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
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a
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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
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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