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79 Construction Permit 2017 (2) C;', \-t-M Com(1 Commonwealth of Massachusetts (s‘ck0 ) k c- 4 Cit /Town of Northampton oNumber ' hill=w Application for Disposal System Go_,1 Construction Permit Fee Form 1 A DEP has provided this form for use by local Boards of Health if 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 Important:When filling out forms Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system on the computer, ® Repair or replace an existing on-site sewage disposal system use only the tab key to move your 1=1Repair or replace an existing system component cursor-do not use the return 1. Location of Facility: key. �� 79 Ad Old Wilson Rod Address or Lot# Northampton (Florence) MA 01060 &01062 City/Town State Zip Code / 2. Owner Information Sandy Blackmon And Mary Fitzgerald Name Address(if different from above) City/Town State Zip Code 695-9961 Missfitz2@comcast.net Telephone Number 3. Installer Information TBD Name Name of Company Address City/Town State Zip Code 44444\ "sr fr.Ai Telephone Number Z C• ' j t� • 01. g. Designer Information • • .:., Alan Weiss Cold Spring Environmental Consultants Inc. Name Name of Company 350 Old Enfield Road Address Belchertown MA _ 01007 City/Town State Zip Code 413-323-5957 Telephone Number t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3 Commonwealth of Massachusetts aai7 ,N , — � City/Town of Northampton Number -4141111 - Application for Disposal System ‘,-.1-1 / Construction Permit Fee Form 1A A. Facility Information (continued) 5. Type of Building: Dwelling ❑ Garbage Grinder(check if present) Type of Building3 Bedroom Other: T yp Number of Persons Served ❑ Showers Number of showers ❑ Cafeteria IDOther fixtures Specify other fixtures: 394+ 6. Design Flow: Gallons per Day Calculated Daily Flow: G94 Gallons 7. Plan: 09.07.2017 Date of Original 01 Number of Sheets Revision Date Septic System Repair Plan Title of Plan 8. Description of Soil: Loamy Sand 9. Nature of Repairs or Alterations(if applicable): New leach field 14'x 38' 10. Date last inspected: Date t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3 :�v.y_.�i.�•`KTt71.:'-a`11�t�=Ji"Ii`IL.-- - -- - --- - - -. - ..�.�....�,..,-�...�---•-_ --.-.-_..__..__.- ----- --- - `•'-arl Aagnassissig Page I of 3 ALAN E.WEISS,10.-S-,RS,L.S.P. Licensed Site Professional Registered Sanitarian Hydtnoeolost -Wetland Consults President -Soil and Water Testing •21E Site Investigations • 350 Old Enfield Rd. -Percolation Tests and Date: 12c1'} Belchcrtown,MA 01007 -Septic Designs (413)323-5957&323-4916(FAX) -Title S Inspections • aeweiss@chatler.net Commonwealth of Massachusetts t\ic4N.g. 0 , Massachusetts . Soil S itabi lity Assessment for On-site Sewage Disposal . Performed By: ��4� 11.12. �S S S4 Date: glz.Ct4- W imessed - Witnessed By: Dew-• .4`)t 7 -Leel construction ❑ Repair L Pe Lib , ((AA- 0 Mce. V©?]ice Review ?ublicned Soil Survey Available: No ! v C"c Publish.73 l�l4rti 't3o�iCa-of Scale (nl5 Drain—ge Class Il�}{I Soli _i ma_t,OnS . J`=:Cici Geoiogic Rez-on Available: No ?1 Yes Publica_ion Scab 10(5 .: -:AiCciC Metal NET. • Flood Insurance Rate Map: •._. .. . . Above 500 yea flood boundary No ❑Yes Within SOO year flood boU idaiy No 2Yes ❑ Within 100 year flood bounda-y No ?AI; Wetland Area: 5 f National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range:Above Norma] eN rnal L Bel(,v Normal ❑ Other References Reviewed: kart DEP APPRO t'"3)FQ101. 12167195 y.r ±age2of3 Location Address or Lot No. 771' G lb /ice: i 0 . 0n-site Review' - • Deep Hole Number / 1/ Date: e _' _ Time: %SD Weather C lvs.1G� .6f Location (identify on site plan) Land Use v Slope(%O) Surface Stones 0 yPS Vegeta ion rZc (C• / L.ndiorrn ... • Position on landscap_ e iskett on the back) . ... _. . -._... . . Distances from: Open Water Body (CC 14 ; _,� Drainaoe moray .50 PossiDie Wet ,-.rea (CO c.r i..- t t Property '_frit. 2c) iw�z Dri„kine Water We' cC c4 feet Other aye:.. DEEP OBSERVATION HO= P i OG. , — Deed-:: . soil. f .S•-•317.----...s, _ J�.c - i:."=25) ; 3 ��S�r $`JJ:-JL $rii ,--- 2 ,:/ jf1 N'S ` s -a.:SGZ.$_":Y.S."Svi. .Cr . =.C; % 1 J eV �i a '4(fie } i I 31—k6 ` j4 r 1 3`� SSS I Cgy14 12. /r' 1 .6c, 1 ,t+44_ • A i r-5 i /0 l I IN r - 1 . i, '' LS 1zsiirv , • ' A- -7,6 I Ii . ' 1tu • . • 4 Ll • AI ,r • 1., 1 6 ALA - Farcrr.Mztoriaf {geologic) 6U 1 qs�. 4 7r\ D $edvdc fiiJ "f'`\• ' De9Th to Groundwater- 5:anding Water in the Hole: /c5"-f-, 19' v, Weeping from Fr race: 49 Estimamd Seasonal High Grund Water: go" 1 e ss D 'AP?ROVED FOB -nir,195 1 • r..r 414 / Ct Ss f QS ± 3 COLD SPRING Commonwealth f Mas chusetts ENVIRONMENTAL, INC. ►�_ , City/Town of a��� 461 f 0 350 OLD ENFIELD RD. Percolation Test BELCHERTOWN, MA 01007 z= v w" Form 12 Quet55 La �.n5f-40r.me4 q t 3 57-S-5`I Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. 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 form, check with the local Board of Health to determine the form they use. Important:When A. Site Information filling out forms 2 i� • on the computer, 5 ( � I�� /fit C use only the tab �G c%E- W-'\ / ! key to move your Owner Name cursor-do not 71 d u L 1 i L 5 t_J /'" use the return Street Address or Lot# key. /V0 e/6,4 2 �abCity/Town State Zip Code , 11(... Contact Person(if different from Owner) Telephone Number Nern B. Test Results ik 7 DaTime Date Time Observation Hole# /� Depth of Perc v. 2`/ Start Pre-Soak '/i< End Pre-Soak fje �� Time at 12" q Time at 9" (" �� ,4!/, .rGlril Time at 6" g Time (9°-6") / Rate (Min./inch) ' (.)F M.4S'• ;= ' Test Passed: Test Passed: ❑ �e ,...tvat yG Test Failed: ❑ Test Failed: ❑ jf }� � Test Performed By: .1 'i i ,f ,• o,:rte,: I 4- • 4'-'( J�( k�D�{ 0"•`'‘.4' t , Board of Health Witness • - Comments: t5form12.doc•08/15 Perc Test•Page 1 of 1 dge J OI .5 Location Address or Lot No_ • Determinaiotz or Seasonal Hi'Ji Water Table Ma shod Used: — Depth observed standing in observation s pth weeping from i hole._...... inches observation hole... .. Depth to soil mottles Inches .. inches El Ground water adjustment ._._-___. €eet • • Index Weil Number _._.._.._ Reading Date Adjustmentfactor _.- Index well level Adjusted around water level -.-of - Naturally Occurring Pervious Material Doest least sour feet of nature/1y occurring pEr- e :iS rh :e;i^e exist ! 1 ctSd - s0=5%0;= the area proposed for the absorption system? If not, what is the depth r" naturally - Jf na� 7 !• oCcurr.i 7�g pervious material?• Lit ift�ation certify that on 0 , approved by (date) I have passed the the�e r�r:tent of� soil evaluator examination was performed by Environmental Protectors and that the above analysis formed me consistent1 _ with the required training, expertise and experience was rf ind310 CMR 7_ Signature Date r 71b • (--- -z OF �f #9 3 z m • omitb I , aras � DET.'APPROVED FORM- t 2/0719s C',. >r2.P° Plan Book 50 Page 29 00.I MI I . F a u� A44, er frm. /10-.4.. 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