408 Title 5 Application/Permits 2012, 2005, 1974, Conservation Commission Permit, Trench Permit, L0+ Ad ;A _+ 4.
• Massachusetts Department of Environmental Protection 4D Nair scorns leek
��.I Bureau of Resource Protection—Wastewater Permitting Program Site Address or Map/Lot Number
(\`■a Form 12 Percolation Test
A- Facility Information
1. Facility Information
Neat 4egt)
Owner Name (('' ((���
4 DPt N1o(11n Ya.v.,..t Icoao Map/Lot
Street Address Nt A D 1 D(o Z
City State Zip Code
Percolation Test-
Date: 512.-4/oc
Observation Hole # _F I P Z
-
Depth Of Perc 42" 39 "
Start Pre-soak 9:z5 I0
End Pre-soak 9 : 56
Time at12" 9 :56
Timeat9" lo: l2 0•,30
Timeat6" 10;35 10:9-7
Time (9"-6") 2-3 M is 9 MbJ
Rate— Min/Inch 3 hele1 trJ
Minimum of 1 Percolation test must be performed in both the primary area AND reserve area.
Site Passed [ "Site Failed U
Performed By: \lark psor HILLTOWN ENVIRONMENTAL CONSULTING
n ,1 P. O. BOX 226
ff
Witnessed By: Yrrt 354 Ma tletn NORTH HATFIELD, MA 01066
(413) 247-5464
Comments: -----
DEP Form 12 Percolation Test• Page 1 of 1
L°+ Adj....a- -1
Massachusetts Department of Environmental Protection 4ot) Nom-I, F-.-.s Rood
Bureau of Resource Protection -Wastewater Permitting Program Site Address or Map/Lot Number
. c\ Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (minimum of two hol es required at every proposed disposal area)
Deep OhservationH&!e: Date: 5,Z1 ,O` i 3� C:ood S::
/-- Time- Weamer: y
t Deep Hole Number a Location (Identify on Plan ):
2. Land Use: Woods Surface Stones: Man Slope % : Vegetation:p ( ) _S Ve elation: Pir`e �:.cL
(e.g.woodland, agricultural field,vacant lot,etc "Bev Ilan,
Landformy. -1.1 I R;a3° Position on landscape:
3. Distances from: Open Water Body ?bat ft. Drainage Way too-t- ft. Possible Wet Area IoD+ ft
Property Line So ft. Drinking Water Well 150 ft Other ft.
4. Parent Matenal: Gla.;.1 T I I Unsuitable Materials Present: Yes ❑ No g
If Yes: Disturbed Soil❑ Fill MaterialD Impervious Layer(s)❑ Weathered/Fractured Rock ❑ Bedrock ❑
5. Groundwater Observed: Yes 0" No ❑
If Yes: Depth Weeping from Pit 94" Depth Standing Water in Hole lob Estimated Depth to High Groundwater: 38
Redoximorphic Features Coarse Fragments
Depth
Soil Soil Matrix: (mottles) o by Volume
(In.) Horizon/ Soil Texture Color-Moist Depth Color Percent Gravel Cobbles Soil Structure Soil Consistence
Layer (USDA) (Munsell)
&Stones (Moist) Other
0 -6 A st, IDYR3i't- Ious_g- cru...L
1, -10" 3,9 SL- Z.SY s/4 ...>uurQt .-R-oLit
Ie-112 C/ Slr 2.5 S 361 I°nz4/e
y 5)3 z.SY �/I S% I 07 51/4 w.afsig“ able.
Additional Notes
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 4
L6+ Ad;ar....+ -6
Massachusetts Department of Environmental Protection 400 Nor+l, fw.ms Rid
Bureau of Resource Protection-Wastewater Permitting Program Site Address or Map/Lot Number
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
D. Determination of High Groundwater Elevation L 7-
1. Method used: ❑ Depth observed standing water in observation hole A. B.
❑ Depth weeping from side of observation hole A. B.
Ly Depth to soil redoximorphic features (mottles) A. 34 " B. 3£3 "
❑ Groundwater adjustment(USGS methodology) A. B.
2. Index Well Number Reading Date Index Well Level
Adjustment Factor Adjusted Groundwater Level
E. Depth of Pervious Material
1 Depth of Naturally Occurring Pervious Material
a. Does at least four feet of naturallyy occurring pervious material exist in all areas observed throughout the area proposed for the
soil absorption system? Yes IJ No❑
b. If yes, at what depth was it observed? Upper boundary. lb'' Lower boundary: f D B"
F. Certification
I certify that 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.
ra I
/• ,- . 71.t. 24 2005
Signa •redSOil Evaluator Date ./ HILL TOWN ENVIRONMENTAL CONSULTING
P.O.BOX 116
Mark Thompson April 29, 1997 NORTH HATFIELD,MA 01066
Typed or Printed Name of Soil Evaluator Date of Soil Evaluator Exam ` (I1JJ 14]-Sd64
&Ynes+ Mt+hia.. Nor'i-h a.n .bn < + 1
Name of Board of Health Witness Board of Health J
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 4 of 4
• Le-(- Aolyn“.r.- 4-b
Massachusetts Department of Environmental Protection 4-0o 'No I oao(
Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
IA. Facility Information I I
Owner Name- N¢' I 1-1oe+5-leas HILLTOWN ENVIRONMENTAL CONSULTING
P. O. BOX 226
Street Address 406 NorFk Fr...s Roe.0l Map/Lot'. NORTH HATFIELD, MA 01066
r (413)247—5464
City: Y Ior cpc.L State: MPt Zip Code' 01062_
B. Site Information
1. (Check one) New Construction Ly Upgrade ❑ Repair ❑
2. Published Soil Survey available? Yes fal No ❑ If yes: I`MI I ; 1 5040 �f c.3 Paxf0h
{� Year Published Publication Scale Soil Map Unit Soil Name
Soil limitations Peres CIow Iy
3. Surficial Geological Report available? Yes ❑ No ❑ If yes:
Year Published Publication Scale Map Unit
Geologic Material Landform
4. Flood Rate Insurance Map:
Above the 500 year flood boundary? Yes No ❑ Within the 100 year flood boundary? Yes ❑ No [V
Within the 500 year flood boundary? Yes ❑ No 171 Within a Velocity Zone? Yes ❑ No ❑
5. Wetland Area. National Wetland Inventory Map
Map Unit Name
Wetlands Conservancy Program Map
Map Unit ,Nammee
6. Current Water Resource Conditions (USGS) c/05 Range. Above Normal l� Normal ❑ Below Normal ❑
Month/Year
7. Other references reviewed:
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 1 of 4 •
• Massachusetts Department of Environmental Protection Nor4A- Ewms Rol. (vorA-llamp}ov.
0 Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (minimum of Iwo holes required at every proposed disposalarea)
Deep Observation Hole: Date: 5/24/os Time: lo;oo Weather: CLudy 5oi
1. Deep Hole Number I Location (Identify on Plan):
2. Land Use: Wood 5 Surface Stones: Many Slope(%u): G Vegetation: P;4i
(e.g.woodland agricultural field,vacant lot,etc
Landfonn: 'III R;d9 a Position on landscape:
3. Distances from: Open Water Body zoo ft. Drainage Way IUD+ ft. Possible Wet Area IOD r ft.
Property Line 75 ft. Drinking Water Well I Co ft. Other_ft.
4. Parent Material: 6loo;ct Unsuitable Materials Present: Yes❑ No❑
If Yes: Disturbed Soil❑ Fill MaterialD Impervious Layer(s)❑ Weathered/Fractured Rock ❑ Bedrock ❑
5. Groundwater Observed: Yes ❑ No EY
If Yes: Depth Weeping from Pit _ Depth Standing Water in Hole Estimated Depth to High Groundwater: 36
Redoximorphic Features Coarse Fragments
Depth Soil Soil Matrix: (mottles) %by Volume
Horizon/ Soil Texture Color-Moist Depth Color Percent Gravel Cobbles Soil Structure Soil Consistence
(In.) Layer (USDA) (Munsell)
&Stones (Moist) Other
D -7" k SI... Ion 3/z— No>< <......6
7-16" 3 6L Z.5y51+ {.;e,Lt. ...^.ae'nre. co•4-s
16 - 1 ' IDVCa/b
SL 2 .5Y 5�5 36" 2 .Sy VI 57. lo% S% -ce,AL1,- w.afs.ae.
Additional Notes
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 4
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Adjustmentfactor
Ad]usten grOUna waterlevel
Depth of Naturally Occurine 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?
If yes what is the depth of naturally occurring pervious material?
If not,what is the depth of naturally occurring pervious material?
Deep Hole Number:
Location(identify on site plan):
Land Use/Vegetation:Lawn/grass
Landform:
Position of Landscape:
Distance front
Open Water Body
Possible Wet Area
Drinking Water Well
Date:
On-Site Review
Time: Weather:Cool&Overcast
Slope(%):
Feet
Feet
Feet
Drainageway
Property Line
Other
Surface Stones: none
T.P.# 1-1
Feet
Feet
Feet
DEEP OBSERVATION HOLE LOG
Depth from
Surface
(Inches)
Soil
Horizon
Soil Texture
(USDA)
Soil Color
(Mansell)
Soil
Mottling
Other(Structure,Stones,Boulders,
Consistency, %Gravel)
6_6/ .t
9,-Zii
abg6
/V�_
W II 12e Ufax
C,
A
1
sal,——
5c
LS
05
Np4 .
7.5y �Z
talr5/q
N.
Parent Material(geologic)
D_p
e th to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water: >
Depth.to Bedrock: >
Weeping from Pit Face:
BOARD OF HEALTH
MEMBERS
JAY FLEITMAN,M.D.,ACTING CHAIR
SUZANNE SMITH,M.D.
DONNA C.SALLOOM
DIRECTOR OF PUBLIC HEALTH
XANTHI SCRIMGEOUR,MHEd,CHES, BOARD OF HEALTH
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
(413)587-1214
FAX(413)587-1221
Site Suitability for On-Site Sewage Disposal
Project Number:
Performed by:M 4r M SOU
Health Inspector:
•
Site Address
crag
New Construction 0
Date: f
Equipment
T.P.a 1-1
212 MAIN STREET
NORTHAMPTON,MA 01060
Client Name&Address
/AV fl01-454 ,�/
v08 ,U. .ins 7J
Flo aSel p.14.
ed
f(;Ale.-krcies fen-
P!u reveal
Office Review
Published Soil Survey Available: No 0 Yes ❑
Year Published Publication Scale Soil Map Unit Drainage Class Soil Limitations
Surficial Geologic Report Available: No 0 Yes ❑
Year Published Publication Scale Geologic Material(Map Unit) Landform
Flood Insurance Rate Map:
Above 500 year flood boundary❑ Within 500 year flood boundary ❑ Within 100 year flood boundary ❑
Wetland Area:
National Wetland Invetory Map(Map Unit) Wetlands Conservacy Program Map(Map Unit)
Current Water Resource Conditions(USGS): Month
Range: Above Normal O Normal O
Other References Reviewed:
Below Normal ❑
I I I
Perc 1-1
Time
_________
Measurement
Time
Measurement
Begin Saturation
q:40
r-1 fj r/
Begin Saturation
{i 1 SGT
End Saturation
ti 6 rj
End Saturation
(&*My'
9"depth
Measurement
.i
101006/r4
9„depth
Measurement
i 6119 #,A1
6"depth
Measurement
l0:0164441
6"depth
Measurement - .. . -
--i-6.::.&l
ate+
Elapsed Time
9"to6"
3• d Irj
Elapsed Time
9„m6„
.3 pt1� �
Percolation Rate <2 nun.Pm
Bottom of Percolation Test Hole:
ercolanon Kate:
Bottom of Percolation Test Hole:
—Determination for Seasonal I i it W
Method Used
Depth observed standing on observation hole>
❑ Depth to soil mottles inches
Index Well Number
❑ Depth weeping from side of observation hole inches
❑ Ground water adjustment inches.
Reading Date Index well level
yoi A biztpu / 14415,4,1
Checklist for Septic System Plan Review /
B' Application page attached to plan
p-'PE or RS stamp, date,signature OR-P/2
<Variances to property line setback distance must have Surveyor stamp
E- Legal boundaries noted {7/5 /Z
/
IFi Easements notedot /f) -
Pi Dwellings and buildings existing or proposed noted
V Location of driveway or parking areas,other impervious areas
8 /Losation and dimensions of reserve area(new construction only)
/@ System design calculations
Q"Garbage grinder,yes or no
B"/Benchmark not disturbed during construction within 75ft of facility
• North arrow
R
Contours
Wi/ueep hole location(s)and data
!Y rc hole location(s)and data
1ations
Names of approving authority and soil evaluator
❑ Location of water supplies, public and private
o Within 400ft of system in case of surface water and gravel-packed public water supply
o Within 250ft of system in case of tubular public water supply
o Within SOOft of system in case of private wells(50ft from tank)
lY Well statement, if applicable-
C}'Jpcation of any surface waters, rivers,vegetated wetlands
£Vj,tCation of water lines and other subsurface utilities
Q/_pbserrved and adjusted groundwater elevations in vicinity of system
❑' f(ofile of system
2/Le us plan to show location of facility, including nearest street
p//tv�terials of construction and specs for system
71 aS baffle
Pj6in center line of tank
Se-washed stone - - ---hedule 40 PVC for trafficked areas, house to tank
Sy stances noted from house to tank, etc.
E sing is proposed,design and specs of dosing system _ N �.
When alternative technology is required,complete Ian and ecs indu ng hydraulic profile
DBrenches preferred over beds
(,,St poyancy calculations for tanks or components partly below groundwater level
JG7 ' slope outside of mound,toe ending 5ft from property line
❑_'
Local upgrade requests on the plan,all variances
6�Lo upgrade forms attached to the application
�o.,r std e ucA 1e .recw_c1 SO ' or 9K5�
Cis .F.jC`a doWn "rd . S nGH
ttes
BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMITH,MD.
JOANNE LEVIN,M.D.
Benjamin Wood,MPH,Director
Javede Mir,MPH.Health Inspector
Petiole Abbott RN,Public Health Nurse
Heather McBride,Clerk
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587-1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON,MA 01060
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE:As of 1/1/11, Septic System Permits will not be issued by the Northampton Board of Health
until we receive this form signed by the Northampton Conservation Commission Staff Member.
The Conservation Commission can be reached by contacting:
0 Sarah LaValley,Conservation,Preservation and Land Use Planner
SLaVa Ilev @northa mptonma.Rov
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton, MA 01060
Property Owner
�"�//et
Engineer: AzA /�prrp50t%
Cji
Cof1e atioommissr Conservation, Preservation and Land Use Planner
Date: I [Mk-
mow k ri\ra vwr ou>QA, but hj additkhittP distunbctroz
Address: /6//t% 1+1.5 fait
Commonwealth of Massachusetts
City/Town of
0
Septic System Installation Checklist
1.//s,�
B. Application Checklist (cont.)
2. Construction Inspection
a) Building Sewer(310 CMR 15 222) Approved N/A Problem
All waste pipes tied into building sewer Basement check LJ / ❑ ❑
Schedule 40 PVC 4'or cast iron Verify by reading pipe [� ❑ ❑
Minimum slope of 0.01-0.02 Visual fV ❑ ❑
Pipe laid in continuous straight line Visual ,.� ❑ ❑
Pipe laid on compact, firm base Visual L(,V ❑ ❑
Cleanouts precede all changes in Verify by visual/tape ❑ ❑ ❑
alignment/grade
Cleanout provided every 100 ft. Verify by visual/tape ❑ ❑ ❑
Back-till material clean Visual ❑ ❑
b) Septic Tank(310 CMR 15 223) App roved N/A Problem
Tank is set level with 6°stone under Check with level ❑ ❑
(15.228) ��,,//++
Tank is required size/loading per plan Verify with plan ,6G ❑ ❑
Inlet and outlet are at proper location Verify with plan IV'
❑ ❑
(15227) � //��
Tank is water tight(15.226) Test ,l�Y ❑ ❑
Outlet tees extend 6' above flow line Verify by visual/tape a#7. ❑ ❑
Approved filter device placed at outlet DEP list [2� ❑ ❑
Gas baffle installed at outlet tee Visual ,L.�,Y/ ❑ ❑
Inlet and outlet tees on center line Visual Q ❑ ❑
Tank is backfilled with acceptable material Visual L1l' ❑ ❑
Notes:
O!"- ev- cie4
Septic System Installation Checklist 11-09.doc•date
Form Name•Page 2 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist(cont.)
c) Distribution Box(310 CMR 15.232)
All outlet pipes at same elevation
per plan
Inlet tee min. 1°over outlet
Number of outlets
D box set on level base
Top of D box 36" max depth
D box is water-tight
D box has a minimum of 2"thick wall and
IT inside dimension
d) Pump Chamber(310 CMR 15231)
Tank is set level
Proper volume is provided
Float elevations set per plan
Min. 2"delivery line to D box
Number of pumps:
Specified pump provided or designers
approval for equal pump
Correct pump sequence
Covers set to grade
Electrical permit provided
6"of stone beneath chamber
Chamber is water-tight
Min. 91 cover provided
Correct loading provided per plan
Notes:
Check by adding water
Number of laterals
Visual and wltape
Visual
Visual and w/tape
Add water
Visual and w/level
Check plan and tank
Measure w/tape
Visual
Visual
Test
Visual
Visual on tank
Approved
per plan
are-
L1I/
Approved
N/A Problem
❑ ❑
N/A
Problem
❑ ❑
❑ ❑
❑ ❑
❑ ❑
❑ El
❑ ❑
❑ ❑
❑ ❑
❑ ❑
❑ ❑
❑ ❑
❑ ❑
Septic System Installation Checklist 11-09.doc•date
Form Name•Page 3 of 6
Commonwealth of Massachusetts
-p' _ City/Town of
fl Septic System Installation Checklist
B. Application Checklist front.)
e) Leaching Facility(310 CMR 15.240) Approved N/A Problem
No frozen material used including back fill Visual
No clay, tailings or stones larger than 6°for
cover material
Soil at bottom/sides of excavation matches
info on deep holes
❑ ❑
❑ ❑
[a ❑ ❑
All impervious layers removed Visual ❑ ❑
No remaining A/9 horizons Visual ❑/ ❑ ❑
Groundwater conditions match plan and Visual/check plan ❑ ❑
deep holes
❑ ❑
❑ ❑
/IS ❑ ❑
Pipe slope equal to 0.005. peck�1V3 • —?//////e. ❑ ❑
Leach area per design(15.241) t1J/ ❑ ❑
❑ ❑
,I_V ❑ ❑
Back fill material is acceptable �.t-A ly ❑ ❑
Vented if under impervious cover per plan
(15.241)
Vent is protected from precipitation
and animal entry
Cover of a minimum of 9°over each area
Excavation is level and at required dep
Removal of 5 ft material and replacement eck plan
(if in fill)
eck plan
Final contours correct per plan Check with plan
❑ CI/ ❑
Surface/subsurface drainage away from r, / ❑ ❑
each area 4JV/
Final grade and side slopes are stable (y ❑ ❑
Distribution lines are capped, vented, or rid" ❑ ❑
connected together —/
Impermeable barrier(15.255[2]) L✓ ❑ ❑
Retaining wall inspected by PE
Retaining wall is water-proofed
Retaining wall/barrier is at correct
depth/height
Septic System Installation Checklist I1-09.doc•data
0
❑ ❑ ❑
Form Name•Page 4 of 6
Commonwealth of Massachusetts
icesCity/Town of
ti Septic System Installation Checklist
B. Application Checklist(cont)
f) Leaching trenches(310 CMR 15.251)
Number of trenches:
Depth of trenches:
Width of trenches:
Trench spacing per plan
Stone is double-was 15.247)
g) Leaching fields (310 CMR 15.242)
Length of field:
Width of field:
Min. of 2 distribution lines
Separation distance conforms to plan
Stone is double-washed[3/4"to 1%1(15.247)
h) Leaching Pits(310 CMR 15.253)
Number of pits:
Depth of pits:
Stone is double-washed[3/4'to 1%1(1E247)
Each pit has min. 1 20"access cover
Piping network and configuration of
pits/chambers per plan
i) Tight Tank(310 CMR 15.260)
Approved N/A Problem
n/ �/ ❑
(/ Lh ❑
/ ❑ ❑
IV ❑ ❑
; ❑ ❑
LcY ❑ ❑
V
❑ ❑ ❑
❑ ❑ ❑
❑ ❑ ❑
❑ ❑ ❑
Tank is set level with 6°stone under Visual and with level ❑ O.F' p
Tank is proper size per plan Visual with plan ❑ ❑ ❑
Pumping contract has been provided ❑ ❑ ❑
Covers to grade Visual ❑ ❑ ❑
AN alarm set at 3/5 tank capacity Check floats by raising ❑ ❑ ❑
AN alarm test on separate circuit Set off alarm ❑ El ❑
Septic System Installation Checklist 11-09.1oc•data Form Name•Page 5 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont.)
j) Certificate of Compliance(310 CMR 15.021)
As Built Plan Submitted
Signed by Installer
Signed by Designer
Certificate of Compliance Issued
Notes:
Date
Date
Date
Date
Fr- G-475-
4 — .00 SIP d el_Lz.✓S
Septic System Installation Checklist 11-09.doc•date
Form Name•Page 6 of 6
Commonwealth of Massachusetts
c< City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
C Showers
Specify other fixtures:
6. Design Flow'.
Calculated Daily Flow:
7. Plan:
1
Number of Sheets
Sewage Disposal System Upgrade
Title of Plan
8. Description of Soil:
See Form 11
9. Nature of Repairs or Alterations(if applicable):
replace entire system per approved design
10. Date last inspected:
C Garbage Grinder(check if present)
C Cafeteria
518
Gallons per Day
440
Galion
Nov. 10, 2012
Date of Original
Revision Date
Date
Number of Persons Served
❑ Other fixtures
t5forml Adam 06/03 Application for Disposal System Construction Permrt•Page 2 of 3
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not 1. Location of Facility-
use the return
key 408 North Farms Road
Address or Lot
Florence
City/Town
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form 1A
d /5
tuber
$ /oa
DEP has provided this form for use by local Boards of Health it they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it
A. Facility Information
Application is hereby made for a perm
2. Owner Information
Neil Homstead
Name
Address(if different from above)
City/Town
o:❑ Construct a new on-site sewage disposal system
Repair or replace an existing on-site sewage disposal system
❑ Repair or replace an existing system component
MA
State
State
413-320-3728
Telephone Number
3- Installer Information
Name Name of Company
I 81R rDSt
Address
/JL Tfi-A*( p r Ai
City/Town
4. Designer Information
Mark Thompson
Name
P. O. Box 314
Address
Chesterfield
C,ly/Town
t5formta.doc•06/03
01062
Zip Code
Zip Code
tat pfo6U
State Zip Code
Z7 (
Telephone Number
Hilitown Environmental
Name of Company
MA
State
(413) 296-4499
Telephone Number
01012
Zip Code
Application for Disposal System Construction Permit Page 1 of 3
Commonwealth of Massachusetts
City/Town of Northampton
Application for Disposal System
Construction Permit
Form IA
/0/02- /6--
Number
$ ao
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
not to place the system in operation until a Certificate of Compliance has been issued by this Board
of Healt...��_
Signature
Date
�Appjication Approved By: ��
� ��' Date
Application Disapproved for the following reasons-
21 ii%r". •
jl
`!EALi p
t5forml a cloc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key
Commonwealth of Massachusetts
City/Town of Northampton
Disposal System Construction Permit
Form 2A
019/.?-/S
Number
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
intonation must be substantially the same as that provided here. Before using this for, check with
the local Board of Health to determine the form they use
t5form2a doc•06/03
Permission is hereby granted to:
t
Name
�9y /BC.S
Address
Name of Company
?fc..rv.(1�nl o r0 6 0
1 State Zip Code
City/Town
to perform the following work on an on-site sewage disposal system:
❑ Construction
® Repair or replacement
❑ Repair or replacement of system components
408 North Farms Road
Facility Address
Florence MA
City/Town State
Neil Homstead 413-320-3728
Owner Telephone Number
01062
Zip Code
The work to be performed is further described in 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 construction must a completed within three years of the ate low.
�-, P Ye
/42_
Approved by Date
T4 . 41/ -2
Title
212
I• UIi. =• •,r
HEALTH
01 060 Disposal System Construction Permit•Page 1 of 1
Important:
When filling out
forms on the
computer.use
only the tab key
to move your
cursor-do not
use the return
key.
Commonwealth of Massachusetts
City/Town of Northampton
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
information must be substantially the same as that provided here. Before using this for, check with
the local Board of Health to determine the form they use
t5form3 doc•06103
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
Z Repair or replacement of an existing system
❑ Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
DSCP Number DSCP Date
Neil Homstead
Facility Ovmer
408 North Farms Road
Steel Address a Lot g
Florece MA 01062
Ctty/Tovm State Zip Code
Designer Information:
Mark Thompson Milltown Environmental
Name, ,e y °�� Name of company
"
Signature Date
Installer Info ation:
Neme a / e/ Name of Company
fVtoN/
Signature Date
Use system is coP ��on co pliance with the provisions set forth below:
The issuance of this certificate shall not be construed ass�aa guarantee th t the system will function as
desi j. eel/
Approving Authority is 6 Po/a?
Signature
Date
Certificate of Compliance•Page 1 of
CHECK OR FILL IN W HERN:A1'YL1LAELL
No..45y
THE COMMONWEALTH OF MASSACHUSETTS
Nil OF HEALTH
(t O F ."
Appliratiun fur'tiupunul urke'Tuntitrurtiuu lirrntit
Application is hereby made for a Permit to Construct ( ) or Repair (L an Inc:nuttul Sewage Disposal
Fee,,_'i l i/
System t: nrs
LaaApq-"`
or Lot No.
Address
Iuesaler Ad'
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of person- Showers ( ) --. Cafeteria ( )
Other fixtures
Design Flow galiens per person per day. Total daily now galIon,_
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching are-l vl- ft
Other Distribution box ( ) 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 of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterltions—. nswer when appli ble -%f,� �h- fte4valL- LL__ /jai I '°2 tectra 14.40,
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary 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.
Si
k 't�
Application Approved By
use
Application Disapproved for the following reasons'
6'
Permit No._ -� /
Date
Issued._ .6? - _/_99.74'
Date e
THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH
1 pplirtttinn fur fliapnsttl ilinrkn nnztrurti n f rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an lndit idual Sewage Disposal
System ;t: - f .-� —s C
Location Address or Lot No.
Owner
Address
A
▪ — _ . ... .. installer Addrcss
Z Type of Building Size Lot Sq. feet
Dwelling-No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
et
yOther—Type of Building No. of person: Showers ( ) — Cafeteria ( )
L
E Other fixtures
Design Flow gallons per person per day. Total daily flow gallon..
4 Septic 'rank—Liquid capacity gallons Length Width Diameter Depth
a
ts Disposal Trench—No Width Total Length Total leaching area sq. ft.
z
Seepage Pit No Diameter Depth below inlet Total leaching are- l_ ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
aTest Pit No. I minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
z
D Description of Soil
4
3
�+ --s
J Nature of Repairs or AlterationL;>nswer when aappicAble_,-4y
t ! -C" " - `i24a∎ r at:k'-_ t /a.-+/ it i, it.,"
/
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary 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.
Sigtie,d „r
I
Date
Application Approved By
Date
Application Disapproved for the following reasons'
Date
Permit No._i^ Issued
Daft
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qtrrtifiratr of (finmplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
or Repaired
n:.tancr
at
has heen installed in accordance with the provisions of :Article XI of The State Sanitary 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.
DATE Inspector
//
NO....
Permission
to Construct
at No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Biopnottl.-Worko atnnotrurtion /remit
is hereby granted_/_ /-
or-Repair ( -an Individual Sewage Disposal System
t
street
as shown on the application for Disposal Works Construction Perm itNo
DATE
FORM 1255 Hoes & WARREN. INc
PUBLISHERS
FEE.-01-
' Dated—f ,
I of Health
No. NS 27
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH P '�«�2
/ own OF Nor4-4 wniphh pl. deh
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
:perndc ( 1 Abandon ( ) - I e mphne S Ster ❑Indiddual Components
.Appucatmn u[era .,., ,,,,,,, ,, _.
Qg
cr-��s Frm s ? L
/
ei � ovnf 44 �%<C170�'ISJ✓ °(�C
p
4o Wor/it >arms Rd. for¢nce PA O104.2
_
t�.�.o"
AJII{5,,
S94"VYJD
� id.Pnomn+
1II I N I ran meN '
)LU V,rvl.
Line
-w
In.110 .N( „n.
Po.&ox.314 Chen A `,e!d AIA- o1o(2
,o-,.,
296- 44-99
•��°•.
lcltphn0C•
TCICph lC♦
Type of Building: S) F
(C mily Dweflit'.,
3
Dwelling—No,of Bedrooms
Other—Type of Building
Other fixtures
Design Flow (min.required) 4-9S_gpd Calculated design flow 495 epd Design flow provided 499 gpd
Man: Date C/23 05 / Number 'sheets 1 Revision Date
'Mlle Se way_ I (3�OSaf i yr ee 4�
Description of Soil(s) Sec Co i ( F nt (. r rose, l(
Soil Evaluator Form No. Name of Soil Evaluator_AIL.-ln^firon Date of Evaluation 5124105
DESCRIPTION OF REPAIRS OR ALTERATIONS
No.of persons
Lot Size Sq.feet
Garbage Grinder (...-1
Showers ( ). Cafeteria ( )
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITU 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board ,
.,Signed
ad
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
N
�. ,!h!J "d� THE COMIMONWEALTH,OF MASSACHUSETTS
BOARD OF HEALTH
Jvwn OF r' VOri a eh dons
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
I Abandon [ ) - L4(�mpletc Scstem Individual Components
C avuct (tii Repair f )
1, Abandon f ) —
rFE (J0 -!11)
fi
41-1/4//r)
AppiIcat.( t P cant ,.
/'� j
�.�� .dr�/�o. !L f' rvn (tom°c(
(/
1vvltt �'Io is sower 1I,LCA onoJtJd-t c
9 C IOC 1
�,+d, e,„�1 k-, <e kill
i, i.,.
Add
GIhl2
— a.,raR.o-
��.
t-i.t no,..'
i--� r1 ! . ..SEtty cl1.c'„-/gI
o '
r'0 %ox 314 �l.ca crt,eTr( /"(4
mnan...>„m,
/god.
sews,
ra'rnowv
r.arn,.,,=
S
i.. /
Type of Building: � -� - �,
Dwelling—No.of Bedrooms
Other— Type of Building
Other fixtures
Design Flow(min required) 4
Plan: Date ! /:3/MS
Title . w avr jQ(7.%fl
fi ov e
3
No.of persons
Lot Size Sq.feet
Garbage Grinder (
( ). Cafeteria ( )
Description of Soil(s)
Soil Evaluator Form
gpd Calculated design flow i9 ow 4/S epd Design flow provided 4 gpd
Number otshects I Revision Date
{en, elyt�
Fi i
:e
• I C,=. I- �,, ; I
No.
Name of Soil Evaluator to I Acr Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
/2±/hS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
MU 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Boar - th.
s 7 , t i� Date
Inspections_
FORM 1 - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
t f,
Of
`5>THfit sn
ev
No.ri ,j �'.�
THE COMMONWEALTH OF MASSACHUSETTS
Ai briLIsomytati BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) �]l.omplete System
The undersigned hereby certify that the Sewn e Disposal System:Constructed( ).Repaired( ).Upgraded ( ).Abandoned( )
jr, V _ �/
ised
FEEII )b,O)
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
j Approved Design Flow Q %'/ (gpd)
plans relating to application No ^n —s dated ( >-�
Installer / = Ls—d`" /'l;" S'..'` /
-I
Designee f `avf - / +A-f. r, Inspector �t� -✓�.-i( - Date ''r,I( 7/
'i
The issuance of this certificate shall not be construed as a guarantee that the system will function os designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
bze
No.
THE COMMONWEALTH OF MASSACHUSETTS Fry
Nod-}-kna,p{-o.v BOARD OF HEALTH g'�74
//dill f"r/1/;.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Upgrade Abandon an individual sewage
Permission is hereby granted to C'/nst�ct ( t/J Repair (, ) pg ( ) ( )
disposal system at 7/ Ato I-1.^.y . r J01-i.— _� as described
,J
�/ //I5
in the application for Disposal System Construction Permit No. �/) is —� / .dated «
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date ,, ' O Board of Health •)
.Li p.N I
H
" l
FORK - DSCP DEP APPROVED FORM 5/96
FORM t2551REV 5/96}
IINW t Hopes&WARREN
PUBLISHERS - BOSTON