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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