Lot 1 Septic Application & Plans No
THE COMMONWEALTH OF MASSACHUSETTS
�i BOARD OF HEALTH
1. r y OF ./Ya.F:.ze?•amP>ait/
.Apptiratiun fur Eispnsd ini orb trnnstrurtinn jrrmit
Application is hereby made for a Permit to Construct (✓f or Repair ( ) an Individual Sewage Disposal
System at:
_......._e FFear.7.r/a.D...._........!5...0,
Location Address or Lot�o.
_✓-4.. .162 Mesrd?e/cli .22, Lrz.,7 sr . Le.r1e,tm c7 e/
Owner Address
Instiller Address
Type of Building Size LotaC40 7—` Sq. feet
Dwelling—No. of Bedrooms '-' Expansion Attic ( ) Garbage Grinder (—)
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow .57 gallons per person per day. Total daily flow..3ra A gallons.
Septic Tank—Liquid capacity/35, gallons Length.r-A '" Width.6 =0 ' Diameter Depth-.1-f-51”/
eE2Disposal T....dr—No. Width Z-fJ Total Length ...7Z Total leaching area./°A° sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Dosing tank ( )
Performed by✓ />'h�°.r //uN..rLE.y
minutes per inch Depth of Test Pit g L
minutes per inch Depth of Test Pit 7'—C"
z Other Distribution box (
.a Percolation Test Results
,.t Test Pit No. 1
Test Pit No. 2
NGet. Date 4/51271--
Depth to ground water Ko.vcr
Depth to ground water..H4.&4
rG
O Descri ption of Soil.2 ' O,tCGAN 7Af.'rc"-- / is"SG> 40/Tit' 4 9.::C:i24..t.25 Z �7
.6 44..dc.=Z- ?'-o" cS: f.Y. Cx.efau z. cv..i..77+ RnL/t-
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By
Application Disapproved for the following reasons'
Date
Date
Date
Permit No Issued
Date
1]N V ado 50c 1
V
.os 'Z )l 54 4 -0(10-1. at l Q� s 'b21o0H
5z,'z No qw' e at '90/ 471/9 (131k13M
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tt 'rPJ )4LtN
•
0010 -ifw SYY14i4).-icn
N O N V ) x,1.1, Ott
V W tl 1 1 1 1 M
Pere Test Witness Payment Record /7/n/t/34,21.7
Date: 1/4.-.5*," Amount: $ HZ. 1$571 .
Property Owner 4414--S.. 6114/76
Property Addres E( I`4ylt—Wt/�d�f`-t° X
New Construction_,/Repair C
WILLIAM A.CANON-LANDSCAPE ARCHITECT 3124 i
PH.413-527-6535 F%.013-527-6389
158 NORTHAMPTON STREET,RT 1O 53-7093/2118 'j
EASTHAMPTON,MA 61027-1020 115 — awucxz i.
LAIR
riMlilF ���//'���� yCJ{,— -!'.V- /I IAi v -.-_ P HI- -9-`2- {
� UN{i tp 1- /a •.As - s _ DOLLARS IS """"" I�
• ESSAVEAS N S BANK L...
1 /;f� �'
F✓• l • '}lo •3$(o CHE�T2K�f RV, /'
FOR WIT ) f-J(12.1-5 HRe. Air • _. _..
1: 2 L LB 709 3 5t: 409034 L 210 3 24
FORM 11 — SOIL EVALUATOR FORM
OWNER ' S NAME:
LOCATION ADDRESS: LOT #
JOB NUMBER: DATE: 6 7I7/47
COMMONWEALTH OF MASSACHUSETTS
IJo27'4-1 AMPT6IJ Massachusetts
oil Suitability Assessment for On-Site Sewage Disposal
Performed By:Thoo GL65 Mac Leo)?
Witnessed By: Pc4cq( M , F`r�C,✓\1C
Location Address or CNESTQ.FI EL2D 0204
Lot e
owner', Name. 1-1T-1 C.L.1.4 PP
Address. end to mac ii we STREET
Telephone e V l/&i &)i2f/O C-7-00-5
Cz-s-- 911'1
New Construction In Repair ri Number of Bedrooms
. Office Review
Published Soil Survey Available: No ❑ Yes
Year Published 1921 Publication Scale: / n= 13205oi1 Map UnitChad �
�SL
Drainage Class Soil Limitations
Surficial Geologic Report Available: No n Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year Flood boundary NO ❑ YES El
Within 500 year Flood boundary NO pri YES ❑
Within 100 year Flood boundary NO 2 YES ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS) : Month
Range: Above Normal n Normal
Other References Reviewed:
Below Normal
d
ea
'
pia
7, ,W maS
a,o
0 0
'
i
a 71S`a�,�J
FORM 12 — PERCOLATION TEST
OWNER ' S NAME:
LOCATION ADDRESS: LOT #
JOB NUMBER: 77-64+¢
COMMONWEALTH OF MASSACHUSETTS
/ /o2TN /1/11PYohh Massachusetts
Percolation Test
Date: 6117/9-7 Time: Ih A4
Observation Hole
#
1
- Z-
Depth of Perc .
S l I
S0 .I
Start Pre-soak
) 0 : e_.
End Pre-soak
O . i E
Time at 12"
10 ; 11-
)05(
Time at 9"
'pa L3
Time at 6"
)OS3O
Time (9"-6")
Rate Min/Inch
3
3
Site Passed
Site Failed n
Performed By:-C)ovc LIDS Mctc Lena?
Witnessed By: ;c4si roc Ufa'v\e
Comments:
OWNER ' S NAME:
LOCATION AOORESS:
JOB NUMBER:
FORM 11 - SOIL EVALUATOR FORM
Page 2
97-044
On -Site Review
LOT #
Deep Hole Number / Date: 4//7/9-) Time: 9).5DOM Weather: PTLV Gay a.°
Location (identify on site plan)
Land Use: F/i9Yr(OL'T) Slope (%) Z Surface Stones F_4)
Vegetation: GRA) CS[gr-
Landform:
Position on Landscape (sketch on the back)
Distances from
Open Water Body 2-0o-4 feet
Possible Wet Area 200-4 feet
Drinking Water We11 NcN feet
Drainage way 2- Cerfr
Property Line NAII
Other:
feet
feet
DEEP OBSERVATION HOLE LOG
Depth f on Surface
(in hes) .
Soil Horizon
Soil Texture
(USDA)
So'l Color
(N nsell)
Sail Mottling
0t9 "
9 "- Z/ "
2/"- 3-li4
3r - 96"
I3to
Ct
Co i pccr
CSM Jt
loyR4 j
IoYR 5%
I o'/R Shp
0 her
(St ucture. Stones. Boulders.
Consistency. % Gravel)
5 (ZIA3Ll�
taw Srot4C
rg + at_ 5-
ic2 S, c.
zs7 & ,c.
Per?
2M
FE u) .NTONLr
Trent Material (geologic) NASAL
Depth to Bedrock: rsfrefri 'H
cth to Groundwater: Standing Mater in the Hole: tics/LC Weeping from Pit Face: /JCLi
OWNER ' S NAME:
LOCATION ADDRESS:
JOB NUMBER:
FORM ii - SOIL EVALUATOR FORM
Page 2
97-c44
On -Site Review
Deep Hole Number 2- Date: G ill /91
Location (identify on site plan)
LOT # I
Time: ) I : I& ANWI Weather:CLDt SC
Land Use: // )Y'L sri Slope (%) 2 - Surface Stones 'FEW
Vegetation: 2,/2.45Ccx
Landform:
Position on Landscape (sketch on the back)
Distances from:
Open Water Body 2ao4 feet
Possible Wet Area Zao-t feet
Drinking Water Well )vo.v(e feet
Drainage way 2erc
Property Line I.d�
Other:
feet
feet
DEEP OBSERVATION HOLE LOG
Depth from Sur ace
(Inches)
Soi1 Hor]ion
SoiI Texture
(USDA)
So 1 Color
(Munselll
5o i1 Mot ling
ZI— 36"
ccs"- ` 2 "
c,
Cz
ISNUO`9
Lo AVN
SAUDI
LdnM
Gc A ftSOE
6AlJD
FINer
(3Anra
Other
(Structure. Stones. Boulders.
Consistency. i grovel)
arent Material (geologic) &AIs4L, 77C L.
Depth to Bedrock: 7Z A
!lath to Groundwater: standing Water in the Hole: A/O1126r Weeping from Pit Face: JLJO/✓dr
I)
OWNER ' S NAME:
LOCATION ADDRESS:
JOB NUMBER:
FORM Si — SOIL EVALUATOR FORM
LOT #
DATE: LIf1147
Determination for Seasonal High Water Table
Method Used:
I I Depth observed standing in observation hole inches .
❑ Depth weeping from side of observation hole inches .
Z. Depth to soil mottlesls 45 inches . 2= �%x,hckcr
❑ Ground water adjustment feet .
Index Well Number Reading Date _index well level
Adjustment factor Adjusted ground water level
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorbtion system? \y•- .y
If not. what is the depth of naturally occurring pervious material?
Certification
i
I certify that on /0 S (date) I have passed the examination approved by the
Department of Enviro mental Protection and that the above analysis was
performed by me cosistent with tfa._Qequired (raining. expertise and experience
described in 310 DMR 15.017 11
,
Signatu
Date
6777