23 Septic Application Permit & Perc Test 1999 • ssit
EPLI R,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
To/.J.tt
OF %[
T/>,./
Rr �
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
.q l l:i i<„m∎r. I;inqi on.ttuLt t aepec , rgel i sk nc sion I ) - c „plcic S,at. ,Stchidqieq ((In-11,011Lnc,
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( '1/3) ss f - 000?
_,d-1 .Cann 4. Br:Su _ia' _ e.5 .
"i o... .,. M, 4,36,o
( ) 'I9s - 57e3
7t pe ot Building-_Re.grr Ct22Lt?2 f
De repine—Nu. of Bedrooms 3
Other—Tcpe of B uildim"
Other fixtures
No.of per
Lot Size &D , m0 Sq feet
�N OGarhage Grinder ( RE 1-to)E
Showers ( ). Cafeteria ( )
TI
Design Floe (min. required) 3 32 upd Calculated design now 320 epd Design flute provided 332- ;pd
Plan: Date 2. ) /r/`1r/ Number of sheets if Rex ision Date
IS le.Dn - 5rfe nan5urpare 1)14,1->ozaLdt'ISfYPath gA. L Syalerp, -be'A .n
Description ot Soils) 6)- Loa M S e.2L - /20 S,a rC/5 (Cole rS Of /lee/ el //tit )
Soil Evaluator Form No. Name of Soil Ecaluatorb• /mss, c . . Date of Evaluation 3 /a'F /`n
DESCRIPI ION OF REPAIRS OR ALTERATIONS A ba /0 el 5A 5 (Lea ell- Pal )
600 rya/ pct , st7, Clt es tt &e , 5 Ctc1 ft b rt 2
7r t rites cr y-, it/F,t7, 4TG,2 c)ti?PT aS pe r apprc eel 1',"),<-7,)
The undersigned agrees toinsmll the above:described Individual - wage Disposal System in accordance with the provisions of
TITLE 5 and further agrees noyk place the system in operas. ntil • ertificate of Compliance has been issued by the Board of Health.
Signed i" L �`5_. . AC+/ Date ,2
Inspections
-FOR
APPLICATION FOR DSCP
c` O 4/q?\-, �� .
DEP APPROVED FORM 5/96
THE COMMONWEALTH OF MASSACHUSETTS 1't
A/D/Z77-14 ri--/PMAI BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
CR'Individual Components) =Complete System
hereby certify that the Sewage Disposal System:r'paste eled( 1.Repaired l 1.l'pgraded( 1-Abandoned ( 1
at _a3 _Du inplt“_.)_,D r. I-IJrm 724,,y l--3-op e r f>_-t)
has been installed in accordance. g ith the provipions of 3111 CAIR L[)t1 (Filk 3) and the minim ed design plans/as-buil
plans m121111:2 to application Nod dated Approved Design Flog (xpd
Installer JC_. t _.3-
// 1r tat / - l
Let (y 1
Designer: T /t h_ $ / - - LI �'L - Inspector 7`/ to F��-✓— Date WI 2.-•
The issuance of this certificate shall not becnstrued as a guarantee th(t the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No
Vies
THE COMMONWEALTH OF MASSACHUSETTS H ±56
AJOIZA-IAhPTOAJ BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( /) l:porade (st 1 Abandon ( ) an indni dual Sc"age
disposal system at �r3 .��/a1)/t. brio° fJ Thin n Prr%per/-9__)_ as described
'in the application for Disposal System Construction Permit No. 2 -C4/-1 .dated U/y
Provided: Construction shall be completed within three years of the date of this pert�ocal codiyions mint he met
ry /99 /t
Date �✓'� I�/ Board of Health '�'s ^G - L'-'�'�--+-
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 'REV 5/96■ I IX W HOBS B WARREN
PUBLISHERS-BOSTON
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF 5
Commonwealth of Massachusetts
Notr--Th PTOµ , Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
Lie submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or
nonconforming system with a design flow 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 failed or nonconforming system with a design flow
of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full
compliance, as defined in 310 CMR 15.404(1), 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.
1) Facility/system owner
Name JAI,eS TO3i N-I 52 .
Address 2`4 Clnesivutit St . t•loreore_ xA Ott, 61-
Phone # (4V3) Se - oLo7
Address of facility 23 btnpit.) Drive nlov-l-c,,, „.,P+r,.,
2) Applicant (if different from above)
Name
Address
Phone #
3) Type of facility
residential commercial _ school
_ institutional
(Specify)
S
DO APPROVE)FORM.MOMS
lobin ' 11-024
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 OF 5
4) Type of existing system
privy cesspool(s) k conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits,etc.)
Leas.[,- Pmt
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system Si{µ gpd
Approved? -c yes approval date 5/zo/et,
no why?
b) Design flow of proposed upgraded system 332.tgpd
c) Design flow of facility 33o gpd
6) Proposed upgrade of existing system is
a) ✓ Voluntary
_ 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) Describe the proposed upgrade to the system
Ab.noon F>Jea S AS ( Lead. (a-t ') Snstau Soo 9a1
Le-C-c-k. Iiit , 5 criAzt to F b-Box .nd i'�->o Tr.e.wc.ke5
Olt S I ru(7-IL-(-lt&TOla_ txrwt5
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
S
Percolation rate of 30-60 minutes per inch (state actual perc rate)
DPP APPROVED FORM-13I0I/95
lob,n '11- 014
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 & perc rate) h Ax . t ' redu.chlon 3.cal ^``"' 1,
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(I)(i)(1). The evaluator must be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
feet
s
As determined by:
Evaluator's name
Evaluator's signature
Date of evaluation 3 /1st /99
OR APPROVED FORM-12/07I95
"'Cob�n ' 99 -o24
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 OF 5
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 complete 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):
S
a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
Ecav�or.ic.s Seto GonS+Ya A4t5
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
E co i.�o vw+c S
DR APPROVED FORM-MOOS
olo;• • cn -021
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5OF5
c) a shared system is not feasible: Alor AU AILA6LE.
d) connection to a sewer is not feasible: No-c .4.%./n.R
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? ✓yes_no
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. I am aware that there may be significant consequences for submitting
false information, including, but not limited to, penalties or fine and/or
intpris• ,..: - it for knowing violations."
/ AlSr e
OWIYr's si.$.
C)e FEES �7D�/4/
Print Name
6
Date
Ka}Invyn �{. T ,rLd9les - Goa, , R.5 . 2 Ju u a /955
Date
Name of preparer
(4i3) '-/98 - 6-?83 /4[. /-i 5+, hlwl4jield /-iA 4/34o
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 construction.
S
DV APPROVED FORM-13M1In
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
/JoILT'NAHrrT .L , Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility/system owner Nana:luTca To loin Adds:21A- Cl^.ntr u . St , F l o re,..c.e,
Address of facility 23 Du_t% ,.j briva. , Gov-H-.ay..(aio rt
Type of facility: residential ✓ institutional _ commercial school _
design flow per 310 CMR 15.203 u33 2 . 9'F gpd
System designer. Name V.1-1 a i ' -'raj Address I'ro�+'�..�'�r�e t-.A 013(o Phone No.459 Saga
Local Upgrade Approval granted for:
reduction in setback(s) (specify)
pert rate of 30-60 min./inch (specify rate)
I
reduction in SAS area of up to 25%
(specify % reduction &size of SAS)
reduction in separation between
SAS &high groundwater
(specify reduction&pert rate)
relocation of a well (explain)
V1/4.0-...14 n&u.0 red...chonn
3 .L3 tn /.rich Cbtsign Rate - SA^'^ /
local variances granted (no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval ;//'�� �j ,C,,//, / /�
Board of Approval of proposed upgrade /"e� er-S/rfG LEI 4, 4,24 T
2j1 y—, N &Title V
- S t /town ate
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.
S
D@ APPROVE)FORM-13109/95
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
Iottn 4.∎ TOIL . Massachusetts
LOCAL.UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Fact lity/system owner: Name:-.‘Irwts Toloin Address:21.4 Clunix...t St, Vlore-IA-cc
Address of facility 23 fik.y bri.+e , .'10,�4+..�w. -ton
Type of facility: residential ✓ institutional _ commercial _ school
design flow pa 310 CMR 15.203 -51,z . 9'/' gpd -
141a 3
System designer: NameleILBn ' -Graf Address '�r�soY+i..n:�ud hA 013(.o Phone No.4 4sg3
Local Upgrade Approval granted For
reduction in setback(s) (specify)
perc rate of 30-60 min./inch (specify rate)
reduction in SAS area of up to 25%
(specify % reduction&size of SAS)
reduction in separation between
SAS &high groundwater
(specify reduction&pew rate)
I ' net O-44 ww.0 rydt..chon
3.t.1 Men /.nc1- CDesir Rate - 6• •;•• /,.■c-..i
relocation of a well(explain)
List local variances granted(no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval
Bond of H h Ap Approval_s e of pro posed upgrade Qr AtM 6 �-t . 4 i o
N &Title `/s/'/iikownn &e
2sr'
no 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.
DPP APPROVED FORM-11/07l95
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70w¢
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FORDS 11 - SOIL EVALUATOR FORM
Page 1 of 3
No. Date: -Z944
Commonwealth of Mas::a:husetts
Neal Lor r. ) Massachusetts
,Soil Suitability Assessment for Ott-site Sewage Dispo
Performed By: »ErtA tat it ..t !1sP _P ._.. Date: 3:.25Y'..
Witnessed By: .-.&t 'a
I 'am e"'mei . 23 Dun pity At,
New Ccrju'Jctcr '` Re:air Zy
Omce Review
Published Soil Survey .Available: No Yes a
Year published Publication. Scale I b Soil Map Unit /7 Hee
Drainage Class b)lc tssivE sou Limitations s f e FE 1 R40 Pen C c.f ar
Surf tie! Geologic Repot Available: No E. Yes [i
Year Palished Dubl!ceion Scale
Geologic Mate.sL Nap.Unit)
Lexteorm bUTSVR4b irt.set&.E
Fined insurance Pate Sian:
Above 500 year ^ccd boundary No ❑Yes 2
Within 300 year tflccd boundary No gifts
e..-.....Ti •v, Teo;•
di. 4* cNa Tau% S7.
tam t
elesrueg. P/4 0101.a
9)131 Y et o?
Within 100 year flood bounder/ No g..Yes
Wetland Ares:
National Wetland inventory Map (map unit)
Wetle.ds Conservancy Program Map (map unit)
Curer.: Water Resource Conditions (USGS): Month
Rerge :Above Nouns' ❑Normal g$elew Normal ❑
Other Refbences Rsviewsd:
00 Yreevm 7Obt• I:;Otirf
Location Act:ess :r Dun,p4 v Detj U
FORM 11 . SOIL EVALUATOR FORM
Page Lot 3
On-site RevleW
Dee? Mole Number a Cate:. '3 -ii'tf rime: ._ 'Nea•ie•
Location tieeRity on site ?Ian}
Land Use R✓S nr4L Coot (%I � Surface Stones in
Vegetation 44L&r V,
Lendfcrtn B°fl.J-s 15 pro y e_e
Position on landscape ;ske:en on the back{
Distances from:
Open Water Sod./ i on feet Drainage way -llaWe feet
Possible Wet A:ea JCOtt feet Properly Line_�r?�_ 'eet
Orinking Water ..I CC;Ty feet Oth.ei
• MIN:.WWN bn 2 nVl Tae IAa'J A Cv L1i rnvn�aa'J U�a�4a•��Anaq
Parsn;Mst.n. 1/601 00C1 t lino -el S), 0..esee.dracla /or
paac-:e Gracne..rsrr Swedery net in:nett ale: /B9
Estm.d-S.arvi 5"r
bo
Wetting from Pit hest
On APPlO V WW 700.01• I::0V97.
DEEP OBSERVATION 1-OLE LOG'
Osote t= std e:r:::1 • sail Tecaa
Suraca (keen; i (USDA;
Soil Cater
IMunseel
'led :tine
Met;in; (Str=;re. 3::,tz. aOw an. C:Nbnn ••f. %
3 u
C to 1),
t= A6
2.le (D $O
So 7; alo
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Fe„, r,,,Iorr G,4nr,./4-
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I
ILO S,E MC%!rU,9 rj91J}/ ,D ,6
5an,r g-r.ac 5q,"> ,ut s.evut'
LottCi 6,76»n, A 'd
5-4,., /0 ,
gerct Ott— r•
• MIN:.WWN bn 2 nVl Tae IAa'J A Cv L1i rnvn�aa'J U�a�4a•��Anaq
Parsn;Mst.n. 1/601 00C1 t lino -el S), 0..esee.dracla /or
paac-:e Gracne..rsrr Swedery net in:nett ale: /B9
Estm.d-S.arvi 5"r
bo
Wetting from Pit hest
On APPlO V WW 700.01• I::0V97.
°O R\! I - SOIL EVALUATOR FORM
Page ?.of 3
_cos:iar. _crops or Lc: ::o. raj Duu004y 1)C-111
On-sire Review
Deep Hcie :carter Date:3'S591' Time:t.2 Aw Weacer(;LB92
Location lic!'a'antity Or, site plan!
Land Use !SL^kIC✓ L. . . Slope (°
Vegetation L..pw r2_ ... .
Landrorrn Put v4_4_7$2c.rfet _.
Position on lands:ace sett(sketon cn the tack)
Cistances from:
Open Water ccc/ /DO feet
Pooss:tie Wet A;__ /D0* feet
Crin:Png Water '..41€!1 G11-5, feet
Drainage wavMDNC feet
Pr_-_rtv !ir.e ]..Z feet
Ct at
__. .._. . v e, i ivic i . — _
Ce:an keen
Sura:a Ilneessl
Se:l nerxen
- i T-r
_ (USuAi e
Sc:l _ie
IMunselll
Son
Mav rt;
Cc:u
(Storrs. =:ores. ?c leers, Ceintrzerci, %
Craved
O ID ID"
ID To 3(.
7�(• TD flop
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qD Ts /12
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L.&O E wt&pi
v»e 5-4up IS%e
1j44Utt.
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TI2a-n i gi ue •.lNa/ In G2A✓E1.
a5 E . i eDry
* na , ID yp
ilEmny Fluent mil Lty -(I RND
7,DR.+r; .Vt &cc JE L- y
pare". maacan(;salaam 6 vT rar4S4
._-. v -ea_.. Sbrei:;Water in:.t.: c!e:
_retrain-4 Saar_-.zi ern Crenne Waver:
7
70I
l/
Dearneeec_ri:
Z�
Wee:in;ne .Pe Face: yb
DE?AinOv En 70 z 1. n:mcns
ORS: ?' - SOIL LVALUATOR FOR
Page 3 or
Locac:cr. Address or L_: \'o. 23 a)vNphy jig•
Decerr,-ina ion for Seasonal High Water Table
iMethcd
Li Dept-. C_served s:ancinc in observation hole memos
" Deptn weecinc from side of observation holeirci°s
S. Dep:h to s_ii me :es irc• es
1 GrQLnd 'water _just..._..; fear
elc;usled _ _. ' 'ware- le
-r• r •"-_t.� o r.j;e_ ,c
Does !'ee: t_. fee: o. rat_. af v co' _ - . tai
_ exist in all area
^cLa 're Sp..•a:s: syste.-. xl-
no:, ..na: is tc_ ce_- . na.u. =„y coo_rri-c ;=. . ,c.:5 r—: = .a[?
n _
Certfloa
i ce_rtffy trz: o.n, (date: I have :assail the scii evaluator exaninatior
approved.Qb y the tie a ..^ant of Cnvironmer.ra that Use above analysis
was performed by me consistent wit. e%r- ::fired Protection expertise and experienc:
described in 310 GAR )17. Air
Siena
I
_r?.2?SQ._
Date `''...D.y•99
FORM 12 - PERCOLATION TEST
__cation Address cr Lot No. 2,1 Atal v at '
VG
COMMONWEALTH OF MASSACHUSETTS
Nectkampte , Massachusetts
Percolation Test'
Date:3'2-`t -44
Observation Hole
De:tr of Perc
Stan Pre-soak
e-ssoak
End Pre-scak
Time at 12."
Time at 9"
Time at 6"
Time (9"-6")
Time:. 9.DB AM
Rate Min./Inch
' Minimum of 1 percolation test must be performed in both the primary z ea AND reserve area.
Site Passed 2 Site Failed ❑
Performed Ey: $wtir IZ• L- gcnzsn` ------..----_ .._.
Witnessed By: PE (C2 me to IkrA) - -
Comments:
OE^APPAO VEI YORK-LIV07195
Pers Test for Jim Tobin
0 Ti
Streets98
Copyright e 1 9S&1 g97.Microsoft Cognation and/or its suPolrers All nghts merved Please■srt our web site t htp//maps.esµdia.
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