661 (Mistaken as 666) Title 5 Application/Permits 1998, 1997, Water Analysis Report and Soil Survey No.
Cory
J
FORNI 11 - SOIL t1 ALL ATUR FORNI
Page t of 3
Date: 3-14- 7
Commonwealth of Massachusetts
oeal—ftw TOt3 , Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By: Ti4c3tky S 4A cUUUIS AS ,
Witnessed By: ficrsg o -1
Dam: 3-/3 'iQ
II-- -
m- 666 N RTN .ine.MS PG
• Noa-&]nm•p]ZSrJ , Y41A
New Construction [d�Repair ❑
wT-•�^�. PA-rizicC- 60(--.(S/ -
:. W:..`• 626(o 4077J1 FAeYNS RC.
/S'O(t130/1'yjDA! 41,2 7/e 6C
«;3) 5se- ozsy
Office Review
Published Soil Survey Available: No ❑ Yes
Year Published /95.0 Publication Scale /1;am e, Soil N1„p Gan
Drainage Class 4 ley We.I I Soil Limitations f-;4: Get; iA✓<n;oC-
Surficial Geologic Report Available.: No ❑ Yes ❑Year Published Publication Scale
Geologic Material (Map Unit)
Landforrn RiOcC
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes �2
Within 500 year flood boundary No gYes ❑
Within 100 year flood boundary No Le/Yes ❑
Wetland Area: -
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS): Month
Range :Above Normal 2/Normal I ❑Belc v Normal
Other References Reviewed:
UFY•ItMOV D FOMM-I:AI;YS
A
rUR\I 11 • SOIL EVALUATOR FOR\1
Page 2
On-site Review
Deep Hole Number1� Date: 3-13 - 9 r Time: 1 / 00 f/1
Weather C LLF.¢1 c,
Location (identify on site plan) -105' FKd4.4 Li/u7cK of 57-()n16 (,./;[,L
Land Use .VAC AA)I Slope i°%),?'./0 /'Surface Siones FE co
Vegetation UPCRND Fa RE OM- P E CEDAP X M ^°
Lendiorm
Position on landscape (sketch on the back) N(u 5E-C,To ) PF ??-o p U 1-J/ _
Distances from: l
Open Water Body 700 feet Drainage way feet
Possible Wet Area /00 r
feet Property Line— 2-s r feet
Drinking Water Welt 72o0 ' feet Other
DEEP OBSERVATION HOLE LOG
Depin ham Susan I Sod Haruon
IIncne ■
Sod Tenure Sol Cover
IUSDNI ,IMunnlll
•
Sod Monona
SA•1P
LtiR d l
m �lz.
Omar
ISIfuClun. Stone, 800MHL.
Canssrency- % Gfa Vel'
ti/11 ciols/Cf26 P,A.,C
a
Nl ll LTA
/2 t �� hn/ I/Cv/R '-/> ( M/11
02D ' /zo
/c /R 3/r*
FEw Soo s
FR ,AG/ :
7t,171 /D / c>k
P30,7“OcRs
nraacG. rr10.151s;
Parent Material (geologic) 17L L Depth to Bedrock: N IC,
Depth to Groundwater: Standing Water in the Hole: /11 Weeping from Pit Face. /6c
Estimated Seasonal High Ground Water: WGP.0C U(35c.j-'V
FORM It - Soil. L\ ALL .11OR FORM
Pa 3 of 3
Location Address or Lot No. GO' / fi l - AKt -1 iA 7,1c /,'pry's /dct,Tr>,hp-70,1J
-
Determination for Seasonal High Water Table -
Method Used:
,�/ Depth observed standing in observation hole /1/ inches
L'J Depth weeping from side f observation hole /')O "inches
0 Depth to soil mottles N//-1 inches
0 Ground water adjustment feet
Index Well Number
Adjustment factor
•
Reading Date Index well level
Adjusted ground water level /d3
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in ali areas
observed throughout the area proposed for the soil absorption system? -/e3
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on ///q5r- (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 I u...
DEP APPROVW FOAM•12,07;95
Wel
U
AGIN NIS
No. 9E2
AFGISTI-°„
`A NIT APtn.
ate
Gre
TIM'' HY
E.
CO
FORM 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS_
AIORTt14M(J ION , Massachusetts
Percolation Test
Date: .3- 13 ''77 Time: [lb P„^
Observation Hole #
,/
Depth of Perc
_ % 6 ,/
Start Pre-soak
/0 f
End Pre-soak
is 05-P/14
Time at 12"
/ : 2s"PM
Time at 9"
_ l/5- P/14
Time at 6"
2 ,' /6 PM
Time 19"-6"1
a Sal okhri S
Rate Min./Inch
33
"co 0 NASxf
Site Passed Q Site Failed ❑
MAGINNIS
No.982
RfC151F0
AN IT 0
Performed By: I.kriffy E . lMt/ (dtJAJis FS
Witnessed By: PF 1 R IVtc CRCAst) " (ti C -J A(LECCA
Comments: QaS((3 /YI ,NI/V1Lof JO FYI P7
--r-
e
� LIYSS .ILL .Si/ C) - /5.MMpt ,4E At^FJUpg{)
ruKN1 11 • SOLL ENALLAfOit FORM
Page 2
On-site Review
Deep Hole Number si / Date: 3-33 -479 Timer /foe pm WeatherdLGWR/[oLQ
Location (identify on site plan) S. /5 ' 50-Th of 50E 8crrek
Land Use V/:lGHN7 Slope i%j ' /0 /°Surface Stones G=.
VegetationUPL.1J raft)) — OAR-, plue , X-MAS1iP-CCs/ ety)fk/ CAisSEZ
Landform
Position on landscape (sketch on the back) Ai (v i6�r.1N cF A?cfosaD Lo-,--
Distances from: / _I
- -Open Water Body 7/00 feet Drainage way feet
Possible Wet Area 7/00 feet Property Line ' 1 r feet
Drinking Water Well 7200 r feet Other
DEEP OBSERVATION HOLE LOG
Depth from Surtta
ranches)
Son Horizon
Son intuit I son Color
IU$D41 .IMunstlll
•
$on Motong
0- I1 /, A 5/away
Lok„tl
'1 - al
al /32
SAL.)DI
0Ret
-OIMr
ISINQur. S1oM6 6ObMVI
Cons■vrency. % Gravel.
�
/
/a 3�' N � yeuc. oRC-P,u,L
M/77si<
/ot/R.3/6 NJ,9
/o/R '/ ti/A /u ��, 61pVL
Qc.,tDg<
Few Sfo�es
FR-AGCs
Parent Material )geologic)
peoth to -Groundwater:
Depth to Bedrock: ti /A
Standing Water in the Mole: No•jE Weeping from Pit Facet
Estimated Seasonal Hlgn Ground Water; 7 /U V CNONc ✓g5Fp VG1
FORM 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS
/JoRThAq TOrl , Massachusetts
Percolation Test
Date: 3 -13 - 9 Time: •2:00 Ptiii t
Observation Hole #
d a
Depth of Perc
/ Orr
Co
Start Pre-soak
-
End Pre-soak
5 sPM
Time at 12"
/: S5-PM
Time at 9"
:c20 Pm
Time at 6"
Time 19"-6"1
Rate Min./Inch
Site Passed Er Site Failed ❑
Performed By: T40f6y 6' tirlA6JAW,J )< X5,
Witnessed By: PETER /4CEPLAuJ eviC,TH RA&C
Comments: D65/610 /S M P1 - Ctnss // :56/ C
No
FORM 3A - CERTIFICATE OF COMPLIANCE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ltJoKFMmq,.) MA , MA.
Fee
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) L'Complete System
The undersigned hereby certify that the Sewage Disposal System;
Constructed (✓1, Repaired ( ), Upgraded O, Abandoned 0--
by: D MC COA/57 uCT10Al CO
at:
66,6 iyoRm FAiams Rcno — LoT4
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.
dated . Approved Design Flow 725 9ifgpd)
Installer DM CCuS)RuC1 )0)U CO. — A M})ERS), rylF}
Designer..%) OHy 5 MA6//VrU)S Inspector .44 crER(s A)
Date /Z_ 0,_9y
The issuance of this permit shall not be construed as a guarantee that the system will
function as designed.
OEP APPROVED FORM 5)96
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F G THE COMMONWEALTH OF MASSACHUSETTS All 'V y/i7
. � / / / ere,
ii�oc
+> by { '`1J ASSACHUSE7T5„ pion
f ispusni $g em (dung s p Permit
FEE
❑ ° ea N Irmission is ereby granted to V.I.
E ... y
c St!. 5nt3truct( or repair( )an On-site Sewa• System located at
p
m c .-f• O rt
.s
o
�5�p�' described in the above Application for Disposal System Construction Permit. The applicant recognizes his!her
""4 t comply with Title 5 and the following local provisions or special conditions.
',-1 �onstruct�iionn must be completed within two years of the date below.
te 8 V, 4 ° •T 1257 Approved by
FOAM¢55 Rev a/95 AM SUL KM CO ESTOM MA
THE COMMONWEALTH OF MASSACHUSETTS
FrF
Ct) -
MASSACHUSETTS
application for !ispoont $gstem Construction Permit
Application is hereby made for a Permit to Construct ( ) o Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No-
6/AOI-VAr ,
'ts 6'0+.
owner's Name.Address and Tel.No.
/4Jri7GV fr2J,/Jas 7Lc
Installer's Name.Address.and T
DM D Co-n,1-
No.
Designer's Name.Address and Tel-Na
y�j 118 in.,is
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
Design Flow
SF
Garbage Grinder
No per Persons Showers( )
Cafeteria( )
Plan Date 11
Title
72_5 gallons per day. Calculated daily flow
Number of sheets
e%l gallons.
Revision Date
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected.
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by t 7 and of Health. �y
Signed :•ii <' i Date /1 21/97
Application Approved by �i ee v Date /%/ /4 %
Application Disapproved for the following reasons
Permit No Date Issued
THE
COMMONWEALTH I OF MASSACHUSETTS
-' / I MASSACHUSETTS
Certificate of Compliance
/$-/y.T. CEyyRTIFT,j the-Ofsitel$eyza�f Disposal System installed (� of fepaire0,replaced( onr
at ' lyeg4een-cpgstructed in
accordange wan Ehe,provisions of Title 5 and the for Disposal System Construction Permit No ' r dated
/ Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this ceee cote shah twit be coat as a guarantee that the system will functionessigned. This
Certificate expires on
DATE .0 f I )�� Inspector - z r - ��
u
Ca' Ef)
2i.c
"4 N
TS• .i
te n o a
V y N 8 0 •
E .,� m N g]ermrssmn ereb
p " Ot�c strati( or
c-
THE,COOMMMONWEA TIC H OF MASSACHUSETTS /// ~
/"/�i` /I'i141.)- '—�-•MASSACHUSETTS FEE 57
3�ispnsal $g1emInnsteuctinn lermit
u
repair granted to
&i(7I ,�Dr-J -rc:7),.v
it( ) an On site Sewage System located at
G�) djs described in the above Application for Disposal System Construction Permit. The applicant recognizes his;her
s.tiyttto comply with Title 5 and the following local provisions or special conditions.
€e N
tl1 i[%l. onstructiortpust be c rgpleted within two years of the date below. /.
2J N COY �/a+. •9, / i< �
ei y �p 'E (- ` Approved by
FORM¢55 Rev 195 A.M.SULKIN CO-BOSTON MA
THE CO
A. i
MONWEALT
Jertifie
that he On ice Sewag
OF MASSACHUSETTS
. MASSACH US ET7
to of (Inmplittnre
Disposal System installed
for
gas
JAN 1 21998
pr .NS
�r rep ,, ona
THIS IS TO CERTIF I O t . t % . '
,n I AM / ,
as been constructed in
at Construction �i""%� dated
accordance/with,the pr visions of Title 5 and the for Disposal System Construction Permit No
d 5// / • Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be co s trued a guarantee that the system will function as deli ed. This
Certificate expires on
...74etil I ) %57r Inspector �•r
DATE