29-016 (5) r / M D H ;� kor Drive, NDr�G,a - �„
Bureau of assachus R esource Protection epartment of Environmental — W astewater Permitting Program Protection 32 Site Address or Map /Lot Nu iber
Form 11 - Soil Suitability Assessment for On -Site Sewage Disposal
- __ _
D. Determination of High Groundwater Elevation
1. Method used ❑ Depth observed standing water in observation hole A. B. 1
1
[3 Depth weeping from side of observation hole A. > 132. " B. 1
[/ Depth to soil redoximorphic features (mottles) A. > 13 2 B. ■
❑ Groundwater adjustment (USGS methodology) A. B.
2. Index Wei! Number Reading Date ___ Index Well Level
Adjustment Factor _ Adjusted Groundwater Level
E. Depth of Perviousi Material A
1. Depth of Naturally Occurring Pervious Material
a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for th
soil absorption system? Yes Q No ❑
l
b. If yes, at what depth was it observed? Upper boundary: 8 r, Lower boundary: >, , "
F Certification
I certify that I have passed the soil evaluator examination* approved by the Department of Environmental Protection and that the
f above analysis was performed by me consistent with the required training, expertise and experiende described in 310 CMR 15.017.
Altlial e - y. . - --Z N 3 �y 2,00 HILITOWN ENVIRONMENTAL CONSULTING
Signa ire of Soil Evaluator Date P.O. BOX 314
Mark Thompson April 29, 1997 CHESTERFIELD, MA 01012
(413) 296 - 4499
Typed or Printed Name of Soil Evaluator *Date of Soil Evaluator Exam
N•I: A • iiiiiii
Name of Board of Health Witness Board of Health
l 1
DEP Form 11 Soil Suitability Assessment for On -Site Sewage Disposal • Page3 of
1
M ssachu tt Department f E
A s of Protection 3 Z NicLor 1r-,ve or
a Bureau of F esource Protection — Wastewater Permitting Program Site Address or Map /Lot Number
' ' \ 'Form 111- Soil Suitability Assessment for On -Site Sewage Disposal
,1
C. On- Site' Review (minimum of two holes required at every proposed disposal area)
Deep O s
p eivation Hole: Date: 7/3I /09 Time: 9-0O Weather: c-thn y
1. Deep Hole ,Number umber ( Location (Identify on Plan ): See- Slc�{ -4h
2. Land Use: L-611../r) Surface Stones: -" 1 Slope ( %): 2. Vegetation: G C06 5
(e.g. woodland, agricultural field, vacant lot, etc �J
Landform: of a (-I'o, Position on landscape: je .:beer. I•lale.
, 'Deck ° i
3. Distances from: Open Water Body 200+ ft. Drainage Way I00.+ ft. Possible Wet Area ioa+ ft.. . ' 1
Property Line 3D ft. Drinking Water Well 15D+ ft,. Other ft. rt, 3z.
4, Parent Material oct+w &S Unsuitable Materials Present: Yes E No U a
a ,J o `
�A
If Yes: Dis urbed Soil❑ Fill Material❑ Impervious Layer(s) El Weatherel /Fractured Rock ❑ Bedrock ❑ I-1 ∎ ckor br�'0 /e. _-
C Nei S-- ole�
e
5. Groundwal r Observed: Yes ❑ No Er'
,,
If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: ? ( Z•
i
So
Redoximorphic Features C rse Frayrnents
p a
Soil Soil Matrix: (mottles) % by Volume
Depth ;Horizon/ Soil Texture Color -Moist Depth Color Percent Gravel Cobbles , _ Soil Structure Soil Consistence
1 Layer USDA (Munsell)
( ) & Stones (Moist) Other
0 -8" • A -C'5 Io\ik)2 — c_rt-k vi 1dos -re
V _ p 3 w L6 i D IK. Jr /1- Iv / �5V YhAssive: � Cr7r
24 ' C 5 10 8,613 — to / o/ 5ingl� -- 5
1 d (b sr.,..,“,,, 005-2_ -s - • ,,,,,, t 4- g ro,J¢ (
dditional Notes
HILL, OWN ENVIRONMENTAL CONSULTING
P.O. BOX 314 DEP Form 11 Soil Suitability Assessment for On - Site Sewage Disposal • Page 2 of 3
CHESTERFIELD, MA 01012
(413) 296 - 4499
\i 1
Massachusetts Department of Environmental Protection 31 Hickory r v e_ l -}fat .
o � �.
tn�.
Bureau of Resource Protection — Wastewater Permitting Program S Address or Map /Lot Number
Form 11 - Soil Suitability Assessment for On -Site Sewage Dispotal
t A. Facility Information
Y ..--,
Per-mec - B j +
Owner Name: I zA:b�4- t e-i c_k HILLTOWN ENVIRONMENTAL CONSULTING
P.O. BOX 314
Street Address: 3+ e-s 5+. Map /Lot: CHESTERFIELD, MA 01012
A 1 (413) 296 - 4499
City: Nore L ✓�.w 4t v AA t(t ,
t
State: NI Al Zip Code: - OO
l(I i
B. Site Information
1. (Check one) New Construction ❑ Upgrade ❑ Repair ❑
2. Published Soil Survey available? Yes [/ I No ❑ If yes: 15B I 1; 1584-0 , H A I- ir.ck(r .y
Year Published Publication Scale Soil Map Unit Soil Nam
¢
Soil limitations C LA.-tio4.1 G' ve_ p -cr (4
3. Surficial Geological'Report available? Yes ❑ No ❑ If yes: _
Year Published Publication Scale I Map Unit
Geologic Material Landform
4. Flood Rate Insurance Map: _Z 5c 1 G7 ' 001 A
Above the 500 year flood boundary? lies [i/ No ❑ Within the 100 year flood boundary? Yes C] I No e
Within the 500 year flood boundary? Yes ❑ No ❑ Within a Velocity Zone? Yes ❑ No ❑
5. Wetland Area National Wetland Inventory Ilap
Map Unit Name
Wetlands Conservancy Program Map —
Map Unit Name
6. Current Water Resource Conditions (USGS) 6/09 Range: Above Normal Normal ❑ i' , Below Normal ❑
Month/Year
7. Other references reviewed:
DEP Form 11 Soil Suitability Assessment for On -Site Sewage Disposal • Pagel 1 of3
i
*
File # MP- 2009 -0110
APPLICANT /CONTACT PERSON FEICK ELIZABETH C
ADDRESS/PHONE 34 BATES ST (413) 584 -1090 0
PROPERTY LOCATION 32 HICKORY DR
MAP 29 PARCEL 016 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM ILLED OUT 1697 M
Building Permit Filled out
Fee Paid
Tvpeof Construction: ZPA - ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRE ED:
Approved dditional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER : § 3 J5 . "' 2_
iregg, 0
Intermediate Project : Site Plan AND /OR Special Permit with Site Plan
Major Project: Site Plan AND /OR Special Pelluut with Site Plan W '' ' 4'3
/,•
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance* r
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Co 'ssion Permit DPW Storm Water Management
Signature of 1 ding Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of
Planning & Development for more information.
•
File # MP- 2009 -0110
APPLICANT /CONTACT PERSON FEICK ELIZABETH C
ADDRESS/PHONE 34 BATES ST (413) 584 -1090 0
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
(G NING FO FILLED OUT ' 0(6—
B uilding Permit Filled out
Fee Paid
Tvpeof Construction: ZPA - ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner /Statement or License
3 sets of Plans / Plot Plan
THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER : §
Intermediate Project : Site Plan AND /OR Special Permit with Site Plan
Major Project: Site Plan AND /OR Special Permit with Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commissio Permit DPW Storm W to anagement
f f
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact the Office of
Planning & Development for more information.