357 Septic Application 2014 Edmund Smith,Health Agent
Health Department
212 Main Street
Northampton, MA 01060
Richard Scott, P.E.
RM Scott&Associates
31 Shutesbury Road
Pelham, MA 01002
Office: 413-256-0647
Mobile: 413-658-4921
September 9, 2014
Subject: Title 5 Septic System Repair for 357 Coles Meadow Road
Property of Clarence Delisle
Dear Ed:
Enclosed is the original of the Application for Permit and a copy of the design materials for the
septic system repair that is proposed for the subject property. This is a repair to correct a system,
which failed a voluntary assessment under the provisions of 310 CMR 15.00 (Title 5).
The soil testing was completed on June 25, 2014 and witnessed by Ed Smith. All Title 5
requirements for the site testing have been met,and no Local Upgrade Approvals or variances
are required for this permit.
The wetland area on the adjacent property to the east of this construction has been previously
flagged. All construction activities associated with this repair are planned to be outside the 50-
feet buffer zone from the flagging. I will separately send a copy of the proposed repair to the
Conservation Commission so they can provide their signed review back to you. If you believe
that I should seek additional input from the Conservation Commission in this regard,please let
me know.
1 will plan to mail this application for permit to your office in Northampton. Please call me if
you have any questions. If there is an additional permit fee that has not been paid,please let me
know,or contact the property owner,Clarence Delisle, directly at 413-320-2256.
Thanks for your help,Ed, in moving this project along. Mr. Delisle will apparently proceed with
installation This fall, so I will hope to see you at an on-site, as-built inspection in October(?).
cc: Clarence Delisle, Property Owner
Conservation Commision
Prospective Buyer c/o Clarence
Sincerely,
Richard Scott, P.E.
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Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Number
Construction 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 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:
357 Coles Meadow Road
Address or Lot#
Northampton
City/Town
2. Owner Information
Clarence Delisle
Name
MA
State
01060
Zip Code
Address(If different from above)
City/Town
3. Installer Information
Dave Loven
Name
Reservoir Road
State Zip Code
413-320-2256
Telephone Number
Loven Excavating
Name of Company
Address
Westhampton
City/Town
4 Designer Information
Richard Scot, P.E.
Name
31 Shutesbury Road
Address
Pelham
City/Town
t5forta.doc•06/03
MA
State
413-695-7305
01027
Zip Code
Telephone Number
RM Scott&Associates
Name of Company
MA
State
413-256-0647
Telephone Number
01002
Zip Code
Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
Number
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other:Type of Building
❑ Showers
Specify other fixtures:
❑ Garbage Grinder(check if present)
Number of showers
❑ Cafeteria
Number of Persons Served
❑ Other fixtures
6. Design Flow: 330
Gallons per Day
Calculated Daily Flow: 330
Gallons
7 Plan: 08/27/2014
Date of Original
2
Number of Sheets Revision Date
Septic System Design at 327 Coles Meadow Road
Title of Plan
8. Description of Soil:
Underlying soil is Loamy Sand with percolation rate of 14 minutes per inch.
9. Nature of Repairs or Alterations Of applicable):
Connect to existing building sewer. Install new septic tank, pump chamber and soil absorption
system.
10. Date last inspected:
t5formla.doc•06/03
No known previous T-5 Inspection
Date
Application for Disposal System Construction Permit•Page 2 of 3
15forml a.tloc•06/03
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Fonn'IA
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 lace the system in operation until a Certificate of Compliance has been issued by this Board of
Health.
Signature
Application Approved By:
Date
Name Date
Application Disapproved for the following reasons:
Application for Disposal System Construction Permit•Page 3 of 3
Commonwealth of Massachusetts •
, City/Town of Northampton
Ti i
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
A. Facility Information
Clarence Delisle
Owner Name
357 Coles Meadow Road
Street Address Map/Lot#
Northampton MA 01060
City State Zip Code
B. Site Information
1. (Check one) ❑ New Construction ❑ Upgrade ® Repair
2. Soil Survey Available? ® Yes ❑ No If yes: Central Hampshire County/ 1981 711C
Source sail Map Unit
Charlton-Hollis somewhat excessively drained
Soil Name Soil Limitations
3. Surficial Geological Report Available? ❑ Yes ® No If yes: Year Published/Source Publication Scale Map Unit
Geologic/Parent Material Landfonn
4. Flood Rate Insurance Map
Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ® No
Within the 500-year flood boundary? ❑ Yes ® No Within a velocity zone? ❑ Yes ® No
5. Wetland Area: Wetlands Conservancy Program Map Map Unit Name
6. Current Water Resource Conditions(USGS): May 2014 Range: ❑ Above Normal ® Normal ❑ Below Normal
Month/Year
7. Other references reviewed:
Deep Hale form•rev. 3/13 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8
Commonwealth of Massachusetts
.-c, City/Town of Northampton
e„��— Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
D. Determination of High Groundwater Elevation
1. Method Used:
❑ Depth observed standing water in observation hole A.
inches inches
❑ Depth weeping from side of observation hole A. 78 --- B. 72
inches inches
Z Depth to soil redoximorphic features (mottles) A. 39 in 39
inches inches
❑ Groundwater adjustment(USGS methodology) A.
B.
inches inches
2.
Index Well Number Reading Date Index Well Level
Adjustment Factor Adjusted Groundwater Level
E. Depth of Pervious Material
1. Depth of Naturally Occurring Pervious Material
a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
Z Yes ❑ No
b. If yes, at what depth was It observed? Upper boundary: 8�he5----------- Lower boundary: 96nes
Deep Hole form•rev.3/13 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8
S~� Commonwealth of Massachusetts •
$4-41 ,89 City/Town of Northampton
1 if�tN Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
k
F. Certification
I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil
evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017. I further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form,
are accurate and in accordance with 310 CMR 15.100 through 15.107.
Signature of Soil Evaluator Date
Richard Scott, SE 2180 6/16/1995
Typed or Printed Name of Soil Evaluator/License# Date of Sail Evaluator Exam - -
Edmund Smith Northampton Health Department
Name of Board of Health Witness Board of Health
Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and
to the designer and the property owner with Perc !a 12.
Deep Hole form•rev. 3/13 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8
Commonwealth of Massachusetts .
9w--40- -,Q, City/Town of
:W Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
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t5form11 Soil Assessment•rev.3113 Form 11 -Sail Suitability Assessment for On-Site Sewage Disposal •Page 8 of 8
Important:When
filling out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the retum
key
Commonwealth of Massachusetts
City/Town of Northampton
Percolation Test
Form 12
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. 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
A. Site Information
Clarence Delisle
Owner Name
357 Coles Meadow Road
Street Address or Lot#
Northampton MA
City/Town State
413-320-2256
01060
Zip Code
Contact Person(if different from Owner)
Telephone Number
B Test Results
Observation Hole#
Depth of Perc
Start Pre-Soak
End Pre-Soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate(Min./Inch)
Richard Scott, SE2180
Test Performed By:
Edmund Smith, Health Inspector
Witnessed By:
Comments:
6-25-14 8:30 A.M.
Date Time
P1
Date Time
36" bottom
6:46
9:01
9:01
9:24
10:06
42 minutes
14 min per in
Test Passed:
Test Failed:
Test Passed:
❑ Test Failed:
t5form 12.doc•06/03
Pero Test•Page 1 of 1
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Commonwealth of Massachusetts
City/Town of New Salem
Disposal System Construction Permit
Form 2A
Number
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.
Permission is hereby granted to:
Important:When Dave Loven
flung out forms Name
on the computer,
use only the tab Reservoir Road
key to move your Address
cursor-do not Westhampton
use the return
City/Town
key
Loven Excavating
Name of Company
MA
State
to perform the following work on an on-site sewage disposal system:
❑ Construction
® Repair or replacement
❑ Repair or replacement of system components
357 Coles Meadow Road
Facility Address
Northampton MA
City/Town State
Clarence Delisle
Owner
01027
Zip Code
01060
413-320-2256
Zip Code
Telephone Number
The work to be performed is further described in the Application for Disposal System Construction
Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions
or special conditions:
All construction must be completed within three years of the date below.
Approved by Date
Title
t5form2a doc•06/03 Disposal System Construction Permit•Page 1 of 1