73 Septic Permit Appication & Soil Test 1999 No 2 80
SC.
THE COMMONWEALTH OF MASSACHUSETTS Fur s�J
BOARD OF HEALTH
TC&) OF A.)O f- i'yyLi in AJ
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
App]Calon for n rormino(ono:uLi ) RL tpnmd.• t .u.:n,dnnI I - (nmpl.w Seem Iasi.i.m.d(component.
'J 3 Au--t mr....) Drure
CUo.. 4ra.uat
L.:ani...
)vnir..mo.
03 nu-tun/nu F rare_ &Jor+dnameth
SSU- °FOE/ �,- r,ince
7. C.
(sIUi(Y/n,mhfni F.(1Jdd .I LAG 1(..tQ
Box�5IS DLe"erZ rnA 3/0 33
ci - / c)OU
iJJn,.
Type of Building: C
Dwelling—No. of Bedr
Other —Type of Building
Other fixtures
Guru JJ
.3 V
Lot Size Sq.feet
Garbage Grinder ( )
No.of persons Showers ( I. Cafeteria ( )
Design Flow(min. rec aired 3 40 gpd Calculated design flow gpd Design flow provided C/0 gpd
Plan: Date 13- 1 ti -97 Number tf sheets / Revision Date _
Iitte_SeL Ct3 e IRIS tap saj ScS+Pm K {,/t_ - KrQ.I✓3R.
Description of Soil(s) • —7/ g '.j 'rtS
Soil Evaluator Form No. Name of.oil Evaluator/09i LQt)3 'i e Date of Evaluation //-o&9- 9?
DESCRIPTION OF REPAIRS OR ALTERATIONS a l.Je l.J (-//& )^i. � ID" See.
C'a 11e GCldZ.Cl `_O C: 1 ,_b i •• •C4
J
G
• • • . c• • •
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TIDE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
*Signed
Inspections
Date
/27„Q:2.-//g9i
FORM I - APPLICATION FOR DSCP
DEP APPROVED FORM 5/96
R
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 OF 5
4) Type of existing system
privy cesspool(s) conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits,etc.)
l2‘.b)', ,_ck 013
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system ,Wf apd
Approved? _yes approval date
no why?
bl Design flow of proposed upgraded system tI /l/gpd
c) Design flow of facility y� gpd
6) Proposed grade of existing system is
, a) Voluntaryy
Required by order, letter. etc. (attach copy)
Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date)
b) Descnbe the proposed upgrade to the system
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
rPrl„ahon.) o Seib7cr_ be Ad fnA SA coirl
ory :t
Percolation rate of 30-60 minutes per inch (state actual perc rate)
OFT APPROVED FORM. I2(07/9
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE I OF 5
Commonwealth of Massachusetts
NOh `lamP lo&) , Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or
nonconforming system with a design Ilow of < 10,000 gpd, where full compliance, as defined in
310 CMR 15.404(1), is not feasible.
To be submitted to DEP: For the upgrade of a
of 10.000 up to 15.100 gpd and/or for upgrade
compliance. as defined in 310 CMR 15.404(I),
failed or nonconforming system with a design flow
of a state or federal facility, where full
is not feasible
•
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the
addition of new design flow to a cesspool or privy or the addition of new design flow above the
existing approved capacity of a system constructed in accordance with either the 1978 Code or 310
CMR 15.000.
I)
Facility/system owner
Name 0,\a13 \S\t-au5e
Address 7. Y e&Atim Thr %`-�Or -Ang 1't�i'Ir1Y1 Y11n
Phone d 584/ -
Address of facility '7,3� �1-..�Yh Ill 1 t\7-€ /JC r
N% 2 m'7iUnJ
2) Applicant (if different from above)
Name SQ rn�
Address CxS
Phone N
3) Type of facility
residential commercial school
institutional
(Specify)
0@ APPROVED FORM- 12/07195
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE4 OF5
8) Notice to Abutters
No application for upgrade approval in which the setback from property lines or a
private water supply well is reduced shall be compiete until the applicant has
notified all abutters whose property or well is affected by certified mail at least ten
days before the Board of Health meeting at which the upgrade approval will be on
the agenda. Such notice shall include the date, time and place where the upgrade
approval will be discussed.
If the Department is the approving authority, then such notice to abutters must be
completed prior to the date of submission of the application to the Department.
The notices to abutters shall include a copy of the completed application form and
shall reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
Abutter Name
Address
Abutter Name
Address
Abutter Name
Address
Abutter Name
Address
Date notified
Date notified
Date notified
Date notified
9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each
section must be completed):
a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
�ac'e Corgi+ co a-FiciJ
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
100-1- �i
- tGJ- C tuq
On'APPRO VFD FORM• 13/01/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF 5
Up to 25% reduction in subsurface disposal area design requirements (state required
& proposed size)
Relocation of water supply well (identify well, describe relocation)
Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & pert rate) , 3 z Q
%i 0nJ
I) 6vun_i / nCh
Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the
Code)
System upgrades that cannot be performed in accordance with 310 CMR 15.404 &
15.405, or in full compliance with the requirements of 310 CMR 15.000, require a
variance pursuant to 310 CMR 15.410-15.417.
7) If the proposed upgrade involves a reduction in the required separation between the bottom
of the soil absorption system and the high groundwater elevation, an Approved Soil
Evaluator must determine the high ground water elevation pursuant to 310 CMR
15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
feet
As determined by:
•
Evaluator's name 1/v1Chile /,- ICnJ-Q-
Evaluator's signature „rearn,c,.
Date of evaluation %-ed • - .
DEP APPROVED FORM. II/071q5
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
c) a shared system is not feasible:
)UO+ pia_tt C( J
a) connection to a sewer is not feasible:
/U0 fi 0-_2-0.Aka b(e
10) An application for a disposal system construction permit, including all required attachments
(e.g. plans & specifications, site evaluation forms), must accompany this application. Is the
DSCP application attached? 1/vesno
11) Certification
"I, the facility owner. certify under penalty of law that this document and all
attachments. to the best of my knowledge and belief, are true, accurate. and
complete. 1 am aware that there may be significant consequences for submitting
false information. including, bin not limited to, penalties or fine and/or
imprisonment for knowing violations."
Fa lit s'ig44ure Date
AIci Kra.UQ_A
46a/9.a/1//Y i
Print Name
Fn Ivi rcm rn e,U f-ed IFc i d So,tu 1ce ,n /on; I -99
Name of preparer Date
5 �b -2,00 Do hov (F teems rnA 01o3-3
Telephone # & address of preparer
NOTE: Title 5, 310 CMR 15.403(4), requires the system owner or operator to submit to the
Department a copy of the local upgrade approval upon issuance by the Board of Health and prior
to commencement of constmction.
DEP APPROVED FORM. 11/07/95
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
/0or41not ip- , Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT
L T'O 310 CMR 15.404 & 15.405
Facility/system owner: Name: /MA-) KlroLt( PAddress. /3 is.rjunw /3 i i j-f_ AJ
Address of facility 7.3 %4u -C.ctvnu �l'tue AJOr-)-%irt pACAV
Type of facility: residential institutional commercial school
design flow per 310 CMR 15.203 U) i9 gpd
System desiener: Name F_ t F. `2
Local Upgrade Approval granted for
Address POND% -1
,L e ed/° inn A Cio5-3
Phone No. 516-7„)1:50
reduction i n setbackrs) (specify) f e cp Se HA( bA"HA re.wo (.
n en d (pc &ni do-4-ED AJ rt) racy— l Sr/
perc rare of 30-60 mm./inch (sped fv rate)
reduction in SAS area of up rn 25%
(specify % reduction & size of SAS)
reduction in separation between
SAS & high groundwater
(specify reduction & perc rate)
relocation of a well (explain)
,3f
:n-iCt rY n fh
ll m� I On ch
List local variances granted (no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval
Board of Health Approval of proposed upgrade
Name & Title
Signature City/town
Date
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
& BEFORE COMMENCEMENT OF CONSTRUCTION
DEP APPROVED FORM. 12/07/9f
hi
FORM I I - SOIL EVALUATOR EOR11I
Page 2 of 3
Location Address or Lot No. 23 /27A) (34
Ort-site Review
Deep Hole Number I. Date: //'99-9Q Time: MIT-VHIA)]
Location (identify on site plan) SP/ jJe n'ki ..//
Land Use (q0.0�- Slope l%) 0 —1
Vegetation IBS
Landform _.... O n
Position on landscape (sketch on the back) gtC_ S ch
Distances from:
Open Water Body >/0W feet
Possible Wet Area >/00 feet
Drinking Water Well >/00 feet
Weather
ecik-
Surface Stones • •Lsc_�
Drainage way >3--0
Property Line ^- /0
Other
feet
feet
DEEP OBSERVATION HOLE LOG' ~ v
Depth from
Surface(Inches)
Sail Horizon
Soil Texture
(USDA)
Soil Color
(Mongol!)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency. %
Gravel)
p —/O('
e) -4/6`
'i8 -/o,2
9
r
C
SL
S
C-L
/0 VP7/J
.L
e2svy//
A/ -
L
).S k*e
e G/1°
r/
/7-2;x-e.0( s •.'//—fie a e
• M W IMI IM ILF 0 W N Lc nc r non, at turn.,n nun
Parent Material (geologic) G 1 —i2,74,gU DepthtoBedrock: /Oa r�
Depth to Groundwater: Standing Water in the Hole: A%LAS Weeping from Pit Face:
Estimated Seasonal High Ground Water:
6 Are
A4t+_
DEP APPROVED FORM-11/09/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
14131 586-7200
No.
FORM II - SOIL EVALUATOR FORM
Page I of 3
Date: 0-5-99
Commonwealth of Massachusetts
fuOr' frimpifnv , Massachusetts
Soil Suitability Assessment for On-site Sewage osai
Performed By:01 I a i7Q E/ Ln U i , n7 2
� �- e nom, �v
n,, Date: )off'
Witnessed By: Re w ∎
Innen At Or 93 gcl+u rn.v - 101-41{
Lot
New Construction ❑ Repair
V.¢„Nan. /71tL7L) Mrou15e-
""°Oe'•"' X3 1(,�'i-u ,,v 7Jriv2
Tekrhore/
k)or4i-tampf%m YYIA
51-6/ 00 / 0`o60
Once Review
Published Soil Survey Available: No ❑ Yes ❑
Publication Scale
Soil Limitations
Year Published
Drainage Class
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit)
Land form
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes ❑
Within 500 year flood boundary No Eves ❑
Within 100 year flood boundary No ❑Yes ❑
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map(map unit)
Soil Map Unit
Current Water Resource Conditions (USGS): Month
Range :Above Normal ❑Normal ❑Below Nonnal ❑
Other References Reviewed:
DEP APPROVED FORM-13101195
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
n vx FFORM 12 - PERCOLATION TEST
Location Address or Lot No. X13 aulte ) �1Lu-Q P `�
COMMONWEALTH OF MASSACHUSETTS
oor A4'np%C. u , Massachusetts
Percolation Test*
Date: I)
t�Q 9(I Time:. InfenJUV
(� /
I"(0q "
Observation Hole #
Depth of Perc
Start Pre-soak
11-31
End Pre-soak
I Y/O
Time at 12"
1 , L'li
Time at 9"
1 1 0�IC
Time at 6"
1 ),. 36/
Time (9"-6")
J )
Rate Min./Inch
I '
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed ® Site Failed ❑
Performed By: VIII cho e / Lou/ r/zyl_Q .
Witnessed By: )11(1 EA \c1, L L)
Comments: Q/<�,C.r 1-e-ev--.0 %"/ ,4 _..21e h.f2
DEP APPROVED FORM-11/07/95
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. 173 4c.atornt ClAuu .
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole . inches
❑ Depth weeping from side of observation hole.. ...._ inches
® Depth to soil mottles (OH inches
❑ Ground water adjustment feet
Index Well Number Reading Date ........._ Index well level
Adjustment factor Adjusted ground water level ....
Depth of Naturally Occurring 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 not, what is the depth of naturally occurring pervious material?
Certification
I certify that on )) _9L/ (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 y.
DEP APPROVED FORM-12/07/95
Date /��f