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Lot 88 Title 5 Application/Permits, Reports 1998, Local Upgrade Application 1998 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 1 OF 5 Commonwealth of Massachusetts /b,, .jm, ohl , Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP Approved form required by 310 CMR 15.403(1) To be submitted to Local Aoprovine Authority/Board of Health: For the upgrade of a failed or nonconforming system with a design Clow of < 10,000 gpd, where full compliance, as defined in 310 CMR 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 ROLR/vO ¥JE/fAl Tft in/ODEA ) Address / MAPLB Rn06E Recto Phone r (4/3) 586 — OS6zc Address of7Tacility GAm 2) Applicant Of different from above) Name Address Phone 0 SAnsi✓ RS F4G016 3) Type of facility ✓ residential commercial _ school institutional (Specify) 5 8EDROOI ■ /-}ouse No FARBACC D1apo34 L Dfl • PROVFD r00.M 11 r 11 , ....... .r. - 11. . ....,..I •• •• WAN L'.•' KV%✓v nv% Al.. PAGE 2OF5 4) Type of existing »stem privy _cesspool(s)=conventional system Other (describe) Type of soil absorption system (trenches chambers, pits,etc.) 37REMGt1ES o7 (50'c X 3'W x AS'NJ EA N 5) Design flow based on 310 CMR 15.203 a) Design flow of existing system55O gpd Approved? ✓ yes approval date 9-2z-g2 no why? b) Design flow of proposed upgraded system55 °gpd c) Design flow of facilityS56 gpd 6) Proposed upgrade of existing system is a) _ 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 REitACE FAIt,Nj 3 Tit EivC S'S7E41 A '71-1 NC-w Tjfic77(e/c/Z Sw SySTFN) c) Wbicb of the following are applicable to the proposed upgrade? N/A Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per inch (state actual perc rate) 00 4nROVID FORM•I3 0'95 nf4 FORA 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 3 OF 5 Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) / Reduction of required separation between bottom of SAS & high groundwatel (specify proposed reduction & perc rate) SOPERPT)OtJ - 3 M =4 1} Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the `ii7 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 CAR 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 bosom 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 autboriry: D.sance from sod a7sc:,ticr. sysem t: high groundwater 3 feet As determined by: T // /Evaluator's name +`l'f� `�-� Ar _,Evaluator's signature Dateofevaluation NOV6ft'lBE /2� DE7 APPROVED PORN• 12 I'is FOR.V 9A • APPLICATION POK LULAL ter"^^" PAGE 4 OF 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 mating 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 and shall reference the standards set forth in 310 CMR 15402 through 15.405. List of affected Abutters: N/A Date notified Abutter Name Address Date notified Abutter Name Address Date notified Abutter Name Address Date notified Abutter Name Address 9) Explain why full compliance, as derma in 310 CMR 15.404(1), is mot feasible (each section must be convicted):: a) . an upgraded system in full compliance with 310 CMR 15.000 is not feasible: A 4' 56PeRaTiCaj Not/LA REQuift R RA/5E0 BO) � ) Sy/ M�T /s A/OT ENOUGH RaQV) KT PRaf c S+ b) a� daT rs sQ rro'teg Rstunt to 310 CMR 15 283-15 288 is not feasible A3LTERN4T S 6/5T64/1 IS .A1oT fiRcP 10 . TNER& CuILL i3E &StAL. 6R0'w,DCV. o) a1771 !NFtt_7R" SysrE , DO onao.fD ro0.M•is r fl FORM 9A • APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE S OF S c) a shared system is not feasible. 1.16■641306_ s PA -roe 1R RAc Nor %iAou6H Roofv") d) connection to a sewer is not feasible. No SFLaEYZ l VAILaBLE 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, sits evaluation forms), must accompany this application. Is the DSCP application attached? ✓yes no II) Cenification 1, the facility owner, certify under penalty of law that 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 amd/or imprisonment for knowing violations.• F ty owner's signature I- /Atheo%ao& .er,4 %/ / 7�7 Date Print Name t hm. L, t&n&►n1 N1S Name of preparer Date 76 mewocub RD - 'YIA 0413) 527 -539/ Telephone N & 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. DD APPROVED RD PM • IIrEr FkON : DEN9I5 R LPCJURSE No. PHONE N0. : 413+296+4368 Ycv. 13 1998 06:S8DM P1 FORM 11 - SOIL EVALUATOR FORM Page i of? Date: //is/ Commonwealth of Massachusetts A=cmT.u,..tph.a, Massachusetts Soil Suitabiln Assessment for On-site Sewage DisposJ Pa c..red By: ___Dc rue') _.1 _-, 4.ileres Wir=esscd By: ._.�FSe' Nee-:•/ c s:ru:'_':n _ Repair Date: //AA•�.� a-.. T5, RPM* t> tel;inn., see...— g& r„v ptc R 1 >7e 'i^e ma C?X '7 MP To rya aI a 4t 4)3 .5-q4 -OSS2D C9+c 5-26 '37.1D Oflce Review Poo:ishee Soil Scr:e: .a:aiiab It: Nc _ Yu ' Yea: P-3lis:ed Si__ P':.wiica cn Sc:: /47s-17vn so:: Var. U is t 7 AIDA Drainazc Class L✓et, 7x4-bectASoil Limitations - FrarisiT 1e!?-if.— Jut-9.6.!a:elice.. -----. r Se^olio! C-eekgic Ree r:A.ttab!r No ''es -_ Ye_ P, idled .._,.. ❑ColoE;C Material (M r U ±) riot.-._. QLffLQt..I1 F:ocd inscn.-.c: az:: A YCye SOC year :loud Coundr;. NC year recd .c'u.-.f:my No Winir. ICC yezr Rood ccundr/ No Weei td Are= 2+atior..a! We:i rd L-.ventcy Map (map x:i:) Wetlrds Conser+zrry Pniummt Map (map unit) P.L'Glica:icr. S�le V:s gY:s ®YCS C 7 Cnre-: Water Resocre Conditions CUSGS)' }tor.[.`. Reese '.*hove No=a1 ❑\erns: Belew Nonni 'J - a=er Re erences Rsviewe_ ov • aecc.—. Poe•l•neee:n FROM : DEN4IS R LRCDURSE PHONE NO 413+296+43E8 4°v. 13 1998 07.00°M P4 FORM It - SOIL EVALUATOR FORM Page 2.of 3 Loczticn udas Dr Lo;na. S b 4**b41r7/Lr 2/›,t` On-site Review Deep Hoit Numcer 1. _ Date:U 44A I% .oeaticn Ceentify on site ;Lan) ....^•„__ .. Land Use F 4.zbt -41., Slope (!5I . Surface Stones Q .?a. . Vegetation h�xw.�•+.... . _ ._ _.. Landforrn .0 visa?eh. E44''-' -.._,_ Position or landscape Inez:" on the back/ Diszarces !tom: Open Water Badv a.eel' feet Drainage way £o lett Possiole Wet Arx_ BCV feet Property Lire got `feet Odnkng Water 'f:-1 aCky feet Othr Time: Ct:be."' Weather CLea DEEP OBSERVATION HOLE LOG• Cent, P:a, Series(Inr•.asi Sell M r -. Sail Ter._ra (USDA1 50'- Co• r (Munsenl 5ei Met Caw (Su jets, £; ras.ecu:dere.C:rs rcy. % Gnueil o n 18'r 8 Tv $d` St 1 Vg' Y1 r by /ON `V• ay" �1'• is tAO'x A �w C, r r Cy S/ L SQL Lj Fi✓z Spy Lona; Seat, P.1-1- F!s Ga*'eL tor 3/ oie �,Sy� 'Z a- S r% / a i;,5'‘, �A �,[ (art. /j NO No la% AT g� 10•)aa lark 3, 1 D1.Tiile • stye y>e ~ Leese i SOP, Ga9A P( re...yo s e,oeac, rre .�lt/ 1.'+?. r 0.C (gse`nsdr.vx : 3 4i Am.?L7eL I P40.c/.3le+y)b 6er-^s✓/ amb e•i.e.5106 f-r,nefJ NE .rs9N») %4190/, p.naF'S.(.Y-, ens"?a Siva en.*e yi✓= J4•.ty ,...era,. inscni ors ..NA aril. bngJCt/ C09.4-/ ! Pgren: Mattein(clank; 06724,k4 yip C.e•-, iY_cne'ag1/! Stint-i Witte in Ohs cc: I44e Si••r.+:_E Seas-nal F:C brag Water: a o..eeeeereec Pa, Wetting intir.Pt?act: 44 U JO✓em VC FORM.1'10195 FRO^1 : DENVIS R LRC3URSE PHONE NO. 4134296+43E8 I-scatier. Add:ess cc Lc: rto. g /)24tIOE >. 5 Vov. 13 1939 06:59°M P2 FOIt's2 I I - SOIL EVALUATOR FORM Page 2.of 3 On-sire Reti iew cue Mete Number .a-.-. 0 ate:<(/071 Location (itantty an site plan) ,._..- Lend Use arf-r-pw-'3!Air. .. Slope EIS: .1 VC!ta:lcn _ _. Pcsmcn en lands.-ape (skater cr the back: C:stanc,s fr:nt: Open N.'a:ar Scdy i.oG fast Possible Wet Area ,.00. feet CrinkL-.; Water Wet! GYy fast Time: /D.'me.Y+ Weatner C.L6-112 Surface Stones C Sp-. Drainage way Prat err Lne OCP! 74- fee: it fast DEER OBSERVATION HOLE LOG' ]cat,>a- Sul ncr:v_e Sari Taa_re acu CYC: aei::ec-4e CISCA: trIVKein Spl MerMirs Cxu (-_.-.. L S.crn.acckra, Ca'. Gana r.. >. a r (=t l I e rj 0 Te 19 Arr-�� taro // fey' X ),C ro SS C: 'A /or 4 sk To 72 7A'ro t4 it, rm i2o CA 7.4 YC/ % 6Kaoe( TSye Dl eTr✓a- r 174 fby4 /OOrc Ga Roorr rn9 e1nvc,floc roil 1.040SZ So wild Csn- fl/ rcv4,9/a- ye Ay s>eire COr t e` 59AJ.7 - BN✓Ylb'-..at- ,f0 c.44)e- ;t r / F>,:-PE SRU� C CA. Ge.rveL j:re /7J Par.-; Maseral**lie: O Ul-10- +4 A G r Stlrcr;wa:eri-.r..-d.-. S.a•41 1471 Cra:re wear: y'O ,arYtko C .# -fl 5#" e- yE L —Oe.I✓f Lilt Se HC> e 0107Weeccci: !3D- Wanieg ?.ai.. 1.>auE firAPMCY=FO0.,I.iL t.tJ F4OM : DENNIS R LRCJURSE PINE NO. : 413+296+4369 4ov. 13 1998 07:01°M P6 FORM 1i - SOUL EVALUATOR F°R;K Page 3 or 3 Locarior. Address or Lot No 2 roftpfrizz /2t Determination for Seasonal High Water Table Method Used: ❑ Depth cbseraad standing in observation hole .._.. inches Dept. weepir.,c from side of observation hole .._ . :nehas Depth to soil m ottlesta.• 40 inches Ground water adjustment _-__._._ fee: .ncex `/teed Nu.-h=_: ..... R_a_.rc Cate . _. .nce.x ..e'.! level . _. . Ac .r< ':eni factor .. . Ac lusted wale' level.. ;;a7.."7. ..`. Nat. a!iv Qc . r:1C ryi:JS Meterll Doe a: le_ - fist of naturally co-_ rc ; rvic: —___r.=_i exist in all areas „e??r/ed : :ti. the are proposed for ..._ _cif absorction system? • If not vine-. is _.,e Cep:'. of naturally C___...Pc p_. .iz�s -.a teriai? Cerbifoation I certify te: on (date; I have ..a,ee_ the soli evaluator exaniratcr apprcved.bv the Ue err:lent of Environmental ?r_.e_-..en and that the acme analysis was eerorred by me consistent with the re;tired;raining, expertise and experiefc described in 310 CMS 1 - 1 7. r Signet Or?09911-)rib:.'7.:7:99 Data N-/.z•11 PRal . DENNIS R LRCOURSE • PHONE N3. : 413+296+4368 Nov. 13 1994 06:59PM P3 FORM 12 •PERCOLATION TEST Location Address or Lot No. g6 mm Dfc COMMONWEALTH OF MASSACHUSETTS fugopfioa , Massachusetts Percolation Test" Elate: ii--io'9E lime- q. et A Observation Hole Cep&.. of Parc ` S ,, Start Pre-soak 9 ; 5-i End Pre-soak ) 0 : 14 rime at 12" 1t '/c7 'rime at 5" JO; 10 Time at 6" j ZCe) Time (9"-"0") 8 Rate Min./inch J Minimum of 1 'percolation. test must be peRCrred In both the pri ay area AND reserve area Site Passed Z Site Failed 0 Per rrnree By: i%ENN;s Qc h4c0✓45C • ■ nessed By: Pain n2c EeLr,j . Comments; Rat°.nn7r.vD ere1Pf Yo Vfl" an L0177. _ 41.4//LASE,/ oEr ArfOYf-1 iVR"1•y;nrnf 13ona•-p Q} hot 51LTi is.PA 072°42'0.08" 0 os trs 072°.41'30.08". 072°41'0.08" 072°40'30 08". 072°40'0.08" 072°.39'30.08" 072°39'0.08" Ghat Pil;. I i n ma. I'elaa r '(-1341/cer Hill • 1 gdS0 y ng Sta i—Paa m R1VE6' os to dpll • Greml. Rocky Hail ' an e IN 0 to- OAP. Pine Stove in Pynchon - m yptlwOAKY 41 I 0r•• p1 A ,6 o Arai a '5axt.e 11 072°42'0.06' 072°41'30.08" 072°41"006" or 40'30.08" 072°40'0.08" 072°39'30.08" 072°390 08" FLORENCE,MA.-0 Markers.Length=0 feet Northampton,MA-1 Markers.Length=0 feet Name: EASTHAMPTON Date: 11/13/98 Scale: 1 inch equals 2000 feet Location: 042° 18' 14.7" N 072°40'24.8" W Caption: ROLAND JEAN THIBODEAU 88 MAPLE RIDGE RD. NORTHAMPTON, MA R=1""11–= niconc AI cvcroa Copyright(C)1997.Maptech.Inc rr Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high sauc water level observed in the distribution box is due to broken or obstructed pots) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: _ broken pipets) are replaced _ obstruction is removed distribution box is level le9 or replaced The system required pumping more n four times a year due to broken or obstructed pipets). The system will pass inspection if with approval of the oard of Health): broken pipet are replaced obstructio is removed C] FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface . er Cespcoi or privy is within 50 feet of a horde- .g vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF H LTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A .MAN. THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 3) OTHER The system has a septic tank d soil absorption tributary to a surface water .uopiy. The system has a septic r.nk and soil absorption The system has a septa tank and soil absorption The system has a sep-c tank and soil absorption system (S451 and the SAS is within 100 feet to a surface water supply or system and the SAS 5 within a Zone I of a public water supply well. system and the SAS is within 50 feet of a private water supply well. system and the SAS is less than 100 feet but 50 feet or more from a private water suppl, well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates tha the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to cr less than 5 ppm. Method used to determine distance (approximation not valid). (revised 04/05/971 Page 2 of 10 WILLIAM F WELD Governor ARGEO PAUL CELLUCCI U.Govamor N @ COMMONWEALTH OF MASSACHUSETTS NOV'e5 gc EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION' ONE WINTER STREET. BOSTON, MA 02108 617.292.5300 TRUDY COAT Sccrczn DAVID B.STRUFE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioor PART A ,,t� ^ I CERTIFICATION ,{7 q Property Address: fl friop'e 283e Y• • Address of Owner: ?fr�apre" 2tciye lest Date of Inspection: 10" b`7-9c..--- (If different) Name of Inspector: I am a DEP approved system inspector pursuant to Section 13.340 of Title 3 (310 CMR 15.000) Company Name: DENN� WISE Mailing Address: Telephone Number: C.O. x ESIERFIELD.MA OWS4 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on.site sewage disposal systems. The system: Passes _ Conditionally Passes N 's Further Ev. at :y the Local Approving Authority Inspector's Signature: Date:/O.27•S0 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty 301 days of completing this inspection. li the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and comes sent to the buyer. if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: _ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15303. Any failure criteria not evaluated are indicated below. COMMENTS: 81 SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass Indicate yes, no. or not determined (Y, N, or ND). Describe basis of determination in all instances. If That determined', explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Irevieed 04/25/97) Page 1 of 10 PEP on the World Wide Web hit/Newsy magnetstate.ma uYdeg 0 Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 87 m-ep)C Rrvfe Owner: Cr, R. tH II.677E4m Date of Inspection: ]G .a a, q$ Check if the following have been done: You must indicate either 'Yes" or 'No"as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal Flow rates 5 S O during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. ]4 _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was Inspected for signs of breakout. X _ All system components, excluding the Sod Absorption System, have been located on the she. _ The septic tank rnanhoies were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner and occupants. if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined In the field (if any of the failure criteria related to Par. C is at issue, approximation of distance is unacceptable} [15.302(3)(b)] (ravine! 04/25/971 Pan 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: gg maple IZ tope Owner: Rel.. 0.n, nit 3oveeRtl Date of Inspection: ID 27." DJ SYSTEM FAILS: You must indicate e,: .er 'Yes" or"No" as to each of the following. y E 7 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No — X- Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or pcnding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. — X_ Liquid depth in cesspool is less than 6' below invert or available volume is less than 1/2 day flow. - X Required pumping more than 4 times in the last year NOT due to clogged or obstruced pipe(s). Number of times pumped — - Y_ Any portion of the Sod Absorption System, cesspool or privy is below the high groundwater elevation. — Any portion of a cesspool or privy is within 100 feet of a surface water suppiy or tributary :o a surface water supply. — X Any portion of a cesspool or privy is within a Zone I of a public well- Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform baeera, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must Indicate either "Yes' or"No' as to each of the ioilowin The following criteria apply to large systems in additi to the criteria above: The system serves a facility with a design flow of . 000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment •- .use one or more of the following conditions exist: Yes No the system is within 400 feet a a surface drinking water supply the system is within 200 eet of a tributary to a surface drinking water supply the system is locate• in a nitrogen sensitive area (Interim Wellhead Protection Area•IWPA) or a mapped Zone II of a public water supp well) f The owner or operator of any suc system shall bring the system and facilitfinto full compliance with the groundwater treatment program requirements of 314 CMR 5.00 a d 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) P.q. 3 of 30 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4S9 ✓n4yIE g 1 tE Owner: -T, R. *H 14 OP EAO Date of Inspection:lb _a7- 92 SOIL ABSORPTION SYSTEM (SA5):, (locale on site plan, If possible; excavation nor required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ r leaching trenches. numbeglength: 3 — Se/150 leaching fields, number, dimensions: overflow cesspool, number_ Alternative system: Name of Technology: Comments. (note condition of soil, signs of hydraulic failure, level of ponding, condition oi vegetation, etc.) vuf Hole %U restetet Yccw<y 'jv% LY CESSPOOLS: (locate on site pian) Humber and configuration: Depth-top of liquid to Inlet Invert: Depth of solids laver: Depth of scum laver: Dimensions of cesspool. Materials of construcion: Indication of groundwater inflow Icessoog/must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Depth of solids: n_ Comments: (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Dimensions: a.vi..d 04/25/97) P.q. S of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: gs' m4plt R(Dge Owner: -1-E4Mr )ZaI4r ?7 t.4ia0pE4u Date of Inspection: 78 ,19.46 FLOW CONDITIONS RESIDENTIAL: Design flow. S'l& e.p.d.,bedroom for SAS. Number of bedrooms. S _ Number of current residents:y_ Garbage grinder (yes or nobaa, Laundry connected to system (yes or no): Seasonal use (yes or nola water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):PD Last date of occupancy: it/0 I •5, It, COMMERCIAL'IN DUSTRIAL: Type of estaoiishment: Design flow: eallons/day Grease trap present: (yes or no)_ Industrial bt'aste Holding Tank press t: (yes or no) Non-sanitary waste discharged to e Title 5 system: (yes or no)_ Water meter readings, if availa• e: Last date or occupancy: OTHER: IDescnbel GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no), S If yes, volume pumped: LSOb gallons Reason for pumping: ro Srnye)r2 TYPE OF SYSTEM Septic tank/distribution box/soil absorption system _ Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) _ I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Lye.n _ Sewage odors detected when arriving at the site: (yes or no)A (rrvaut 04/35/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25/ 4.440E Owner: S. + R. Y-N'jyo in q4/ Date of Inspection: /o • d->'9 BUILDING SEWER: I Locate on site pianl Depth below erade:3D� material of construction: _ cast iron XL-40 PVC_other(explain) Distance fromrpnvate water supply well or suction line 9 Diameter 14 Comments: (condition of joints, venting, evidence of leakage. etc) Pin Cu Fyec/9A% SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: V% rn. j?fE R i>fG Owner: .). 'R• n-n aVE BD Date of Inspection:1B ]i•%% TIGHT OR HOLDING TANK:_ Rank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _F'•-rglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design tlaw: gallons/d Alarm level: Alarm I. working order _Yes; _ No Dare of previous pumping: Comments. Iconditmn of islet ree, c• dhian of alarm and float switches. e DISTRIBUTION BOX:�L (locate on site plan) �R I Depth of liquid level above outlet invert: J Comments: • (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) E b t P EPrtt Di= Sewn tRRQy ODa2. &4cJrup /N l31)r rive 7'a cuycer> S.A. S. PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or Nol Alarms in working order (Yes or No)_ Comments: (note condition of pump chamber. condi - n of pumps and appurtenances etc.) Irrvau6 04/35/97, Page 7 of ao SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r-� SYSTEM INFORMATION (continued) sC Property Address: p yvl4p)E Q-(VIE Owner: -.D7. F. t8itliab 4L Date of Inspection: ID • 27 t2 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: • Obtained from Design Plans on record Observation of Site(Abutting property, observation. hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEW Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) sa€ Cults D.P-tE , 7 • 4 a ALSO `re) FL4ro (cofa j .ttroc17 27%, (revised e4/25/91) a.ye 10 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8c6 9M.epie tiz I? Owner: J. 9 R. •H i I)A P E9l] Date of Inspection: le• 27••7c SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes imo house) SEE Arbi c, 1FL,A AJ (nrvaud 04/25/97) Page 9 Of 10 N CONSULTANTS , INC. • Land Surveying • Civil Engineering • Septic Systems • Land Development 41 Main Street • P.O. Box 60189• Florence MA • 01060-0189 TEL. (413) 586-7794 FAX (413) 586-8238 July 6 , 1992 Jean Thibodeau 44 Canterbury Lane Longmeadow, MA 01106 Dear Jean : On June 25 , 1992 , NKA Consultants performed an informal perc test and deep hole observation on Lot 30 , Maple Ridge Road . From our initial site investigation , the original perc test location on Lot 30 , Test 428 , is now located within the 75 ' buffer from the drainage swale ( see sketch ) . The new test area was sited outside the 75 ' zone and in an area that would serve the intent of the Northampton Board of Health Regulations and also the proposed location of the dwelling . The deep observation holes indicates the area contains the same soil profile as the original location #28 . The water table was found at an elevation 84" below existing ground versus 70" in the original test . The designer of the system should hold 70" for the ground water . The perc rate for the new area was 2 1/2min/in . Thus the proposed area is similar in characteristics and the soil is adequate for a subsurface disposal system. After discussing the finding with the Board of Health agent , he had agreed the area would be acceptable . At this time , we do not plan to submit a sketch to the Board of Health for their files unless you request it . St- The following is the original perc test data and the new pert information : Perc #28 4-8-86 (by others ) 0-18 topsoil water at 70" 18-36 silty sand pert at 42" 36-54 fine sand perc rate = 2min/in 54-86 fine/coarse sand Deep Hole 30-A 6-25-97 0- 8 topsoil 8- 36 sandy subsoil 36- 72 sand/with some silt 72-120 coarse sand/some fines Deep Hole 30-H 6-25-92 0- 8 topsoil 8- 36 sandy subsoil 36- 78 sand/with some silt 78-120 coarse sand/some Fines Perc Hole 30-C 15min presoak 12"-9" ; 6 : 15 9"-8" ; 2 :30 8"-7" ; 2 : 30 7"-6" ; 2 : 30 2 . 5min/in 6-25-92 water at 84" water at 84" Perr a CHECK OR FILL IN WHERE APPLICABLE THE COMMONWEALTH OF MASSACHUSETT BOARD OF HEALTH City of Northampton _. )}T.piiratinn fur Einpra a1 rc Application is hereby made for a Permit to Construct (x ) or Repair System at: Lot I9. Maple Ridge Raad. Jean & Ro1antTiiitodeau Owner ImuOer an Individual Sewage Disposal or Lot No. Ca„torhtlr.y T. t.nngmeadnw, MA 011 0( Address Address Type of Building Size Lot 3.5.642.__..Sq. feet Dwelling—No. of Bedrooms 5 Expansion Attic ( ) Garbage Grinder (%) Other—Type of Building No. of persons 1f1 Showers ( ) — Cafeteria ( ) Other fixtures Design Flow 55 gallons per person per day. Total daily flow SSA gallons. Septic Tank—Liquid capacity..15IItgallons Length..._.1-0 ' Width 5 wa..7.'Diameter Depth 41 Disposal Trench—No. 3 Width..._3 ' Total Length 15.0 ' Total leaching area 5.f.2-_sq. ft. Seepage Pit No Diameter Depth below inlet Total leaching area_.._ sq. ft. Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed by NSA GADS Ultpnts, In . Date 7/6192 Test Pit No. 1...2..5....minutes per inch Depth of Test Pit.. 6.0" Depth to ground water SA" Test Pit No. 2 .minutes per inch Depth of Test Pit Depth to ground water4.a4 net-.to 70' 16.7-72" __.. Description of Soil 0-8" Topsoil 8"-36" Fine Sand Sandy7some silt 72"-120" Coarse sand/some fines 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 TITLE 5 of the State Environmental 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 - - .. . . . ... . D.e one wee Application Approved By Application Disapproved for the following reasons: Permit No. Issued THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Certificate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by wel.e, - - - at has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 0E/ / ® O lo IA 9 G 6 /e s�° 'G ' w _ ,------- 5■90_ ,so - - / ve% \ 05 f _ e .. / Z eEa" � � \ ` 257 xa a / 'e 1 -1 GN {5 ' EIFF� / AN OO C . .,P 46 0] 6 ap B T In i - a ,c4. _ _ - _ _� IKE N TREE ;� Q 287.55 a 8 v - $ V - LOT 30 N _ a 282 ; \T. \Na , r PERCOLATION TEST(S) Time: I Time: Observation Hole #1 Observation Hole #2 Depth of Perc "� Depth of Perc Start Pre-soak Start Pre-soak End Pre-soak I Il 111 End Pre-soak Time at 12' 10 / d Time at 12' Time at 9" �V i f� 'r �j Time at 9" Time at 6' , '; Time at 6' Iu � Time(9"-6") Time(9"-6") i ' �,5 t✓ Rate Min/Inch 1, Rate Min/lnch ._, 'minimum of 1 percolation lest must be performed in both the primary area AND reserve area. • • ■ Performed by Performed by Witnessed by I Witnessed by Comments: On-Si LocationAddress or Lot# OG a f r Li Owner - , [,per Address * Date �� _ '� Weather —I Engineering Firm Engineer or Sanitarian ——— — - Identity on Site Plan Land Use Slope h Surface Stones I — ---- Vegetation Landform Position on Landscape Open Dlstahces from Water Body Possible feet feet :,Drinldng Water.Well Drainage Way feet feet Property De r'''' Other feet feet Wet Area Deep Hole if: I DEEP OBSERVATION HOLE LOG' MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Depth from Surface(Inches) Soil Horizon Soil Texture (USDA) < LS � / Le S r y1-7)_ Soil Color (Munselp l o t ciwv. 7 » LJC/ 5y GIB , sy/r 107/'yi�' Soil Mottling fa " ,0 4 Sig to-7- I, � ,��vol 'r I/17 Other (Structure,Stones,Boulders,Consistency,%Gravel) p+s-z—ti( cc"—tAA F : . '-4 - /. .. Ii. -„_ (� _ I L F u g ' a _ �i rz c v C q .,i Parent Material(geologic) I crtic2t W jyui---(^ Depth to Depth to Bedrock ) / 0 groundwater. Standing Water in the Hole Weeping from Pd Face %4 y Estimated Seasonal High Ground Water ii (4 - ' DEEP OBSERVATION HOLE LOG* Deep Hole#: 3 I *MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Depth from Surface(Inches) Soil Horizon Soil Texture (USDA) fi?ed >o ,F�1�1 Soil Color. Soil Mottling Other (Structure,Stones,Boulders,Consistency,%Gravel) f,a o � ;/ ' / -1; L I �. 3 (Munsell) ,t6i t'r � . , II�� /a ti� � �1s _1 mar i nt fa r�i oli. '- J ':,p4pth tO fi90 's. v. .� l i % 1 b TO tlwpt,Staf ih e 1. i4i f 4Cea2Fna 3rinMAr n� pl'�a PIP? A N 30 `- COMMONWEALTH OF MASSACHUSETTS Board of Healthy Alk_11 TION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT linstruct( ) Repair(Ve Upgrade( ) Abandon( ) - O Complete System dividual Components Type of Building S,N&L& Fav tir hidA4Lr Dwelling-No.of Bedrooms "1 No.of persons Other-Type of Building Other Fixtures 656 Design Flow(min.required) 6 5 6 gpd Calculated d e r flow 551C Plain Date /l' l6 -t Li Number of sheets Title LA/J aF eye,56.0 5vB5uRfAt& 10 3 , • DSa Soil Dilly)n-8. Soil Evaluator Form No. 5 mr rr 2 5614/ft t. -3a Name of Soil EvaluatorD DESCRIPTION OF REPAIRS OR ALTERATIONS Sy3T$W1 t MN NEW /A) • • tLIRA1O& em Lot Size (pt% 5' sq.f. fO Showers Kr +E ) Design flow provided SS4,4-d gpd Revision Date R ItSta R Date of Es aluation .3 -TRE.t • � /2 0 CUL ',a JNC The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections mx1 Location 36 A1AfLE RID6G RD Owner's Name ROLIOD Cerfri -ritie/oD&mO I �piParcel# Address MAPLE Rf0&E Reap .. Lot# as-4 Telephone# et13) Sic ogza Installer's Name cheer � Designer's Name en fr 11146-i Ail)U /3 I Address FFFF���, Address 9 M fp606 Ra - � }} T3N Telephone# 0115 ,c in _i7131 �elephonc# Type of Building S,N&L& Fav tir hidA4Lr Dwelling-No.of Bedrooms "1 No.of persons Other-Type of Building Other Fixtures 656 Design Flow(min.required) 6 5 6 gpd Calculated d e r flow 551C Plain Date /l' l6 -t Li Number of sheets Title LA/J aF eye,56.0 5vB5uRfAt& 10 3 , • DSa Soil Dilly)n-8. Soil Evaluator Form No. 5 mr rr 2 5614/ft t. -3a Name of Soil EvaluatorD DESCRIPTION OF REPAIRS OR ALTERATIONS Sy3T$W1 t MN NEW /A) • • tLIRA1O& em Lot Size (pt% 5' sq.f. fO Showers Kr +E ) Design flow provided SS4,4-d gpd Revision Date R ItSta R Date of Es aluation .3 -TRE.t • � /2 0 CUL ',a JNC The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections mx1 COMMONWEALTH OF MASSACL,USETTS � CERTIFICATE OF COM! IANCE Description of Work: '11441 idual Component(s) ❑Complete System The undersigned hereby cc,:riftj teat the Sewage Disposal System; Constructed ( ),Repaired ( gr ded ( ),Abandoned I 1 by JU/LL( n0�// b� Fe a- tie" 4 Tr-?AA; %"J7I I;/ rcf , at � . O1 t� /,f--�—/C-,/ � . ppp has been installed lled d nce with the pro tons of 310 CMR 15.00 (Title 5) and the aproved design plans/as—built plans relating to application No SS 7V dated / 1/7—r/,S Apposed Design Flow (gpd) Installer —7")A r .-A} Designer: //ls,(ACG9 Inspector: -� Date: / 2 -/i7-- 7?„ The issuance of this petit shall not be construed as a guarantee that the system will function as designed.0 p tilk i/'T py� F _ FEE COMMONWEALTH OF MASSACHUSEITS if) . M1 DISPOSAL SYSTEM CONST UCTION PERMIT Permission is hereby d10; onstruct( ) . repair(vrti pgrade( ) Abandon( ) an individual sewage disposal system at D d )/t" '--7i.pJL / \ p as described in the application for Disposal System Co strttctiou Permit No. CC— % dated /1/f i// V. Provided: Construction shall be completed within three rears of the date of this p n/ue; A local condifi /Ymust be met. Date_/(47711XBoard of Health Ate Form Form 1255 Rev 5 96 AM.SUIpr co.Boston.MA