246 Soil Suitability Assessment 1999 i�lalq�l
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ENVIRONMENTAL FIELD SERVICES, INC.
P. O. BOX 618
LEEDS, MA 01053
413-586-7200
Dale; Ia
$o: 5 ti ysltn ai P76 My(L-clad id. . Aiv/Lo-Mt.,vy,
Board of Health:
We have completed our inspection of this septic system
and have given the contractor permission to close and cover ie a stem upon
completion of 'any Items listed below, but only after receiving permission
from the Board of Health as well. •
We have taken our measurements and will prepare As-Built Drawings and
Certification Letters which will be forwarded to you, via the oontractor,
within a week or two, presuming all financial issues have been completed.
Please call our office if you have any questions or comments.
Llems whiehteguire further action
Thank You,
Micha'
Eng During anager
,C . •7 CBvCv
/17cc r;i6 .
TPA}
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FORM 11 - SOIL EVALUATOR FORM
Page 2of3 -
Location Address or Lot No. IXVG H6r1-1( IRM OI I1*' Yid
On//-site Review
Deep Hole Number 01 Date3-3O'qQ Time:MOrXLAI3 Weather
Location (identify on site plan) `SQ.) pJ ctn) J
Land Use Iat..a Slope (%)a-S' Surface Stones Pa-u
Vegetation ' '-ct_vre_r I 1) ;Landform /I
Position on landscape (sketch on the back) S O A S Lu t C{,
Distances from:
Open Water Body >700 feet Drainage way 770° feet
Possible Wet Area ?/(to feet Property Line ?/a feet
Drinking Water Well "7/00 feet Other
Parent Materiel(geologipl( x 141A)Q Vh
Dept toBedrock: /G 3 q lags
b
Depth to Groundwater: Standing Water in the Hole' /O2" 96" /
/ Weeping from Pit Face:Se/ � �j //
Estimated Seasonal High Ground Water: ,' Cf p C./ "
DEP APeaovEo FORM- 12/e7/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
DEEP OBSERVATION HOLE LOG'
Depth from
Surface nnchesl
Soil Horizon
Soil Texture
(USDA(
Soil Color
(Moosell)
Soil
Mauling
Other
(Structure, Stones,Boulders, Consistency, %
Gravel)
b' 10"
to°-ao"
01.6/1- 36,r
3lo` Ice'
T
f1
6
.Z
SL
5L
45
L
/oye3)a
/oyey/6
/OVe`//d
Z.
tionoe
wane
st.
/°yc4'"
dS—y"
-Fapsoi /
sub3oll
6- 10"
d„ 3�”
3 °- a1
P1
C
SL
S
L.
/O'1230
I0‘1 .Tu�
10Ivyu
mums
ti�
q,c,
vv'1
tocsin 1
sub�)i
Parent Materiel(geologipl( x 141A)Q Vh
Dept toBedrock: /G 3 q lags
b
Depth to Groundwater: Standing Water in the Hole' /O2" 96" /
/ Weeping from Pit Face:Se/ � �j //
Estimated Seasonal High Ground Water: ,' Cf p C./ "
DEP APeaovEo FORM- 12/e7/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
Date: s
Commonwealth of Massachusetts
A% — Leuw - , Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By: 01 C 1')Q,'./ is u;,uZ.
Date: `3 "30-99
Witnessed By. ...p -ff'r MC-Er/CU /L.)
/.)
a(IG Nay-demu) lle gal
aI
New construction ❑ Repair
Omer/„arAConti Ina K ALL)a
e,Lt,¢Q.berryy tcL1i
1thrhm, Lclemdef/ l'n
0/379
978-3 1/1/- lo398
Office Review
Published Soil Survey Available: No ❑
Publication Scale
Soil Limitations
Year Published
Drainage Class
Yes ❑
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published
Geologic Material (Map Unit)
Landfonn
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes ❑
Within 500 year flood boundary No Elves ❑
Within 100 year flood boundary No ❑Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Publication Scale
Soil Map Unit
Current Water Resource Conditions(USGS): Month
Range :Above Normal ❑Normal ❑Below Nonnal ❑
Other References Reviewed:
DEF APPROVED FORM• 12/09195
Environmental Field Services, inc.
P.O. Box 518 Leeds, MA 01053
(413/ 586-7200
Location Address or Lot No.c l Cc %Wpi
FORM 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS
,A/o 2-24kinit,7 T Massachusetts
Percolation Test*
Date:330 -6r 9
Time:,MOT/v)it1q
U
Observation Hnle k
p '
Depth of Perc
//
Start Pre-soak
/ / /78
End Pre-soak
I / 33
Time at 12"
I' 33
Time at 9"
) 1 ; 3 9
Time at 6"
I / ' i /
I a
Time )9"-6")
71
Rate Min./Inch
Minimum of 1 percolation test must be performed in both he primary area AND
reserve area.
Site Passed ® Site Failed ❑
Performed By: M I Chaff LQ U ) C/A )-e
Witnessed By: --QA -e r (� C Er l a1 10
Comments:
DEP APPROVED FORM-13101195
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
1413/ 586-7200
Location Address or Lot No.
f�
Determination for Seasonal High Water Table
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Method Used:
❑ Depth observed standing in observation hole.......... .... inches
❑ Depth weeping from side of observation hole inches
® Depth to soil mottlessY,W inches
❑ 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 observed throughout the area proposedcfor�the pervious
oil absorption�syste�m?�\Hl)areas
If not, what is the depth of naturally occurring pervious material?
Certification //
I certify that on J. - %7 (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature s� Date y 9
z
IIEP APPROVED FORM 11107/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 07053
(413) 586-7200
PrarAPPPr Aft \ '411* %. -: 11
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/volDoNV 1 L L E Rofr. D (srale NIG
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 OF 5
4) Type of existing system
privy cesspool(s) conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits.etc.)
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system AVM gpd
Approved? yes approval date
no why?
et-eh
M Design flow of proposed upgraded system ,3Vy gpc
c) Design flow of facility 330 gpd
COCK
6) Proposed upgrade of existing system is
a) 7 Voluntary
✓ Required by order, letter, etc. (attach copy)
Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date)
•
b) Describe the proposed upgrade to the system
ci- K )ew 3CQ 'x )a 'x Il„ seepage
-kr) e M-f K)3 j I
added
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
Percolation rate of 30-60 minutes per.inch (state actual pert rate)
P P APPROVED FORM- 12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF 5
Commonwealth of Massachusetts
IJOr-1-han p Ito , Massachusetts
Application for Local U ade Approv I
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To he submitted to Local A .rovin Authority/Board of Health: For the upgrade of a failed or
310 CMR system with a design How of < 10,000 gpd, where full compliance, as defined in
R 15.404(1), is not feasible.
To be submitted to DEP: For the upgrade of a failed or nonconforming system with a design flow
of 10.000 up to 15.000 gpd and/or for upgrade of a state or federal facility, where full
compliance. as defined in 310 CMR 15.404(1), is not feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the
addition of new design flow to a cesspool or privy or the addition of new design flow above the
existing approved capacity of a system constructed in accordance with either the 1978 Code or 310
CMR 15.000.
1) Facility/system owner
Name_ J C_i7 i l Yl2r' 2 a_
Address g C
Phone
Address of facility
2) Applicant (if different from above)
Name YYl-Q_
Address
Phone k
3) Type of facility
I/residential commercial school
institutional
(Specify)
DEP APPROVED FORM• 12107/9s
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 OF 5
8) Notice to Abutters
No application for upgrade approval in which the setback from property lines or a
private water supply well is reduced shall be complete until the applicant has
notified all abutters whose property or well is affected by certified mail at least ten
days before the Board of Health meeting at which the upgrade approval will be on
the agenda. Such notice shall include the date, time and place where the upgrade
approval will be discussed.
If the Department is the approving authority, then such notice to abutters must be
completed prior to the date of submission of the application to the Department.
The notices to abutters shall include a copy of the completed application form arid
shall reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
Abutter Name
Address
Date notified
Abutter Name
Address
Abutter Name
Address
Abutter Name
Address
Date notified
Date notified
Date notified
9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each
section must be completed):
a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
Space cavd CtOSt C ousiderctiioti
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
b e C PSSa"/ur
D@ MPPO VF,D FORM. 12l 07195
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF 5
Up to 25% reduction in subsurface disposal area desien requirements (state required
& proposed size)
Relocation of water supply weil (identify well, describe relocation)
i/ Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & pert rate) 3' se Para-)-j p&)
Other requirements of 310 CMR 15.000 that cannot (specify sections of the
Code)
System upgrades that cannot be performed in accordance with 310 CMR 15.404 &
15.405, or in full compliance with the requirements of 310 CMR 15.000, require a
variance pursuant to 310 CMR 15.410-15.417.
7) If the proposed upgrade involves a reduction in the required separation between the bottom
of the soil absorption system and the high groundwater elevation, an Approved Soil
Evaluator must determine the high ground water elevation pursuant to 310 CMR
15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
feet
As determined by:
Evaluator's name /)')i Chat / (Jr A..)-(9.
Evaluator's signature
Date of evaluation
DIP APPROVED FORM. I2/07/95
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FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
c) a shared system is not feasible:
Nof QUct)lo.b62_
a) connection to a sewer is not feasible:
&)o* Ciun lak)/e
10) An application for a disposal system construction permit, including all required attachments
(e.g. plans & specifications, site evaluation forms), must accompany t is application. Is the
DSCP application attached? yyesno
1) Certification
"[, the facility owner, certify under penalty of law hat this document and all
attachments. to the best of my knowledge and belief, are true, accurate, and
complete. I am aware that there may be significant consequences for submitting
false information, including, but not limited to, penalties or fine and/or
imprisonment for knowing violations. "
4 1„L /i ' — ID / `(7q
Facierwner's signature Date
. l oho meKeN,ua_
Print Name
CAA); r 3r mP.via_Q F t e p d Serfulcw 9-ay-99
Name of preparer Date
5kG 7�0C� Po l3ox ,S/k Leek m fl 0/0613
Telephone k & address of preparer
NOTE: Title 5, 310 CMR 15.403(4), requires the system owner or operator to submit to the
Department a copy of the local upgrade approval upon issuance by the Board of Health and prior
to commencement of construction.
OFF APPROVED FORM1I- I2/%/95
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
DOI 11)0rnPteni , Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility/system owner: Narne..7e2%q MoM PUAddress t-. • %�
Address of facility • ( y- _ �; dfu I = tricIU . ,(.Ve.Udei m/9
•
Type of facility residential institutional commercial school
design flow per 310 CMR 15.203 p//) glad
System designer: Name C. F, S. Address Pa Boy sik
rLPPk
l%berhone No
0/053
Local Upgrade Approval granted for:
I/
reduction in setback)s) (specify)
5 (o 7dco
pert rate of 30-60 mm /inch (specify rate)
reduction in SAS area of up to 25%
(specify % reduction & size of SAS)
reduction in separation between
SAS & high groundwater
(specify reduction & pert rate)
relocation of a well (explain)
3 /YI(gv Inch.
List local variances granted (no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval 'j''
Board of He th Approval of proposed upgrade L -ey- 3 C,f'L e-
P F Name & Title
Si re /Cit �v Dale
S5
City/town Daze
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
& BEFORE COMMENCEMENT OF CONSTRUCTION
DRY APPROVED FORM• I2/01/95