53 Title 5 Application/Permits 2003, Local Upgrade Approval, Soil Survey, Inspections 2003, 2006 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form /ll J'aUxtt-'
�G �✓TT D / ti
9Z'-Sy34
A. Certification
1. Property Information
Property Address:
Owner's Name:
Owner's Address:
Date of Inspection:
Copy to:
Witness:
2. Inspector.
Name of Inspector:
Company Name:
Mailing Address:
Telephone Number:
53 North Farms Road Florence MA
Ronald Fox
c/o Murphy Realtors, 44 Conz St. Northampton MA 01060
3/14/06
Board of Health Florence: Thomas Masters
Number: SSDS-1050
Thomas S. Leue
Homestead Inc.
1664 Cape St.. Williamsburg. MA 01096
1413) 628-4533
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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The septic system condition
must be evaluated and classified into one of the following four conditions:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
The system condition: Passes
Inspector's Signature:
/ 2/74re ^ Date. March 14 2006
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health of DEP)
within 30 days of completing this inspection. If 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 DEP. The
original should be sent to the system owner and copies to the buyer, if applicable and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
5g' 45I4 s3]o 00"3
t5insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form. Subsurface Disposal System
•page 1 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (Cont.)
Property Address:
Owner' Name:
Date of Inspection:
53 North Farms Road, Florence, MA
Ronald Fox
3/14/06
Inspection Summary: Check A, B, C, D or E/always complete all of Section D.
A. System Passes:
Y I have not found any information which indicates that any of the failure criteria as described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
N 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 Answer yes, no, or not determined (Y, N, or ND)in the_for the following statements. If"not
determined" please explain.
(1) N, The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if
the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic
tank will pass inspection if it is structurally sound not leaking and if a Certificate of Compliance indicating that the tank
is less than 20 years old is available.
ND explain:
(2) N Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if
(with approval by the Board of Health). _ broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
ND explain:
(3) N The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
_ obstruction is removed
ND explain:
(4) N Other: explain:
C. Further Evaluation is Required by the Board of Health:
N 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 or the environment:
1) System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water.
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
t5insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•page 2 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (Cont.)
Property Address:
Owner' Name:
Date of Inspection:
53 North Farms Road, Florence. MA
Ronald Fox
3/14/06
2) System will fail unless Board of Health(and Public Water Supplier, if any)determines that the system
is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface
water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well•• Method used to determine distance_
'•This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3) Other:
D. System Failure Criteria applicable to all systems:
You must indicate either"Yes" or"No"as to each of the following for all inspections:
YES(Y)or NO (N)
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N Liquid depth in cesspool is less than 6" below invert or available volume less than 1/2 day flow.
N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of
times pumped
N Any portion of the SAS, cesspool or privy is below high ground water elevation.
N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N Any portion of cesspool privy is within a Zone I of a public well.
N Any portion of cesspool or privy is within 50 feet of a private water supply well.
N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply
with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP
certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from
pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.]
N The System F2fls: I have determined that one or more of the above failure criteria exist as defined in 310
CM 15.303, therefore the system fails. The system owner should contact the Board of Health should be contacted to
determine what will be necessary to correct the failure.
t5insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•page 3 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Sewage Disposal System Form
A. Certification (Cont.)
Property Address:
Owner' Name:
Date of Inspection:
53 North Farms Road, Florence, MA
Ronald Fox
3/14/06
E] Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 to 15,000 gpd.
You must indicate either"Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
YES (Y) or NO(N)
N the system is within 400 feet of a surface drinking water supply
N the system is within 200 feet of a tributary to a surface drinking water supply
N the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)or a
mapped Zone II of a public water supply well)
If you answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in
Section D above the large system has failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
B: Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following;
YES(Y)or NO (N)
Y Pumping information was provided by the owner, occupant or Board of Health._
N Were any of the system components pumped out in the previous two weeks?
Y Has the system received normal flows in the previous two week period?_
N Have large volumes of water been introduced to the system recently or as part of the inspection?
• Were "as-built"plans of the system obtained and examined? (If they are not available note as N/A)
Y Was the facility or dwelling was inspected for signs of sewage back up?_
Y Was the site was inspected for signs of break out?
Y Were all system components, excluding the SAS, located on site?
Y Were the septic tank manholes uncovered, opened, and the interior of the septic tank inspected for the
condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and
depth of scum?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Y a) Existing information. For example, a plan at the Board of Health.
N b) Determined in the field Of any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)j15.302(3)(b)].
Y The facility owner(and occupants, if different from owner)were provided with information on proper
maintenance of Subsurface Sewage Disposal Systems (SSDS).
t5insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form. Subsurface Disposal System
•page 4 of 10
Property Address:
Owner' Name:
Date of Inspection:
RESIDENTIAL
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
53 North Farms Road, Florence, MA
Ronald Fox
3/14/06
FLOW CONDITIONS
533 DESIGN flow based on 310 CMR 15.203(gallons/day)
4 Number of bedrooms (design)
2 Number of bedrooms (actual)
4 Number of current residents
N Is there a garbage grinder?(Y or N) _
Y !. Is there a Laundry Hookup?(Y or N)_
N ', Is the Laundry a separate system?(Y or N) (If yes, separate inspection required)
N Seasonal use (Y or N)
N/A Water meter readings, if available (last two years usage) (gallons per day)
N Sump Pump (Y or N)_
continuous Date of last occupancy
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15203):_gpd
Basis of design flow (seats/persons/sqft, etc.):_
Grease trap present(Y or N):
Industrail waste holding tank present(Y or N):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records: Source of information: Not pumped since construction
N Was system pumped as part of the inspection (Y or N)
If yes, volume pumped:_ gallons--How was quantity pumped determined?_
Reason for pumping: _
Comment'. Recommend pumping this year
TYPE OF SYSTEM:
X Septic tank, distribution box, soil adsorption system._
Single cesspool_
Overflow cesspool
Privy
N Shared system (Y or N) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank(Attach a copy of the DEP approval)
Other(describe): _
15insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•page 5 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Property Address: 53 North Farms Road, Florence, MA
Owner' Name: Ronald Fox
Date of Inspection: 3/14/06
APPROXIMATE AGE All components, date installed, and source of info.
Se tic lan: Cert. of Compliance dated 12-3-03 for completely new system.
Source of Info: BoH
N Were sewage odors detected when arriving at the site (Y or N)
BUILDING SEWER (located on site plan)
20 Depth below grade (inches) Estimated Average
24 Distance in feet from private water supply well or suction line
cast iron Materials of Construction
Comments:
SEPTIC TANK (located on site plan)
Concrete Materials of Construction
15 Depth below grade (inches)
0 Riser depth (inches)
58 Septic tank width (inches) Interior dimensions
120 Septic tank length (inches) Interior dimensions
60 Septic tank height (inches) Interior dimensions
1,812 Calculated gross volume (gallons) Calculated
9 Air space in tank (inches)
1,500 Net Volume (gallons) Calculated
22 Baffle depth (inches)
6 Sludge thickness (inches) Average
8 Scum thickness (inches) Average
32 Top Sludge : Bottom Baffle (inches) Calculated
8 Bottom Scum : Bottom Baffle (inches) Calculated
5 Top Scum : Top Baffle (inches) Calculated
Comments:
Compartmentalized tank, minimal biosolids in second chamber.
By code should be closer to surface via. risers.
Recommendations:
Recommend_puing at this time.
t5insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form. Subsurface Disposal System
•page 6 of 10
Property Address:
Owner'Name:
Date of Inspection:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
53 North Farms Road, Florence, MA
Ronald Fox
3/14/06
!PUMP CHAMBER
N Pump part of septic system: (Y or N)
Pumps in working order (Y or N)
Alarms in working order: (Y or N)
Comments:
DISTRIBUTION BOX (located on site plan) ("D-box")
D-box part of septic system: (Y or N)
0 Depth of liquid level above outlet invert!Comments: about 20" below grade
SOIL ADSORPTION SYSTEM(SAS): Technology Used (located on site plan by estimate):
leaching pits & number:
leaching chambers and number:
Y leaching galleries and number: two rows, each 2 units long
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number.
innovative/alternative system, Type:
.Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
No surface problems seen. Units not opened.
If SAS not located
explain why:
TIGHT OR HOLDING TANK (tank must be pumped at time of inspection)
N Tight tank part of system: (Y or N)
Depth below grade (inches) Measured
Tank width Tank length (inches)
Tank height Calculated gross volume (gallons)
Materials of construction
Design flow: gallons/day
Pumps in working order: (Y or N)
Alarms in working order. (Y or N)
Date of last pumping
Comments'. (conditions of inlet tees, condition of alarm and float switches, etc.)
15insp.doc• 11/2004
Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•page 7 of 10
Property Address:
Owner' Name:
Date of Inspection:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
53 North Farms Road Florence, MA
Ronald Fox
3/14/06
PRIVY (locate on site plan, if any)
N Privy part of system: (Y or N)
Materials of construction:
Dimensions:
Depth of solids:
',Comments: (soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) '.
10ESSPOOLS (cesspool must be pumped as part of inspection)
N Cesspool part of system: (Y or N) ICI
Number and configuration.
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
of construction
Indication of groundwater inflow(cesspool must be pumped as part of inspection)
Comments: (note soil conditions, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
GREASE TRAP (Usually present in certain commercial systems)
Grease Trap part of system: (Y or N)
Materials of construction:
Depth below grade (inches)
Dimensions:
Depth of solids layer
Depth of scum layer
Top of scum to top outlet
Date of last pumping
Bottom of scum to outlet
Scum thickness (inches)
Comments: (recommendation and conditions)
t5insp.doc• 11/2004
Measured
Calculated Inches
Calculated Inches
Average
Homestead Inc. Title 5 Official Inspection Form: Subsurface Disposal System
•page 8 of 10
Property Address:
Owner' Name:
Date of Inspection:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
53 North Farms Road, Florence, MA
Ronald Fox
9/14/06
SITE EXAM (Source of Information)
Y Slope Official Perc Date
_ Y Surface water 10/9/03 Official Plan Date
Y Check Cellar Other Official Source
!, N Shallow wells Other Source
60 Estimated depth to ground water(inches)
!I�Please indicate (check)all the methods used to determine high groundwater elevation:
Y Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Information: Built to Title 5 code requirements.
:RESOURCES: Department of Environmental Protection, Western Regional Office,
Dwight St. Springfield MA 01103 (413)784-1100 Tine 5 Hotline-(800)266-1122
t5insp.doc• 11/2004
Homestead Inc.
Title 5 Official Inspection Form: Subsurface Disposal System
•page 9 of 10
W
iu Distribution Box
a I
I I
0 67'
c _<__ 2 _.__ 112.,..,
•All NORTH
10: 774 69_ �I
II ti Ir -
<-------- / ,
Septic Tank
Leaching Galleys, shown in approximate locations.
Note: No known drinking water sources within 100 foot radius.
COMMENTS:
Recommend gumoing on a 3 to 4 year schedule. Also. a cony of this plan posted in the
basement/utility area would keep this information accessible in future years for maintenance.
r Date: Owner: ��H°F ��S�+r HOMESTEAD •INC. ,
As-Built Drawing is y6m
Existing Septic System 3/14/06 Ronald Fox lre T110NA43 Thomas S. Leue R.S.
- 53 North Farms Road o SUE
Scale: L 20' Revision Date: Florence, MA 01062 �°. ze tel Williamsburg, e S 01096
` Except as Noted `Stem st��� 1413]628-4533 ,
ti
ENVIRONMENTAL DESIGN, INC.
101 OLD FERRY ROAD
NORTHAMPTON, MA 01060
1-413-585-5020
November 7, 2003
Board of Health
Town Offices
Northampton, MA 01060
re: Inspection of Septic System Repair, Fox Home, 53 North Farms Road
Dear Board:
On November 7, 2003, a representative from our office performed an inspection of the
septic system repair installation referenced above. The system was installed by J. C. &
Company of Northampton, MA.
Our representative found that the system appears to have been installed properly and in
general accordance with our system plan dated 09-12-03. The as-built locations of
relevant system components have been documented on the attached sketch.
If there are any questions, please contact our office.
Sincerely yours,
Mich I J. gne
I hereby certify that the above referenced system was installed in accordance with Title V
and theapproved system design prepared by Environmental Design, Inc.
J. C. & Company, Northampton, MA
NORTH FARMS ROAD
TBM: Bottom of
Porch Siding at
Comer Shown.
Elev.=100.0'
1500 Gallon
Septic Tank
D-box
Neighbor's
House
AS-BUILT (n.t.s.)
Fox
North Farms Road
Northampton, MA
11-07-03
Cover
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SYSTEM-REPAIR
NORTH FARMS ROAD 53 North Parma Road
Gomm,MA 01062
CONSTRUCITON NOTES II I tar
11 TWO 0)REIMA LA&mamas CLLO M EACH wmmm OF T@o(Si Ron Fox
DAaAYP(MOEUU+IW SUPPLY MARROW CONCRETE N.4,in WORD 53 North Farms Road
as MOLES AMMAN VRR.aw SA'.I Jr DONS WASHED PONE PIoMDCe,MA 01062
AROUND GAUSS.P m DAINA MAIMS NORM•SIAM GAUSS
1RYSTVS A®Y.It Ir SOIL mvm LAS MTAH Y m IT.Vf N1wI
1 MOM MILL Am4COME A Miss maDwaWaMIlA DisPosAL 413-SS7-3095
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4)RIDffiID Err Lae TO as 4•PVC NDD A IOPENW SYa OP RC
L) ALLOImIm To BS V M.SRT(Q l®WAJRT1.
41 a t TIM I A DSam)T ES IWO CW@ANTO4=DM FITTED wire FIELD 09/04/03
4"PVC SOL 40 MO Mm A GAL Relau MORN.ME PROMS _ SURVEYOR M(/R•
1J 1LIATTN AND E VAIW W*SRC TOW WY M MOW=AS 11 ANY 10 DESIGNER 141 ML
ARAMADATDaRM M MOT SAYARYN/twos WORN SQUIRED Casa (I✓!?( WADI
EaAW9 AMMO'S.NOEL RIWfm @ANY PROBLEM AM EWRMI UO br. I NaWW
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DESIGN 09112/03
LIMA The cleaRTID TO Ta INLET MO Mt rm TROPES m err Mt yY
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AUTO NS IAA RAYS.SEW IavUMS SODPOOa6 vJM.YA
41 ANY TMOIL,tU .m PILL NfIATE m amf ASORID IRS IAAORNO IYVmn H
•MnRRTA®W M=ACT CMm SANDwrmM PUmAOMOAUSYS I.wI DESIGN REFERENCES
in MOM An D®a®MOW ANY la68@T®ma I IAMB NAIEIM. SITE TRN
101 ET OVuAIn At EISIMONI NOON a PLOW. 48L TO nOVW6 AT WIT IP
M aIVU MID MOWN OR mai laumYIDR REV MO eMSTanrsaRUNRP. PR..Wmm
I U wNW.ACT08 T1 Wart nRmn ISIS IOCA'MME POOR 10 03E111IN9n.AND nW
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124110 SYSTEM As MAIN MOMS A WOCAL MOAN ATNOVAL Mt A TEE POOL BBENvLARX Fa.CSSS.,
▪ AMTO TO WNM MEB MD APPLICATION AC OM&aa TERUM. p.em-IKO
IJ3ML MTIN'T€TO E LAW.Trtay.M EATRVVOC TALMfl ® /m
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u m.agI..RC Mountie.3 BC GM – _ ` APPROVALS&REVISIONS
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.TA•S 1.647203•66.0.710171/84.111•513010
No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
Date: /07103
Commonwealth of Massachusetts
A.4-72 4+— , Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By:
Witnessed By: �<--��— f21ces—( .&_
Date: o9/3Y,YaI_
Lamm
CT? /VO-%^ I-Gl1--Mr--
ew construction ❑ Repair
Office Review
Published Soil Survey Available: No ❑
0.m1 Kurt
Appne..M
Tekplpe,
kl._ U c
.r-5-2—go 98
Year Published
Drainage Class
Yes
Publication Scale
Soil Limitations
Surficial Geologic Report Available: No cK Yes ❑
Publication Scale
Year Published
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No DYes
Soil Map Unit
Within 500 year flood boundary No Yes ❑
Within 100 year flood boundary No Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions(USGS): Month
Range :Above Normal ❑Normal ;21Be1ow Normal ❑
Other References Reviewed:
DFP APPROVED FORM•1207/95
ENVIRONMENTAL DESIGN INC.
101 OLD FERRY ROAD
NORTHAMPTON,MA 01060
413-585-5020
a.
FORM I1 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. S1.7 h-
Deep Hole Number 1 ) 2-
Location (identify on site plan)
Land Use 1 nr
Vegetation 9
Landform
Position on landscape (sketch on the back) (1L"`_
Distances from:
Open Water Body > )00 feet
Possible Wet Area >/do feet
Drinking Water Well >NNO feet
On-site Review
Date e:97 Time: °'"^"`j' Weather ieCti /—
Slope (%)p_-20
Surface Stones rx-oh-A -
Drainage way ›S—05
Property Line '> / fJ
Other
feet
feet
DEEP OBSERVATION HOLE LOG•
Depth from
Surface(Inches,
Soil Horizon
Soil Texture
(USDA!
Soil Color
(Mons))
Soil
Mottling
Other
(Structure,Stones,Boulders,Consistency, %
Gravel)
0 - /2
p
SL
70Yt?lR
Ah4 ._
77;7,,;/
/2 - y2
Sc
(j-LS
JOYYs/
A10A-4--
c-1u74,ce
HO - 72
C 1
c--,X)--)
jaYzr/
/✓p..^-
rr/ed-
72-//y
C2-
S;14-1. 0,a.,
26,Rith
>77'' s
�a 7a"
0 -36
inxc &
Tell
STha9c fl
& k4&
`-: l∎
36 -8H
C\
s11.-
02-sryl3
n/D U
>s---C
riici,
81-1402
C2
Sn4-1,wa,-
;.sry/2
7 s-yR
. . . r . a •a ar
Parent Material (geologic) DepthwBedrock: J/�] ,
Depth to Groundwater:
Standing Water in the Hole: A/O•(-•
Estimated Seasonal High Ground Water: 72 "
DEP APPROVED FORM-Waves
8y„
Weeping from Pit Face:
ENVIRONMENTAL DESIGN INC.
101 OLD FERRY ROAD
NORTHAMPTON,MA 01060
413-585-5020
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. Sri ,1- 917—At-ins-7c+a._42( � � .0 J k-
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole inches
❑ Depth weeping from side of observation hole inches
M Depth to soil mottles 72,8`(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 naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? Ye-C
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on A/Ov, 9q (date) I have passed the soil evaluator examination
approved by the Departfnent 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 >%/l43
MP APPROVED FORM•12107195
ENVIRONMENTAL DESIGN INC.
101 OLD FERRY ROAD
NORTHAMPTON,MA 01060
413-585-5020
FORM 12 - PERCOLATION TEST
Location Address or Lot No. S`3 A/ci,-,'L Anus
COMMONWEALTH OF MASSACHUSETTS
,AJ— LL^p4c Massachusetts
Percolation Test`
Date: 9,/y%a3 Time:. /77m-- jA,;
r
Observation Hole #
T /
Depth of Pere
6 ii
Start Pre-soak
/O .' GS'
.End Pre-soak
/0 .06
Time at 12"
/a a/a
Time at 9"
/d , 6,
Time at 6"
/d : 3 L/
Time (9"-6")
g
Rate Min./Inch
?
Minimum of 1 pe colation test must be performed in both the primary area AND
reserve area.
Site Passed Site Failed ❑
Performed By: Jrl i r�a.e,� JOVY?AJ.
Witnessed By: - ye ) -e. /i?cE;_ka..,1
Comments:
DEP APPROVED FORM-12/07/95
ENVIRONMENTAL DESIGN INC.
101 OLD FERRY ROAD
NORTHAMPTON,MA 01000
411_c£c_cnnn
Location Address oritot:# i s A) ' it-4- }
Qate' ... ',:, , )1 -7 %/I 3 I
PERCOLATION TEST(S)
Time: 1 I Time: ! I
Observation Hole #1 Observation Hole #2
Depth of Perc
(/ 4 - Depth of Perc
Start Pre-soak /0 0 c Start Pre-soak
End Pre-soak End Pre-soak
gi
Time at 12" 7 Time at 12"
Time at 9" Time at 9"
Time at 6" Time at 6"
Time (9"-6") Time(9"-6")
--,
Rate Min/Inch Rate Min./Inch
*minimum of 1 percolation test must be performed in both the primary area AND reserve area.
SITE }SITE , '' [SITE -I SITE
PASSED _ FAILED _ 'PASSED ____ FAILED _ I
Performed by I Performed by
Witnessed by I Witnessed by
Comments:
NORTHAMPTON BOARD of HEALTH- Title 5- Site Review
Deep Hole it: /
DEEP OBSERVATION HOLE LOG*
'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface(Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil Mottling
Other
(Structure,Stones.Boulders,Consistency,%Gravel)
n
'C
% '
i
1
Par 'tlilatenal,(ged
1._ '
7- 7(1
De01.113 Hre»u.----' r SlaoiL 9Waf a kiole
/ '/ � 6"Ee�s ... .;Fare
/17/7/'
Estimatedseaioaalf gt7GmundVVater„µw,,,
"a
Deep Hole#: )—
DEEP OBSERVATION HOLE LOG*
'MIN 101.1 Or NJO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface(inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil Mottling
Other
(Structure,St ones,Boulders,Consistency,%Gravel)
r
�L
r
Depth to
ter S •f.• a-_. .Ax`
'ESmaaF�cateum, raun
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE I OF 5
Commonwealth of Massachusetts
, Massachusetts
Application for Local Unarade Aonroval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To be submitted to Local A roving Authority/Board of Health: For the upgrade of a failed or
nonconforming system with a design flow of C10,000 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
of 10.000 up cc 15,000 gpd and/or for upgrade
compliance. as defined in 310 CMR 15.404(1),
failed or nonconforming system with a design flow
of a state or federal facility. where full
is not feasible
NOTE: Local upgrade approval shall not be ranted 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.
I) Facility/system owner
Name
Address Ss L
Phone # <f/? - 92— .Th0%fi'
Address of facility
?)
Applicant (if different from above)
Name
Address
Phone #
Type of fact ivy
residential corrunercial school
institutional
(Specify)
DU?APPROVED FORM-12/07r95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL.
PAGE 2 OF 5
4) Type of existing system
privy cesspool(s) t/ 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 N/A gpd
Approved? ,s/Oyves approval date
no why?
b) Design flow of proposed upgraded system S t gpd
e) Design flow of facility 495-gpd
Proposed upg a e of existing system is
a) 1/ 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 /I
�e.w /$7/a a//a_Cp4ri %-/c 1,44
..147 'X /,2 ' X
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 perc rate)
00 APPROVED iORM. 1Z.07/9
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF 3
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 & hi_en groundwater
(specify proposed reduction & pert rare)
Other requirements of 310 CMR 15.000 that cannot be met (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 nigh 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 mte s✓N;FI. -pe mcc_1n.:L.
Evaluator's signature
Date of evaluation o9
OQ APPROVED kURM- 11107/9S
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 shat) be compiete 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 Co 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 15.402 through 15.405.
List of affected Abutters_
Abutter Name
Address
Abutter Name
Address
Abutter Name
Address
Abutter Name
Address
Date notified
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
a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
ere— S-'rp eckSt_ S�topic_ ) iw.-S4-a7'WtiC',
b) an alternative system approved pursuant to 310 CMR 15283-15.288 is not feasible:
/&J1
DO APPROVED FORM. I LOWS
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
c) a shared system is not feasible:
av'e.i LA-Itt .
a) connection to a-sewer is not feasible:
AL L ave.;
10) An application for a disposal system construction permit, including al: required attachments
(e.g. plans & specifications, site evaluation forms), must accompany this application. Is the
DSCP application attached? xves no
11) Certification
. 1, the facilio- owner. certifc under penalty of law that this docurnent and all
attachments, to the best of my imowledee and belief. are true, accurate. and
complete. 1 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. "
Print Name
Name of preparer
/0/ 0(0( Pei-7-y 'id, mr3 9/2 S 8s=r�ozo
Telephone # & add of prepares
NOTE: Title 5, 310 CMR 15.403(4), requires the system owner or operator to submit to the
Depatvnent a copy of the local upgrade approval upon issuance by the Board of Health and prior
to commencement of construction.
OFP APPROVED FORM-t2/07ID5
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
1elti, Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facilinosystem owner: Name
u Address'
Address of facility
Type of facility residential institutional
design flow per 310 CMR 15.203 2-/corm et- _ school
y 9r gpo
System desiener. Narne F y
Address 101 J t
phone .Va..,. —S'Tj1,G
Local Upgrade Approval granted for:
reduction in sctoaclus) tspecifb)
peen raze of 30-60 mtu./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)
List local variances granted (no DEP approval requird per 310 CMR 15.412(4))
List varances ¢tamed requiring DEP approval
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.
DEP APPROVED FORM- 11107/95
+ No37-d3 THE COMMONWEALTH OF MASSACHUSETTS Ftfl
t BOARD OF HEALTH
C1 •y OF Nor2-Lv
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct f ) Repair (x} Upgrade ( ) Abandon t 1 - j{i Complete System ❑Individual Components
S",5 AZ -&_ Fat—
-to I._ r 0 X
I.oeme(1
onwr;ranee
Map,raaal'
y
C
c0 . Lm=
A ^ renp ho'e
�
)QI did
\thins,
5'8S=Sao 20
s
e
ikaA470-4.1 11449
-
_
1.11,1rus,
,.I pn„n,n
,alepaon,.,
Type of Building: . s''+.A._
Dwelling—No.of Bedrooms
Other—Type of Building
Other fixtures
Design Flow(min. required)flP Bpd Calculated design flow
Plan: Date O9 — is-0? Number of sheets it1Y'f er
Title - • • s - — -
Description of Soil(s) k —
Soil Evaluator Form No. A/fri Name of Soil Evaluat
DESCRIPTION OF REPAIRS OR ALTERATIONS
ry[`
Lot Size Sq.feet
Garbage Grinder (IC
No.of persons Showers ( ), Cafeteria ( )
gpd Design flow provided J s'a? Bpd
Revision Date N09
Date of Evaluation C99-O° C
law {ic
y o •
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place e sys W in operation until a Certificate of Compliance has been issued by the Board of Health.
Date /%143
Inspections -
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No ??-- f;2
THE COMMONWEALTH OF MASSACHUSETTS
A/(1-4771 i. ,%A2 BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) C71 Complete System
The undersigned hereby certify that the Sewage Disposal System.Constructed( ).Repaired( )_Upgraded( ).Abandoned( )
4
by:
at ' 1, ,( f .f. T.ii.-1 1. �^/
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. 7,--C3 dated / C /1/',' . Approved Design Flow 5 3 (gpd)
Installer
Desiener_i Inspector r2-;<-F, f21 o Date
The issuance of this certificat6 shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
FE[
No.
0,4�r�
THE COMMONWEA,LTH OF MASSAG USETTS FEL
N4l 2 f 7 -4N.v24i BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Cgn»truct ��) Repair (}') Upgrade ).Abandon ( ) an individual sewage
disposal system at S a V "/r Y' 7 -/-j <la%: ,z! as described
in the application for Disposal System Construction Permit No. - a dated
Provided: Construction shall be completed within three years of the date of this permit.All total conditions must be met.
'yiI J" '� - 2,1 Board of Health N E- (
Date (/- -
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 i REV S/961
0116 W/ HOBBS 6 WAPPEN
PUBLISHERS - BOSTON