIck
WATER ANALYSIS REPORT
Invoice Number: 16385
Sample Location: 259 Chesterfield Rd Leeds, MA
Sampled by: Henshaw Well Drilling
Date Sampled: 7-2-13
Date Received: 7-2-13
Parameter Sample Result MA DPP/EPA Maximum Comments
Contaminant Limit (MCL1
Total Coliform Bacteria Absent Absent OK
E. co05 Absent Absent OK
§ Microbiology Certification N: M-00851 for Total Coliform &E. coil(SM 92238-COlilert®)
Additional Water Quality Parameters
Parameter Sample Result Detection Limit MA DEP/EPA MCL Comments
Color 117 PtCo Color Units 1 PtCo Color Units 15 PtCo Color Units *
Iron 0.52 mg/L 0.01 mg/L 0.3 mg/L *
Manganese 0.061 mgiL 0.001 mg/L 0.05 mgiL *
Nitrate 1.1 mg/L 0.1 mg/L 10 mg/L OK
Nitrite 0.019 mall 0.001 mg/L 1 mg/L OK
pH 6.8 pH Units No Limit 6.5 -8.5 pH Units OK
Sodium 1 mg/L 1 mg/L 20 mg/L OK
Conductivity 0.2 mS/cm No Limit No Standard No Standard
Turbidity 999 NTU 0.5 NTU No Standard No Standard
Chloride 6.4 mg/L 0.1 mg/L 250 mg/L .50 soft
Hardness LOS mg/L No Limit No Standard >1.00 hard
Parameters marked with an asterisk are above acceptable MCL. Please refer to the
attached sheet for more Information, 'log of the parameters that are over the limit should
decline to below MCL after a few weeks as the water and materials Floating m the well settle.
Analyst: TS Cate: 7-2-13
1
Massachusetts Department of Environmental Protection - Drinking Water Program
Inorganic Contaminant Report
I.SAMPLE INFORMATION:
SAMPLE ID#:
Name:
17002
City/Town:
IOC
LEEDS
Pat Melnik
IL ANALYTICAL LABORATORY INFORMATION:
Primary Lab MA Cert.#: M-00851 Primary Lab Name:
Howard Laboratories
Subcontracted?(YIN)
Y
Contaminant
Location Name
Sample Information
titiositore all um umurd
of fm a abrr
d
m applied
Date Collected
Collected By
Date Analyzed
259 Chesterfield Road
n(Mluluple
®(S)Ingle
❑(R7aw
8(F)Inisbetl
12/212013
H.W.D.
Routine or
Special Sample
Original,Resubmitted or
Confirmation Report
If Resubmitted Report,
(1)Reason for Res bmission
list below:
(2)Collection Date of Original Sample
❑RS ®SS
El Original❑Resubmitted D Confirmation
❑Resample 0 Reanalysis❑Report Correction
ARSENIC
SAMPLE NOTES Such emit a ManffitdlMuIGple sample,list the scum s that were on-line during sample collection).
0.010
IL ANALYTICAL LABORATORY INFORMATION:
Primary Lab MA Cert.#: M-00851 Primary Lab Name:
Howard Laboratories
Subcontracted?(YIN)
Y
Contaminant
Result
mglL)
OWL)
(WA)
Lab Method
Date Analyzed
Analysis rtLab
Analysis Lab Name
Lab Sample OK
ANTIMONY
0.006
ARSENIC
ND
0.010
0.0041
ICP 200,8
12/6/2013
M-CT008
Premier Laboratory,Inc
E312392
BARIUM
2
BERYLLIUM
0.004
CADMIUM
0.005
CHROMIUM
0.1
CYANIDE
0.2
FLUORIDE
4.0
MERCURY'
0.002
NICKEL
0.1'
SELENIUM
0.05
SODIUM
20*
THALLIUM
0.002
'Fluoride also has a secondary MCL f 2.0 mgIL Community water systems which exceed this limit must provide public otice pursuant to 310 CMR 22.16.
'Please note that if method 245.1 is u ed for me cury,only m thou revision 3.0 will be accepted by MA DEP,
No current MCL,however DEP Office of Resea ch and Standards has established a guideline(ORSG)limit for this cant minant.
Was this Sample composited
by the Lab?
COMPOSITE SAMPLE NOTES
List the composlted sources by DEP Source Code QO(X0AIX40W,up to five Individual sources per sample.
Yes❑
LAB SAMPLE NOTES
I certify under penalties of law that I am the person
authorized to rill out This form and fhe information contained herein is
true,accurate and complete to the best extent of my knowledge.
Primary Lab Director Signature:
Date:
1/6/2014
If not submitting these results electronically,mail TWO copies of this report o your DEP Regional Office no later than 10 days after he end of the month
in which you received this report or no later than 10 days after the end of the reporting period, whichever is sooner.
DEP REVIEW STATUS(Initial&Date)
❑Accepted ❑Disapproved
Review
Comments
I]WOTS
Data Entered
Massachusetts Department of Environmental Protection - Drinking Water Program VOC
Volatile Organic Contaminant Report Page2of2
PWS ID#:
1132000
CASY
UNREGULATED
VOC CONTAMINANTS
Results
V9/L
MDL
Pg/L
67-563
CHLOROFORM'
ND
0.50
75-27-4
BROMODICHLOROMETHANE
ND
0.50
124-48-1
CHLORODIBROMOMETHANE
ND
0.50
75-25-2
BROMOFORM
ND
0.50
541-73-1
M-DICHLOROBENZENE
ND
0.50
74954
DIBROMOMETHANE
ND
0.50
563-58-6
1,1-DICHLOROPROPENE
ND
0.50
75343
1.1-DICHLOROETHANE'
ND
o.50
79-34-5
1,1,2,2.TETRACHLOROETHANE
ND
0.50
142-28-9
1,3-0ICHLOROPROPANE
ND
0.50
74-87-3
CHLOROMETHANE
ND
0.50
74-83-9
BROMOMETHANE
ND
0.50
96-18-4
1,2,3-TRICHLOROPROPANE
ND
0.50
630-20-6
1,1.1.2-TETRACHLOROETHANE
ND
0.50
75-00-3
CHLOROETHANE
ND
0.50
594-20-7
2.2-0ICHLOROPROPANE
ND
0.50
95-49-8
O-CHLOROTOLUENE
ND
0.50
106-43-4
P.CHLOROTOLUENE
ND
0.50
1OB-861
BROMOBENZENE
ND
0.50
542-75-6
1yDICHLOROPROPENE'
ND
0.50
95-63-6
1,2.4-TRIMETHYLBENZENE
ND
0.50
87-61-6
1,23.TRICHLOROBENZENE
ND
0.50
103-65-1
N-PROPYLBENZENE
ND
0.50
104-51-8
N-BUTYLBENZENE
ND
0.50
91-20-3
NAPTNALENE•
ND
0.50
87-68-3
HEXACHLOROBUTADIENE
ND
0.50
108-67-8
1,3,5-TRIMETHYLBENZENE
ND
0.50
99-87-6
P-ISOPROPYLTOLUENE
ND
0.50
98-82-8
ISOPROPYLBENZENE
ND
0.50
98-06-6
TERTAUTYLBENZENE
ND
0.50
135-98-8
SEC-BUTYLBENZENE
ND
0.50
75-694
FLUOROTRICHLOROMETHANE
ND
0.50
75-71-8
DICHLORODIFLUOROMETHANE
ND
0.50
74-97-5
BROMOCHLOROMETHANE
ND
0.50
1634-04-4
METHYL TERTIARY BUTYL ETHER
(NISEI'.
ND
0.50
'Required
•DEP ORSO limit established.
Lab Sample 10#:
E312392
CASs
ADDITIONAL
UNREGULATED and/or NON-TARGET
VOC CONTAMINANTS
(Report if analyzed or 0000e 0004)
Results
PNL
MDL
yg/L
10999-9
TETRAHYDROFURAN(THF)'
75-65-0
TERTAUTYL ALCOHLOL(TBAY
1748-03-8
TERT-AMYL METHYL ETHER(TAME)'
637-92-3
ETHYL TERTIARY BUTYL ETHER(ETBE)
108-20-3
DI-ISOPROPYL ETHER(DIPE)
67-64-1
ACETONE'
76-13-1
FREON 113'
78-93-3
METHYL ETHYL KETONE(MEN)*
108-10-1
METHYL-ISOBUTYL KETONE(MIBK)'
❑Chec this box if attaching lab report to show additional VOC
results/contaminants tested.
Surrogate Name
%Recovery(70-130%)
1,2,Dichlorobenzened4
103%
Bromofurobenzene
101%
I certify under penalties of law that I am the person
authorized to tilt out this form and the information contained herein Is
true,accurate and complete to the best extent of my knowledge.
Primary Lab Director Signature:
Date:
1/6/2014
If not submitting these results electronically,mail TWO copies of this report o your DEP Regional Office no later than 10 days after the end of the month
in which you received this report or no later than 70 days after the end of the reporting period whichever is sooner.
DEP REVIEW STATUS(Initial B Date)
Review
❑OOHS
❑Accepted ❑Disapproved
Comments
Data Entered
BOARD OF HEALTH
MEMBERS
JAY FLEITMAN,M.D.,ACTING CHAIR
SUZANNE SMITH,M.D.
DONNA C.SALLOOM
DIRECTOR OF PUBLIC HEALTH
XANTHI SCRIMGEOUR,MHEd,CHES, BOARD OF HEALTH
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
(413)587-1214
FAX(413)587-1221
hal
#55?7- 5a9 I
Project Number:
Performed by:
/ Health Inspector:
Site Suitability for On-Site Sewage Disposal
6257 „ , Site Addrr S pi
ew Construction
OtRCe Review
Date:
Equipment Operato
Published Soil Survey Available: No O Yes ❑
Year Published Publication Scale Soil Map Unit Drainage Class Soil Limitations
Surficial Geologic Report Available: No ❑ • Yes ❑
Year Published Publication Scale Geologic Material(Map Unit) Landform
Flood Insurance Rate Map:
Above 500 year flood boundary O Within 500 year flood boundary ❑ Within 100 year flood boundary ❑
T.P.# 1-1
212 MAIN STREET
NORTHAMPTON,MA 01060
vvi
31) c �9�leti{' i�Y
Client:7e&Address
&LI
Repairler J / '�
�or Bert Y
Wetland Area:
National Wetland Invetory Map(Map Unit)
Current Water Resource Conditions(USGS):
Range: Above No rgMl O
Other References Reviewe
Month
Normal 7
Wetlands Conservacy Program Map(Map Unit)
Below Normal O
ion Test Results
Pero 1-I
Time
Measurement
Time
Measurement
Begin Saturation
9(35.>h
Begin Saturation
101a SAM
End Saturation
91192••
End Saturation
I0-r{(/I,1
9„depth
Measurement
__
_
9"depth
Measurement
6"depth
Measurement
-
�'l'ju�i
6"depth
Measurement _ _
_ 4.:-.a.. .•
Elapsed Time 1p �,�tk1ig1�
9"to 6„ 9i3S11:1_A to ;
•V
�A
i
Elapsed Time
9"to
i
t01.Seni
Percolation
Bottom of Pe
to <2 min7n
lation Test Hole: _' q
2
Percolation Rate: ^"
Bottom of Percolation Test Ho e: 3 gni„ti
Determination forSeasonal Ht drWaterTable
Method Used
epth observed standing on observation hole>
Depth to soil mottles inches
Index Well Number
❑ Depth weeping from side of observation hole inches
❑ Ground water adjustment inches.
Reading Date Index well level
Tp
3
nth of Naturally Occuring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
If yes,what is the depth of naturally occurring pervious material?
If not,what is the depth of naturally occurring pervious material?
Deep Hole Number:
Location(identify on site plan):
Land UseNegetation:Lawn/grass
Iandform:
Position of Landscape:
Distance from:
Open Water Body
Possible Wet Area
Drinking Water Well
Date
On-Site Review
/6/i,Time:
Slope(%)
Feet
Feet
Feet
Weather:Cool&Overcast
Drainageway
Property Line
Other
Surface Stones
T.P.# 1-I
9ont
Feet
Feet
Feet
DEEP OBSERVATION HOLE LOG
Depth from
Surface
(Inches)
Soil
Horizon
Soil Texture
(USDA)
Soil Color -
(Mansell)
Soil
Mottling
Other(Structure,Stones,Boulders,
Consistency,% Gravel)
s-i2
1 z--so
30-8'
P
1S
C
SL
t /5
G 1.....1
,Oyr W4
fO/ 44
Jaye sh
gnNan- 30"
7iyr fA
u
At
1
t ,
Stevi e
. ,
* r
, 1
1,
c,
S. aril
E
Parent Material(geologic)
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water: >
Depth to Bedrock: >
Weeping from Pit Face:
Ll
Massachusetts Department of Environmental Protection - Drinking Water Program
Radionuclide Report
I.SAMPLE INFORMATION:
Sample ID#:
Name:
17002
Pat Melnik
City/Town:
R
Leeds
II.ANALYTICAL LABORATORY INFORMATION
Primary Lab MA Cert.#: M 000SI Primary Lab Name:
Howard Laboratories
Subcontracted?(Y/N) Y
Was this sample
composited by the Lab?
DEP Location Name
Sample Information
Date
ed
Collected
Collected By
259 Chesterfield Road
❑(M)ultiple
0(Sppgle
®(R)aw
❑(E)inished
12/2/2013
H.W.D.
Routine or
Special Sample
Original,Resubmitted or
Confirmation Report
If Resubmitted Re
(1)Reason for Resubmission
ort, ist below:
2)Collection Date of Original sample
❑ RS 21 55
®Original 0 Resubmitted 0 Confirmation
❑Resample 0 Reanalysis 0 Report Correction
2.37
SAMPLE NOTES
-(Such as.if a Manifold/Multiple sample,list any sources that were on-line line during sample collection).
M-PA153 Benchmark
II.ANALYTICAL LABORATORY INFORMATION
Primary Lab MA Cert.#: M 000SI Primary Lab Name:
Howard Laboratories
Subcontracted?(Y/N) Y
Was this sample
composited by the Lab?
COMPOSITE SAMPLE NOTES
List the composited source by DEP Source Code(XXXXXXX-XXX)and dates collected,up to four consecutive quarterly samples per single
entry point.
0
LAB SAMPLE NOTES
Contaminant RESULT
SW Des
(al)
MCL
MDL
Lab Method
Dale
Analyzed
Lab
Sample ID#
Analysis Lab
MA Get
Analysis Lab
Name
GROSS ALPHA 43.6 3.77
(PCT/L) I
2.37
EPA 900.0
12/14/2013 I E212392
M-PA153 Benchmark
URANIUM-activity
(pci/L)
Report Uranium result and MDL in(pCilL)as analyzed.otherwise se formula to calculate [Uranium pg/L x067=Uranium pCi/LI. Chec this box if result is calculated
ADJUSTED GROSS
ALPHA(PCIIL) I
—
15
The MCL or Adjusted Gross Alpha Gross Alpha minus Uranium)is 15 pCi/L.
5 pCJL.I(g gross alpha exceeds 115rpa/L.uranium must also be measur da result is equal
to A orrlless Ilan measurement
URANIUM-mass
(pgIL)
0.038
30
0.0010
200.8
12/6/2013
E212392
M-GT008
Premier
Report Uranium resull and MDL in(pg/L)as analyzed,otherwise u e formula t calculate [Uranium pci/L/0.67=Uranium pg/LI. Check his box if result i calculated 0
RADIUM-226
(pCi/L)
0.47 0.13
0.94
EPA 903.0
12119(2013
E212392
M-PA153
Benchmark
0.86
EPA 904.0
12/19/2013
E212392
M-PA153
Benchmark
RADIUM-226
(pCi/L)
-0.28 0.51
COMBINED RADIUM
(p CriL)
0.19
—
5
The MCL I r Combined Radium(Radium-226 plus Radium-228)is 5 Ci/L.
A gross al ha measurement may b substituted fort a radium-226 a alysis,if the gro s alpha result is
equal to o less than 5 pelt. If gro s alpha exceeds 5 pCJL radium- 26 must also be measured.
GROSS BETA
(pCi/L)
The MCL for gross beta is 4 mrem/year.II gross beta exceeds 50 pCi/L,analy is el the sample for Photon Activity shall be performed to i entity the major adioactive
constituents. Gross Beta testing is optional,unless specifically required by DEP.
RADON
(pCi/L)
u
r
-'Radon testing is optional,unl ss specifically required by DEP. T e MA guideline for Radon is 10,000 Ci/L.The EPA has proposed a radon MCL of 300-4000 pCJL.
I certify under penalties or law hat l am the person authonzed
to fill out This form and the information contained herein is true, 1/6/2014
accurate end complete to The best extent of my knowledge. Date:
If not submitting these results electronically,mail TWO copies of his report to you DEP Regional Office no later than 10 days after the end of the month
in which you received this report or no later than 10 days after the end of the reporting period,whichever is sooner.
Primary Lab Director Signature:
DEP REVIEW STATUS(Initial&Date)
❑Accepted 0 Disapproved
Review
Comments
❑WQTS
Data Entered