13 Disposal Const Application 2019 Common ealth of Massachusetts
City/Town of NORTHAMPTON Number
Application for Disposal System $
,e Construcion Permit Fee
Form 1A
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 Iformation
Important: El
When filling Application is her by made for a permit to.M Construct a new on-site sewage disposal system
out forms on Repair or replace an existing on-site sewage disposal system
the computer,
use only the Repair or replace an existing system component
tab key to
move your 1. Location of FFacility:
cursor-do
not use the 13 MEADOW AVENUE
return key. Address or Lot#
y)f�l FLORENCE MA 01062
Y� Cityrrown State Zip Code
Henan
2. Owner Infor Imation
TOM HILBINK c/o DOUGLAS THAYER
Name
Address(if different from above)
ft®RENCEI MA 01062
City/Town State Zip Code
413-585-5994
Telephone Number
3. Installer Infolrmation
DAVE LOVEN
Name I Name of Company
230 RESER OIR ROAD
Address
VMSTHAMPTON MA - 01027
Cityrrown State Zip Code
413-527-5184
Telephone Number
4. Designer Information
MARK TI-10- –PSON HILLTOWN,ENVIRONMENTAL
Name Name of Company
P. O. BOX 314
Address
ghEsMifififf IELD MA 01012
Cityrrown State Zip Code
(413)296-4499
Telephone Number
t5form1a.doc•06/03 Application for Disposal System Construction Permit-Page 1 of 3
A. Facility Information (continued)
5. Type of Building:
® El
Dwelling Garbage Grinder(check if present)
Other: Type of
Building Number of Persons Served
Showers Number of showers ❑ Cafeteria ❑ Other fixtures
Specify other fixtures:
6. Design Flow: 451
Gallons per Day
Calculated Daily Flow: 330
Gallons
7. Plan: MAY 1. 2019
Date of Original
1
Number of Sheets Revision Date
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: Date
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 Health.
Signature Date
t5form1a.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Application Approved By:
Name Date
Application Disapproved for the following reasons:
t5form1a.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
HOLE: DH 1 (ELEVATION-101.17) DESIGN CALCULATIONS CONSTRUCTION NOTES
DEPTH HORIZON TEXTURE COLOR REDOX FEATURES DESIGN DAILY FLOW RATE 110 GP=wROOM x S BEDROOMS-330 GPD 1, CONTACT THE SYSTEM DESIGNER AND HEALTH DEPARTMENT PRIOR TO STARTING THE INSTALLATION SO THAT SUBGRADE AND FINAL INSPECTION ARRANGEMENTS
0.0' A 8L 10YRSl2 NONE DESIGN PERO RATE:6 MINUIESRNCH(TESTED QS MINUTE9ANCH) MAY BE MADE
8-20' B LS 2.6Y 614 NONE SYSTEM LEACHING AREA: X LOTISSERVED BY MUNICIPAL WATER.NO KNOWN WELLS WITHIN 200 FEET OF PROPOSED SOIL ABSORPTION SYSTEM(SAS).
B 28Y SM NONE SIDEWALL:21.76'x (21.78'x1 3. EXISTING SEPTIC TANK TO BE PUMPED,CRUSHED AND BACKFILLED.
70.118' C L
( 40') ( 2-)-180 SO.FT. 4. ALL PLUMBING IN HOUSE TO BE REROUTED TO LOCATION AND MINIMUM ELEVATION SHOWN ON PLAN.CONFIRM FEASIBILITY OF PLUMBING CHANGES PRIOR TO
ESTIMATED SEASONAL HIGH WATER TABLE>IIS`(El"ATION-81.80) BOTTOM:40'x Ir-4808%FT. INSTALLING SEPTIC TANK
S BUILDING EXIT RPE TO BE 4"DIAMETER SCH.40 PVC OR ABS WITH A MINIMUM SLOPE OF 2%AND NO SINGLE BEND GREATER THAN 22 DEGREES.PIPEFROMSEPTIC
TOTAL 13080.FT.•480 SM FT.-S10 SOL FT. TANK TO D430X TO BE 4•SDR 35 WITH A MINIMUM SLOPE OF 1%.
HOLE: DH (ELEVATION-106.60) LTAR(CLASS1801L):810 B0 Fi.x0.740PDI80 Fr. 451 OPD 7LOCATION AND ELEVATION OF SEPTIC TANK MAY BE ADJUSTED IF MINIMUM SETBACK AND SLOPE REQUIREMENTS ARE MAINTAINED.
DEPTH HORIZON TEXTURE COLOR REDOX FEATURES . SEPTICTANK AND MOX ARE TO BE PLACED ON A SIX INCH BED OF STONE TO PREVENT SETTLING AND SHALL INCLUDE INLET TEES AND EFFLUENT FILTER(POLYLOK
PL-W)AS SHOWN IN PROFILE DETAIL
O-T A SL IOYR$12 NONE & GALLERY TO CONSIST OF FOUR U.SL CONCRETE LEACH GALLEYS(S'L x 4'W x 13"D)WITH THE TWO INTERIOR GALLEYS HAVING SIDE ENTRY PORTS.
0-20' B LS 2.6Y 614 NONE 9. SET LEACH GALLERY AT ELEVATION NOTED IN PROFILE,BACKFILL TO PROVIDE A MINIMUM 12"OF COVER AND MOUND SLIGHTLY TO DIVERT SURFACE RUNOFF.
10. FAR END OF GALLERY TO HAVE A SCREENED VENT PIPE EXTENDING 36"ABOVE GRADE
20-110- O LS 2.6Y SRI NONE 11. ALL DISTURBED AREAS INCLUDING THE SOIL ABSORPTION SYSTEM TO BE LOAMED AND SEEDED(HAY MULCH MAY BE NEEDED ON SLOPES AND DURING WET TIMES OF
ESTIMATED SEASONAL HIGH WATER TA13LE>120"(E(ELEVATION 90.60) YEAR
12. '
SYSTEM IS NOT DESIGNED TO ACCOMMODATE A GARBAGE DISPOSAL
13. AVOID DRIVING OVER THE SOIL ABSORPTION SYSTEM ONCE INSTALLED.
PERCOLATION RATE:S MINUTESRNCH 14. SYSTEM COMPONENTS TO BE MARKED WITH MAGNETIC TAPE
1S. GALLERY ACCESS COVERS TO SERVE AS SYSTEM OBSERVATION PORT WITH AT LEAST COVER HAVING A RISER TO WITHIN 6"OF FINAL GRADE
SOIL EVALUATOR:MARK THOMPSON 16. FIELD VERIFY DISTANCES TO PROPERTY LINES PRIOR TO ALL CONSTRUCTION AND OBSERVE LOCAL SETBACK REQUIREMENTS.
WITNESS:DANIEL WASIUK 17. NOTIFY DESIGNER IMMEDIATELY OF ANY SITE CONDITIONS THAT ARE NOT NOTED OR INCONSISTENT WITH THOSE SHOWN ON PLAN.
1& CONTRACTOR IS RESPONSIBLE FOR ALL HORIZONTAL AND VERTICAL CONTROL
DATE:MARCH 20,2018 19. ALL CONSTRUCTION TO BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL CODE
GALLERY CROSS SECTIONAL DETAIL(END VIEW) LEACH GALLERY DETAIL(NOT TO SCALE)
(NOTT08CAL.E) -
\ FINISHED GRADE pp 2%CROWN D4IOXLINE FROM SEPTICTANK
BURVEYMARKER ELEV.-81.00 V �/ �( I L( ACCESS COVER
�-
c:<_._._.:IG )� ..Y
�- _
TUM:HIM IN IC MAPLE TREE / �~FOUND COVERWITH --.....-_--- -N - pmpECRON POEM 4•PERF.PIPE
ASSUMED ELEVATION-100.00' / 1 MINIMUMIr CFCOVER �_ACCESS COVER RISER
2"OFPEASTONE INCLUDES 4.OFTOPSWL TOWITHIN S"OF GRADE
/ I _ ............. ... ...
% I 'PIPE INVERTkgRaIgmi
O END °OO8 • • •
i I ELEV.-08.00 ......■ CAP --exxilr
• 101 SS 87 0° ME....•• Caum
/i 108 1 I 1 3W-IIWDOUBLEWASHED STONE N4•-11R'ooUSUDWASHEDSIONe 4•
101I8 1 1 I
/ PMUSHROOM I I 1 I ELEV.BOTTOM OF�73 HIGH GROUNDWATER ELEV.BELOW 81.60 Z •GAILLERYTO OONSISTOF FOUR UNDERGROUND SUPPLYCONCRETE GALLEYS
/ I VENT 1 1 I (4'XWx181EACH)INSTALLED AS SHOWN WITH PRECAST41PERFORATED PIPE
I •FOUR FEET OF DOUBLE-WASHED 3W TO IW STONE AROUND GALLERY (THE TWO INNER TANKS ME TO HAVE SIDE ENTRY PORTS)
% �ITTREE 1 I NINE INCHES OF DOUBLE-WASHED SW TO Ir'STONE BENEATH GALLERY •FOUR FEET OF DOUBLE-WASHED NP-I Itr STONE AROUND ENTIRE GALLERY
i 1 I •BREAKOUT FILL TO EXTEND IS'IN ALL DIRECTIONS FROM EDGE OF STONE •NINE INCHES OF DOUBLE-WASKED STs'-11/4•STONE UNDERNEATH GALLERY
/ 1 •
\\ TWO INCHES OF •DOUBLE WARRED PEA STONE OVER ENTIRE GALLERYATLEAST ONE GALLEY ACCESS COVER TO HAVEA RISER TO WITHIN S•GFGRADE
/ I W2 •AT LEAST ONE ACCESSCE88 COVERTS HAVE IDSERTa WITHIN 6-OF GRADE •CAPANDVENTOUTLEFENDSOFGALLEEFFECTIVE SME OFGALLEW.40'L.Irw
INbFECT10N PORT I.7l70
i
/ ;: \ i
/ \
off t ::..:::> i 20'DIAMETER WATER- COVER GALLERY WITH 2'OF DOUBLE•
n6Nr RISERS To
SYSTEM PROFILE WASHED 118-,1rPEASTONE
1600 GALLON \ \ \ I 4TANK LEACH GALLERY WTTHINS'OFGRADE
\ 4VLx1rWx1RBD IF BURIED 2.12' EXTEND36'ABOV GRADEVENT
RISER
`•� BEPncrANK � i INSPECTION PORT EXTEND88'ABOVEORADE
` ° 1 RISER TO TO WITHIN 8'OF rA CROWN WITH FINAL
` EXISTING WITHIN GRADE
OF GRADE SEPnOTANX B' GRADE ELEV.•101.00
` .
---------------------------------
-----------
•.;.., �� ! CELLAR WALL '• MIN.12-COVER INVERT
�.:.. I -
88
MAX. COVER
ELEVATIONS
i PVC CH ptC
(4'OF TOPSOIL)1s-aciLisA 108.55
WATERLINEToB 108.00
BE CONFIRMED18BCH.40TEE•
POLYLOK PL6S FILTER' C 102.75
*�. A D • D F H.M..=m D 100.17
MINIMUM 8"BED OF STONE ==.M m m
EX[TPIPE E E 100.00
` ! ELEVATIONF 99.00
26' 40• , *BOTTOM OF STONE
I G* 97.75
SCALE C..: D-BOX
0I 1600 GALLON SEPTIC TANK WITH RISER FOUR TANK 1 E.S.H.G.W.BELOW 91.60
LEACHING GALLERY =
HILLTOWN ENVIRONMENTAL CONSULTING LEGEND SURVMAYIL26,2010 CLIENT JOB TITLE
SCALE I'-W DRAWM:N:YAY 1,20,5
P.O. BOX 314 13ENCHVMXCTM TOM HIL13INK SEWAGE DISPOSAL
CHESTERFIELD MA 01012 ASSUM ASSUMED
TION- REVISED: c%DOUGLAS THAYER SYSTEM UPGRADE
F Ew6nNecommMouR-AnGN--co P.O.BOX 80822 13 MEADOW AVENUE
(413)296-4499 PROPOSED(FILL)CONTOUR N FLORENCE,MA 01082 FLORENCE,MA
DEEP OBSERVATION HOLE 6M (MAP 22B LOT 20)
HILLTOWNENVIRONMENTAL@GMAIL.COM PERCDUTIONTEST HOLE 0 (413)585-5994
Commonwealth of Massachusetts
City/Town.of NORTHAMPTON
Number
Disposal System Construction Permit
Form 2A
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information ust be substantially the same as that provided here. Before using this form, check
with the loca Board of Health to determine the form they use.
Permission is hereby granted to:
Important: DAVE LOVPN
When filling Name Name of Company
out forms on
the computer, 230 RESERVOIR ROAD
use only the Address
tab key to WESTHAMPTON MA 01027
move your City/Town State Zip Code
cursor-do
not use the to perform the following work on an on-site sewage disposal system:
return key. P 9 9 P Y
r� ® Construction:
❑ Repair or replacement .
Repair ar replacement of system components
i
13 MEADOW AVENUE
Facility Address
ft®RENCEI MA 01062
City/Town State Zip Code
TOM HILBINK 413-585-5994
Owner Telephone Number
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 o special conditions:
All construction must be completed within three years of thei date below.
Approved by Date
Title
t5form2a.doc•06/03 Disposal System Construction Permit•Page 1 of 1
I
Commonwealth of Massachusetts
City/Town of NC I RAMU�Tz�N
- Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
A. Facility Information
Owner Name /�/f L/►�
1.3 1 I ct dyV � 1 y e-in tit L
StreeFt^Address Map/Lot#
City State Zip Code
B. Site Information
1. (Check one) ❑ New•Construction [Upgrade ❑ Repair
2. Soil Survey Available? []/Yes ❑ No If yes: /9a/ USz)ASo-J _A
j�
source / Soil-Wap Unit
%r1L le R,.r —Pi ! e—C
Soil Name Soil Limitations
C �L4461_"C{5 IN C e
Geologic/Parent Material Landform
3. Surficial Geological Report Available? ❑ Yes ❑ No If yes:
Year Published/Source Publication Scale Map Unit
4. Flood Rate Insurance Map
Above the 500-year flood boundary? 0/Yes ❑ No Within the 100-year flood boundary? ❑ Yes R/No
If Yes,continue to#5.
5. Within a velocity zone? ❑ Yes - QKNo
6. Within a Mapped Wetland Area? ElYes ONO MassGIS Wetland Data Layer:
Wetland.Type
7. Current Water Resource Conditions(USGS): Range: ❑ Above Normal ❑ Normal .❑ Below Normal
Month/Year
8. Other references reviewed:
ASSESSMENT PERFORMED BY
HILLTOWN ENVIRONMENTAL
P.O. BOX 314
CHESTERFIELD, MA
(413) 296-4499 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page i of
HILLTOWNENVI RON M ENTAL@GMail.com
Cotmi-irtc,„wealth r Massachusetts
Cit /Town of
rt Foy° n i i i - Sc-d Suitability Assessment for On-Site Sewage Disposal
4" ',
4R C. 0 c- ' Re Rei' m continued
IZ� Zo19 > ,. 3o _ L,�,�
1~-=e 'bservatir Hole Number: - —
Date Time Weather
Grow.;.:, [Elevation :t Surface of Hole: Location (identify on plan):
ove�ry Coc.w,r1.
2. Lan,,.' '.';�e - -
fo.g�nd,agricultural field,vacant lot, etc.) SurfaceStonesSlope(°rb)
4egetation Landform Position on Landscape(attach sheet)
3. Distances from: Open Water Body -ZD,o 4- Drainage Way Possible Wet Area
feet feet feet
�
Property Line o o Drinking Water Well Zoa 4- Other
feet feet feet
4. Parent Material: o`'t 'us Unsuitable Materials Present: ❑ Yes 9-116'
1. `(c:�.: ❑ rL..,,urbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
5. Grcundvvater Ob,,.teed: [] Yes If yes:
Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth High Groundwater: y r+
inches elevation
3 Redoximorphic Features Coarse Fragments
Soil Horiio?,11Soil Matrix:Gator- (mottles) Soil Texture % by Volume Soil Soil
Depth (in.) i Consistence Other
i Layer iWoist(Munsell) (USDA) Cobbles.& Structure
Depth �clor Percent Gravel (hfoist)
i Stones
U- loY(� J L /00-le C.rLie4
� Z
� � LL
h'►�SSrife �{-a,�l'� t''�o'f5
f
I �
i
Additionai Notes:
m 11 •rev. 1/10 .Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page of
Commonwealth of Massachusetts
City/Town of 106,4k::1nP
gin Form I I u Soil Suitability Assessment for On-Site.Sewage DisposE.
C. On-Site RevieW (continued)
Deep Observation Hole Number:
Date Time Weather
1 Location
Ground Elevation at Surface of Hole: Location (identify on plan):
2. Land Use Over 1_0vtn e-.
----�— -—
---Jeig7�i-woodtdndi-agricultural-fieldi-vacant-iot�-eto- Surfaw$torfesS
Vegetation' Landform Posti.,.-i on Landsc _tach sheet)
+
3, Distances from- Open Water Body feet Zoo Drainage Way feet Possib, .i'Vet Area
legit
Property Line 4-6feet Drinking Water Well Baa feet Other legit
4. Parent 1�4ateriai: Unsuitable Materials Present: ❑ Ye's (13 No
If Yes: 0 Disturbed Soil Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractur- i1ock . ..:smelt
5, Groundwater Observed: E] Yes RrNo If Yes:
> Depth Weeping from Pit Depth Standing iter In Hole
Estimated Depth to High Groundwater:
inches elevation
Redoximorphic Features Coarse Fragments
Soil Horizon]Soil Matrik:Color. (rnoftle�s) Soil Texture %by Volume Soil Soil I
Depth(in.) I Layer Moist(Munsell) (USDA) Cobbles& Structury consisterit_ 1 Other
Depth Color Percent Gravel Stones
266 57/4 L5 mdS 51've
Z.,5
Additional Notes:
Form 11 -rev. 1110 Form 11 —Soil Suitability Assessment for On-Site Sewage Page.3 of 4-
ASSESSMENT PERFORMED BY
HILL T OWN ENVIRONMENTAL
Commonwealth of Massachusetts P.O:Box 314
CHESTERFIELD,MA 01012
City/Town of l�1olrT�(�4/ F�T�AJ (413)235-4489
Form N1 - Soil Suitability Assessment for On-Site Sewage Disposal HILLTOWF;ENVIRONI'lieNTAL@GMaiicS,
`✓ D. Determination of High Groundwater Elevation .�
1. Method Used:
❑ Depth observed standing water in observation hole -
inches inches ,
( � inches inches
EZ Depth weeping from side of observation hole f r
inches inches inches inches
[]"Depth to soil redoximorphicfeatures,.(mottles) --,, i I� " > I Zo rr
inches inches inches inches
❑ Groundwater adjustment (USGS methodology) - -------
inches inches inches inches
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 paturally occurrinn pervious material exist in all areas observed throughout the area proposed for the soil
absorption system? Yes �] No -
b. If yes, at what depth was it observed? Upper boundary: Lower boundary: �20
inches inches
F. Certification
I certify that I am currently-approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil
evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017. 1 further certify that the results of rely soil evaluation, as indicated in the attached Soil Evaluation Form,
are accurate and in accordance with 310 CMR 15.100 through 15.107. �7 p
Signat re of Soil Evaluator Date
Mgrk % oH,' sav, Ag;I Z9, 1997
Typ dor Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam
Name of Board of Health Witness Board o ealth
Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to
the designer and the property owner with
Form 11 •rev. 1110 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of
Commonwealth of Massachusetts
City/Town ofGlz-r%�gr�-Ip��
Percolation Test
Form 12
w,.
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. DEP Ilas 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
filling out forms A. Site Information
on the computer, -- / / /
use only the tab I G!nom / l� !11 K
key to move your Owner Name
cursor-do not 13 'a C? A vim.
use the return Street Address or Lot#
key. I
oYe M.A
Citylrown State Zip Code _
Contact Perso (if different from Owner) Telephone Number
B. Test Results
317-0 / 0
_
Date Time Date Time
Observatio Hole# I
Depth of P rc
Start Pre-S ak
9 ; (D
End Pre-Soak
Time at 12" f 2
Time at 9" 9 :38
9p . 30
Time at 6" / :3
Time (9"-6
ll
Rate(Min./inch) [A 3�� e"� 1 C
Test Passed: Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Mark T.Thompson (D.B.A. Hilltown Environmental Consulting)
Test Performed By;
c?�Vi Qi WA-5
Board of Health Witness
Comments}
t5form12.doc•08/15 Perc Test•Page 1 of 1