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65 Title 5 Application/Permits, 1995, 2003, Report Appl CO MONWL-1LT11 OI MASSACIIUSLTTS Board of Health, NOe7??Am•P7a10 APPLICATION FOP DISPOSA1. SYSTEM CONSTRUCTION PPRYIT so mf r a Per mu in Construct( ) Repair A) Upgrade( ) Abandon( ) - S Complete System 7 Individual Components Location AMoemlio6 i / ' t,VL Owners Name Qlih gyttRRRS TLLAVAIA 2fafu640-) \Iap/Patrel# /24. - o 91 Add'ess65 020r0/065.JA" law ItloOn#IntP764 MA Lot# L 1 0 'relephene# y/3 <-86 .22-(3 i Installer's Name R I Oft. be.11/L %sal wini06 Designer's same R.p siEEARN 4S$oc /AK Address/yb 2 ✓eE btl✓E, HAD[Ly 14.4 nddreww/46774YCo2 ST 61QRNBY M4 Telephone# y qy /QlLi Telephone# Y13 W7 legi Type of Building IiL LL Ik.)6 Dwelling-No-of Bedrooms Cl Other-Tree of Building No.of persons Other Fixwres Lot Site .ZZ 660 sq_h Garbage grinder( (Ple✓E, Showers ().Cafeteria ( ) Design Flow(mill.required) //0 gpd Calculated design flow ¥ o Plan: Date 1011710 ; Surber of sheets .Z Talc u.nG th a31so 7=•D2 Description of Sails) ANN' LOAM Soil Evaluator Form No. Name of Soil Evaluator R FSMIfHRN�RDate on(vah Design flow prodded 6Dr gpd Revision Date DESCRIPTION OF REPAIRS OR AI TERA'FIONS CAC. 3 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with further aprees to not to place the system in operation until a Certificate of Compliance has been issued by th SignecLE/•aa NY Fl AA hY29C-se_ AC.cuT Date to lzSlo3 TLF.5 and Inspections / CO)1;\IONW[,\1T11 Of 'f\SS;\Cill'SITTS Board of Heath, A1^�Ti41YU'ATohi . .111 Cfl Tlr1Cr\TF Of LION 111J,1N'Cf Description of Work: J Individual Component(s) Complete System The nude igned hereh' cerdh that the Sewage Disposal S .tit n: Consent ed ( ).Repaired IyJ. Cpgr.tied 1 ).Abandoned ( kpiI),•2 012)1)L GX(AVRTIru6 at 5 /1rP I/, ar- nt/ ),e :"ucfrAi V i/ 13e. ..)LA/1 i(f has been installed in at dam e With the p - f 310 C11R 1u.00 111 :1 and the 1 ' ,(d do,, II ,.a+huill plan. relating to n application No_ 93'i23 dared 9)a�a%a3 appvned Design Flow ( yell Installer (C.U l)/Z/Gt Am �� i �a__ Designer: /,� - H� S6/ � Inspector. {/ /lam >f� Date: 43 FE „// ~ p4 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. CO\T\IO;N\\'LATE 01- M[A SAUTUSVITS rfri4' Boom of Health.4jo P TI/A lt4TirJJ .1LL DISPOS:\I. SYSTF T CO 'STRUCT1f)N 11fR II Permission is hereby granted to; Construct( ) Repair(/) ['pgradc( ) Abandon( 1 all individual sewage deposal system at AC- //opts!)IL(/a ±, ItV as described in the application for Disposal System Construction Permit No. 1, - ( 7-dated /1 7 '1 '3 Provided: Construction shall be completed within three seals of the date of this permit. All loc,)t cojnditions)trtQ/the met tur125F. 96 AM.Si 5i Cs eos:an.Ma Date /1� , /i /Board of Health � � " ���/ i' - L THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 �r OF N(5e-1-- 1.'-Ortiz Appliratinn fur Uiapnaal System Cfanutrurtian Permit Application is hereby made.fora Permit to Install ( ) or Repair/Replace (Xi an Individual Sewage Disposal System at: Fri caoial.—cc�� Type of Building Dwelling—No.of Bedrooms Other Type of Building Other fixtures Adar 2,—C- 44 c des - D.xener„r 3 ors No. Add N.., - S�i - 7(lo Add Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( Showers ( )—Cafeteria ( ) No.of persons 6 Design Flow ai,S — gallons per person per day. Calculated daily flow J30 gallons. Septic Tank—Liquid capacity RrCG gallons Length S Width S Diameter - Depth L.'%a Disposal Trench—No. S Width ^-30 Total Length r✓ 4'O Total leaching area tt Jc.w tsq.ft. Seepage Pit No. / Diameter -.S' Depth below inlet 'v5—' Total leaching area u.f _ii -sq.ft. Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed by Date Test Pit No. I minutes per inch Depth of Test Pit Depth to ground water Test Pit No.2 minutes per inch Depth offest Pit Depth to ground water Description of Soil Nature of Repairs or Alterations—Answer when applicable - -� r n�'�i-err �iUavS� 7n2S--9S'” mc..e/4,,v;yi Date Last Inspected Agreement—The undersigned agrees to install the aforedescrihed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code.The un rsigned furthe agrees not to place the system in operation until a Certificate of Compliance has been issued by the ... d/. - calth. Approved By iIi ii .r. Application Application Disapproved for the fn(lontng reasons: Permit No. Issued Dare THE 1 OMMO�IWEALTH OF MASSACHUSETTS r _ /0 ( Imo` BOARD OF HEALTH — (ertifirafe of Unmpppptianrr THIS IS 94 &T Y,„]<hat the On-Site Sewage Disposal Systc4 stalled �) ) or Repaired/Replaced ( ) on t�7j( l/,�qF' l> by 18J`�' ijt�, '"'� �' , for �ik-t^-t-1 /t"("'/!'[C`” at /) c5 it d4 I (.t-t^4 :. IL -r -'�" has been constrye ti�ed in accordance with the provisions of TITL of ate Environmental Code as rib .i{� e application for i sposal System Construction Permit No. dated ..- rfol 1 Use of this syst 9 r?pp tinned on compliance with the provisions set forth below: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS)t;,%3R1 (TEE THAT THE SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on •r. _ • • DATE t I (/ •i L Z Inspector i . / °S No. /7) !C) J THE COMMONWEALTH OF MASSACHUSETTS / FEE. � r (ibvxp b(BOARD OF HEALTH Disposal 'iji trm Lnnoirnriinn Permit Permission is hereby granted to /1//_-✓t-a-e{, �i11 (G re to Construct ) epair/Replace ( ) an On rtepewage Disposal System located at VS tvCrn IA 1 I Vic i S199 as described on 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 coTtmetion float be completed within three years of the date below. l e 1 k< doLH. M1 /y / l i ( % (\ DATE ))4-C') I (� �'�} � l FORM 1255 (REV.4/95) tl_MxWj HOBBS&WARREN TM PUSL'SHERS - BOSTON THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION FORM 12 - PERCOLATION TEST Location Address or Lot No. SinnentA34 il.L bail)" COMMONWEALTH OF MASSACHUSETTS p o ft itwritAJ , Massachusetts Percolation Test' Date: _ 9f zzio3 Time: . _ - Observation Hole # / 007 Depth of Perc S.? " USLLh Stan Pre-soak / SO End Pre-soak 2oS Time at 12" Time at 9" ,248 Time at6" 3y8 Time (9"-6") • 6 0 M b Rate Min./Inch • Minimum of 1 percolation test must be performed in both the primary area AND reserve area. - Site Passed © Site Failed ❑ Performed By: A F S ke/01n x) Assoc /A)C Witnessed By: -ine int L&4/13 Comments- ov APPROVED row•vR/m � oP No. FORM 11 - SOIL EVALUATOR FORM Date: Commonwealth of Massachusetts kietrilcustn)^2 , Massachusetts Soil Suitability Assessment for On-site Sewage Disoosal Performed By: pi:sift,...) aisocor. Date: 9/22-1b4 Witnessed By: . 1:rie.../72 thetAirl3 ar V L ew construction 0 Repair El Office Review Published Soil Survey Available: No 0 Yes Fe Publication Scale /-1.8/0 Soil Map Unit ?)c.C... V Rs Soil Limitations 3itS4L1.1eatikaoictna.c4_ °•••n"••••.5.1 04i0 MAAS "'ha sm:agubi A td -IVUGLEi 65 int estriA)“thf_ ajvt kterttise7-0,3, PIA -5;56 2Z.13 Year Published Drainage Class Surficial Geologic Report Available: No Ea Yes 0 Year Published — Publication Scale Geologic Material (Map Unit) Land form Flood Insurance Rate Map: Above 500 year flood boundary No 0Yes fl Within 500 year flood boundary No 0Yes Within 100 year flood boundary No 0Yes Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) j.114 Current Water Resource Conditions (USGS): Month Range :Above Normal JZINormal 0Below Normal 0 Other References Reviewed: DEP ARROYO)FORM-antis oF Location Address or Lot No. FORM 11 - SOIL EVALUATOR FORM bRld . otrritIMProA) On-site Review Deep Hole Number I det_ Date:-91i2./0.3 Location (id�aen""tify on site plan) SF/ 0 CA? land Use IXy.lt„oNTt/i C. Slope (%) 0 Vegetation 644SS Landform )>rtt)k] SLoAC Position on landscape (sketch on the back) Distances from: Open Water Body too"'f feet Possible Wet Area /ooh feet Drinking Water Well Jo or feet • Time:_. -- Weather GC(4E Surface Stones /J.tau.0 Drainage way _.._.. _. feet Property Line /P2_..._ feet Other .. DEEP OBSERVATION HOLE LOG DATE:SEPTEMBER 22,2003 HOLE HORIZON DEPTH FROM NUMBER SURFACE INCHES 1 A Bw C1 0-7 7-19 13-32 C2 39-120 SOIL TEXTURE LS LS FS SL SOIL COLOR MOTTLING OTHER MUNSELL 10YR113 10YR514 WAVY INTERFACE 10YR111 < 5%8 23" PACKED FINE FAINT SAND 2.5Y414 5%0 sr DENSE,PLATY 10YR1fa FEW STONES SOIL IS DAMP SMEARS ELEVATION AT GRADE:111.50 ELEVATION OF BOTTOM OF H1:101.50 WEEPING-NONE; ESTIMATED GROUND WATER=1r .ELEVATION=105.00 LEDGE-a 120" NOT IN FLOOD PLAIN HOLE 2,SOILS EQUAL TO HOLE 7 • MINIMUM OF Z 1401ta NItaANIL AT EVtHY PROPUS!D Para •arrW lawaapk.ALAG AL_ 7,CC DaWrm l3ie S.as Standing Waw in 1 lot: I/ Etta" Sauced Hly, Gard War Y2" DV,VPa01'.FDOM-ILPrlff UISABJLL AREA DlpdWseudc % /20 rr Weeping from PkFoa: 3 Y FAVE3of `1 FORM 11 - SOIL EVALUATOR FORM Location Address or Lot No 6Smo.em.ie-Ci Nc)z.eNL, AlnPTNAInt?ro k) Determination for Seasonal High Water Table Method Used: © Depth observed standing in observation hole MAX inches ® Depth weeping from side of observation hole&SLUG inches © Depth to soil mottles .__`'Z,._ inches ❑ Ground water adjustment ._._._._ feet Index Well Number Reading Date ._..._.._..._ Index well level _ Adjustment factor _ Adjusted ground water level _.........__.._..__.___.. Depth of Naturally Occurring Pervimzs Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? YGS If not, what is the depth of naturally occurring pervious material? Certification I certify that on SJLY /999 (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 Date 4�J Date p12.2.103 Drl♦rrROV W rORM-Wr,n PA 64.4 oF 1 theaTiOtTAddreg§Or nifl , _ _ Qatejl -`c----M r__.. 9/ PERCOLATION TEST(S) Time: I I Time: Observation Hole #1 Observation Hole #2 Depth of Perc c—C Depth of Perc Start Pre-soak / r S Start Pre-soak End Pre-soak ,/,-- End Pre-soak Time at 12" Time at 12" j‘ i S4 Time at 9" Time at 9" Time at 6" 2 Time at 6" Time (9"—6") " ' Time(9"—6") Rate Min /Inch Rate Min./Inch Or) i z -- *minimum of 1 percc,Jaiion test must be performed in both the primary area AND reserve area SITE ',':SITE I SITE SITE PASSED _ FAILED: _ PASSED ____ FAILED ____ Performed by I Performed by Witnessed by Witnessed by Comments: 1- -- x. 1---9 , )eK NORTHAMPTON BOARD of HEALTH— Title 5— Site Review Deep Hole#: I DEEP OBSERVATION HOLE LOG* 'MINIPo1UM OF TWO HOLES REQUIRED HT EVERY PROPOSED DISPOSAL AREA Deep Hole#: f-- Depth from Surface(Inches) Sol Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure,Stones,Boulders,Consistency.%Gravel) Other (Structure.Stones,Boulders,Consistency,%Gravel) L5 / l° ° 1 fl Par.tr teem .. -gr r.,:_.,'s.f tl2 y' i/ 3,2 " De 3 ;'-BNaetA ? SC (.c, L � 4pTacesI /✓'T//--2- Estimarddleasaua7 tIC-GmuMkraMi.:4, 7 -1 /7 DEEP OBSERVATION HOLE LOG* MINIMUM C c TWO HOLES REQUIRED MT EVERY PROPOSED DISPOSAL AREA Deep Hole#: f-- Depth from Surface(Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure.Stones,Boulders,Consistency,%Gravel) Par.tr teem .. -gr r.,:_.,'s.f ; Decxhxegc wales ,. ' 13.4. .I 1 64-41,4-..-/ S.--.I ice, )I PERCOLATION TEST(S) Time: I I Time: j Observation Hole #1 Observation Hole #2 Depth of Perc Depth of Perc Start Presoak Start Pre-soak End Pm-soak End Pre-soak Time at 12' Time at 12' there at 9' _. 1 Time et,97,. >. , Time at 6" Time at 6' Time(9'-6') Time(9'-6') Rate Min./Inch Rate Min/Inch 1 'minimum ot 1 percolation test must be performed it both the primary area AND reserve area. I Performed by Performed b Witnessed by I I Witnessed by I Comments: On-Site Review I ocationAddress or Lot# - .. _ Date Engineering Firm Identity on Site Plan Land Use 1 Vegetation Landfo m Position on landscape M D RNvm 1/ 7IG� Owner Time Slope go D4t.- I Address W � Weather Engineer or Sanitarian I k pre I Surface Stones 1 Open Water Body Possible Wet Area feet feet Distances from. Drinking Water Well Drainage Way feet feet Property Line Other feet feel Parent Material(geologic) Depth to groundwater Standing Water in the Hole Estimated Seasonal High Ground Water Pe)..j e- Depth t to Bedrock % a !/ I Weeping from Pit Face //A Deep Hole # DEEP OBSERVATION HOLE LOG* 'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Depth, from Soil Horizon F Soil Texture Scdace finches (USDAI r� , 7 -. lid ` ) J c_ c I Soil Color I Soil Mottling Other (Munselp ! ISlructure Stones Boulders. Consistency Yo Graven id 4.'' a - <^ &, ITh7 LOA a -J ,s--y y/3/ O�, ,61-4,17 L (Ib d( I I Parent Material(geologic) L Depth to Bedrock `% Depth to groundwater. Standing Wale r in the Hole A 1 Weeping from Pit ace Estimated Seasonal High Ground Water Deep Hole #: DEEP OBSERVATION HOLE LOG* 'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Depth from Soil Horizon i Soil Texture ! Soil Color Soil Mottling Other ze cinches. (USDA) Munseill iStryclufe Stones Bout ers Consistency ° P,.,/i, - ; 0 5L k 999 /9� uk6 ID71J Parent Material(geologic) Depth to groundwater Standing Water in the Hole Estimated Seasonal High Ground Water Pe)..j e- Depth t to Bedrock % a !/ I Weeping from Pit Face //A