44 Title 5 Application/Permits, Soil Survey, Upgrade Approval 1999, Inspection 2006 Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
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tylwr
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
1
Property Information:
44 North Farms Road
Properly Address
Roger Salloom (413)584-6324
Owner's Name
44 North Farms Road
Owner's Address
Northampton
City/Town
Date of Inspection:
2. Inspector:
Timothy E. Maginnis RS
MA
State
July 20, 2006
Date
01062
Zip Code
Name of Inspector
Timothy E. Maginnis &Associates
Company Name
70 Montague Road
Company Address
Westhampton
City/Town
L413)527 -5291
Telephone Number
MA
State
01027
Zip Code
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes
❑ Conditionally Passes ❑ Fails
L] Needs Further Evaluation by the Local Approving Authority
s •
s Si at re Date
July 20,2006
The system inspect hr shelf submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Northampton-44 North Farms Rd.-Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
44 North Farms Road
Property Address
Northampton MA
01062
City/Town State
Roger Salloom
Owner's Name
July 20, 2006
Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
Zip Code
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
N/A
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND)in the❑ for the following statements. If not
determined," please explain.
❑ The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
N/A
Northampton-44 North Farms Rd.-Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004
Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
44 North Farms Road
Property Address
Northampton
City/Town
Roger Salloom
Owner's Name
MA
State
July 20, 2006
Date of Inspection
01062
Zip Code
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
N/A
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
N/A
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
11/2004
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Sy •
a 3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
44 North Farms Road
Property Address
Northampton MA 01062
City/Town State Zip Code
Roger Salloom July 20, 2006
Owner's Name
Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
"This system passes if the well water analysis, performed at a DEP certified laboratory,for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached
to this form.
3. Other:
N/A
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
11/2004
Title 5 Official Inspection Form:Subsurface Sewage Disposal Syystem•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
44 North Farms Road
Property Address
Northampton MA
City/Town State
Roger Salloom July 20, 2006
Owner's Name Date of Inspection
01062
ZipCode
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ Z Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ Z Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Z Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Z Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ Z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form.)
Yes No
❑ Z The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
11/2004
Title 5 Official Inspection Form'.Subsurface Sewage Disposal
age •
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
44 North Farms Road
Properly Address
Northampton MA
City/Town State
Roger Salloom July 20, 2006
Owner's Name Date of Inspection
01062
Zip Code
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes'or"no"to each of the following, in addition to the
questions in Section D.
YES
NO
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
Northampton-44 North Farms Rd.-Title 5 inspection report.doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal
Se t tem of •
11/2004
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
44 North Farms Road
Property Address
Northampton MA
City/Town State
Royer Salloom July 20, 2006
Owners Name
01062
Zip Code
Date of Inspection
Check if the following have been done. You must indicate yes"or"no" as to each of the following:
YES NO
® ❑
® El
Z ❑
Z ❑
® ❑
® ❑
® ❑
Z ❑
® ❑
® ❑
® ❑
Pumping information was provided by the owner,occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
11/2004
Title 5 Official Inspection Form:Subsurface Sewage Disposal
System•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
44 North Farms Road
Property Address
Northampton MA 01062
City/Town State Zip Code
Roger Salloom July 20,2006
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design):
4
Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
110 gpd
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes Z No
Water meter readings, if available(last 2 years usage (gpd)):
Sump pump? ❑ Yes Z No
Currently
Last date of occupancy: occupied
Commercial/Industrial Flow Conditions:
N/A
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes LI No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
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Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
44 North Farms Road
Property Address
Northampton MA
City/Town State
Roger Salloom July 20, 2006
Owners Name Date of Inspection
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) Of yes,attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
01062
Zip Code
Roger Salloom -property owner
N/A
gallons
❑ Yes Z No
Approximate age of all components, date installed (if known)and source of information:
6 years-Source of information was James Dimos-installer, and Roger Salloom -homeowner.
Were sewage odors detected when arriving at the site? ❑ Yes Z No
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
11/2004
Title 5 Official Inspection Form:Subsurface Sewage Disposal SSyystteom•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
44 North Farms Road
Property Address
Northampton MA
City/Town State
Roger Salloom July 20,2006
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade:
Material of construction:
❑ cast iron
® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:
2
01062
Zip Code
feet
N/A-Town water
feet
Comments(on condition of joints, venting,evidence of leakage, etc.):
Sewer pipe is in sound condition. No leakage observed
Septic Tank(locate on site plan).
Depth below grade:
Material of construction:
22"
feet
® concrete [' metal ❑fiberglass [' polyethylene ❑ other(explain)
(11'L x 5W x 4'D)
N/A
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
(11'L x 5'W x 4D)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Northampton-44 North Farms Rd.-Title 5 inspection report.doC•
11/2004
46"
< 1" -not consistent in tank
N/A
N/A
Observed/measured
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
44 North Farms Road
Property Address
Northampton MA 01062
City/Town State Zip Code
Roger Salloom July 20,2006
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was not pumped at the time of the inspection. It is in sound condition and no evidence of
leakage. Liquid level at outlet was even with invert. Inlet/outlet tees are in good working order.
Recommend pumping now and every year hereafter.
Grease Trap (locate on site plan).
Depth below grade:
Material of construction:
N/A
feet
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity.
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
N/A
Depth below grade:
Material of construction:
❑ concrete ❑ metal
❑fiberglass ❑ polyethylene ❑other(explain):
Northampton-44 North Farms Rd.•Title 5 inspection report.doc•
11/2024
Title 50Rcial Inspection Form:Subsurface Sewage Disposal all Systtem;
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
44 North Farms Road
Property Address
Northampton MA
City/Town State
Roger Salloom July 20, 2006
Date of Inspection
Owner's Name
Tight or Holding Tank(cont.)
N/A
Dimensions:
01062
Zip Code
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
Distribution Box(if present must be opened)(locate on site plan):
Liquid level was even at outlet invert
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The distribution box has 3 outlet pipes which appear to be in good working order.. Each outlet pipe
has a"speed leveler"on it. Outlet invert s are level. There was no evidence of leakage and no solids
carry over.
Pump Chamber(locate on site plan):
Pumps in working order:
Alarms in working order:
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
11/2004
❑ Yes
❑ Yes
❑ No
❑ No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
44 North Farms Road
Property Address
Northampton
City/Town
Roger Salloom
Owners Name
MA
State
July 20, 2006
Date of Inspection
01062
Zip Code
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
The SAS was not excavated. At the time of this inspection, I observed no violations of Title-5.
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
unknown
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,etc.):
No signs of hydraulic failure above ground, no damp soil or ponding. Vegetation at this site is grass.
At the time of this inspection I observed no vilations of Title-5.
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
11/2004
Title 5 Official Inspection Form:Subsurface Sewage Disposal
Page System of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
44 North Farms Road
Property Address
Northampton
City/Town
Roger Salloom
Owner's Name
MA
State
July 20, 2006
01062
Date of Inspection
Zip Code
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
N/A
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
N/A
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Northampton-44 North Farms Rd.-Title 5 inspection report.doc•
11/2004
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
Page 14 of 14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
44 North Farms Road
Property Address
Northampton MA
01062
City/Town State
Roger Salloom June 20, 2006
Owner's Name Date of Inspection
Zip Code
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
Northampton-44 North Farms Rd.-Title 5 inspection reportdoc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System tem•
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North Farms Road — Northampton, Massachusetts
Water line
(ref. only)
AS-BUILT DIMENSIONS
0w 0
Existing
w/f
4 bedroom
house
III
A"
Fx x
%I Inlet cover 'D
:
Outlet coyer
4 pvc Solid pipe
x
x
Septic tank
4' pvc perf pipe
C
Distribution
box ('E')
TITLE-5 INSPECTION PLAN
Subsurface sewage disposal system
44 North Farms Road
Northampton, MA. 01060
Date of Inspection: July 20, 2006
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
44 North Farms Road
Property Address
Northampton
City/Town
MA
State
Roger Salloom July 20, 2006
Owners Name Date of Inspection
Site Exam:
Slope NPAP1�/ Lai'
Surface water Na Nt
Check cellar
Shallow wells
oRy
Estimated depth to ground water:
Please indicate all methods used to determine the high ground water elevation:
• Obtained from system design plans on record
If checked, date of design plan reviewed:
01062
Zip Code
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
® Checked with local excavators, installers-(attach documentation)
• Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
a. Examination of soil around septic tank&distribution box
b. Examination of cellar-no sump pumps or floor drains
c. Review of USGS Soil Survey maps
d. Information from local contractor
f. Approximate elevation of nearby wetland
Northampton-44 North Farms Rd.-Title 5 inspection report doc• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•
11/2004 Page 16 of 16
FORM VA - 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.)
wctt aua; lab/Q
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system/U/9 gpd
Approved? _yes approval date
no why?
It) Design now of proposed upgraded system yll!J gpd
c) Design flow of facilityijf)O gpd
6) Proposed up trail,. 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
Gl rJe<AJ
a t5O 9rJ SepH Ck u )
3O5( 01 c tA
LY.CaCmote id
c) Which of the following are applicable to the proposed upgrade?'
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
Percolation rate of 30-60 minutes per.inch (slate actual pert rate)
arr Arm n'ra roam- I mit'
FORM 9A - APPLICATION FOR LOCAL, UPGRADE APPROVAL
PAGE I OF 5
Commonwealth of Massachusetts
/Vorth 'ID 1(:)'U , 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 A oroviu' Authority/Board of Heald : For the upgrade of a failed or
noncmdonniug 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 15,000 gpd and/or for upgrade
compliance, as defined in 310 CM11 15.404(1),
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--00 lu La Oam M2.
Address -Q f,3-VYe %11.�n��cl
Phone ft
Address of facility Li/Li Ne)r)—A Farmer Qocd
Applicant (if different from above)
Name CC, yvo-e
Address a S
Phone # 0(1 )O0-9
Type of facility
residential coonnercial school
institutional
(Specify)
nv Arrnoveo FORM.uioorn
FORM 9A - APPLICATION FOR LOCAL UPGRADE AI'I'ROVAI
PAGE 4 OF .
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 mall 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 (late of submission of the application to the Department.
'!'he notices to abutters shall include a copy of the completed application for 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
Dale 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:
Ccrr. •;de—rc{1a,.s,
b) an alternative system approved pursuant to 310 CMIt 15.283-15.288 is not feasible:
• ct A4 r ess0.'—I
Op'Al'rao VFL FORM. n/Oltlr
FORM OA - 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)
1Z Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & pert rate) a r 3 e par C,ti o'J
3 rn �m- /L,11.Ch
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
3 feet
As determined by:
Evaluator's name flfl j c ho p
Evaluator's signature
Date of evaluation /p
DO'ArrRO VED FOMI. 11/07/75
o t7i civu-Q
>s
IrOlUtl 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
I'AGE 5 OF 5
c) a shared system is not feasible:
NOt
p r<_,1- ctrl
d) connection to a sewer i. not feasible:
/Vet QUOib (£
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? k/Ves_no
II) 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
imprisonment for knowing violations."
Y
Facility owner's signature Dale
vai. J L 0,610 m 0)-e_
vi int Name
CIJUinolump>vic_Q r lfield SerbiceS 6- 9-99
Name of preparer Date
S S" - 7900 35� 2Ao 3-e° St A)orii nipfo-n) mA
'telephone q & address of preparer
0?0CiO
NOTE: Title 5, 310 CMR 15.403(4), tequires the system owner or operator to submit to the
Depaririont a copy of the local upgrade approval upon issuance by We Board of Health and prior
to commencement of construction.
OFT Arrnv VI/roR M• urem{
FORM 911 - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
/V rthon\p± , Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility/system owner:
Type of facility:
System designer:
Name:Tvi L.16 Jamote Address:9f3e toe hi.-on-JA0)a. eostAe,in
Address of facility LJ t/ 11)0 r -1—/n En i- m S co R C/ Di
Iesidendal yr institutional commercial
design flow per 110 CM It 15.203 A /tJ
school
gpd
Name f'I F . S. Addlcss -335 RA cifrt
IvorI11oyn )' tun
Local Upgrade Approval granted for: O 4)cr0
f
Phone No. Skh-7a00
(eduction in setback(s) (specify)
Pere rate of 30-60 min./inch (specify rate)
reduction in MS area of up to 25%
(specify % reduction & site of SAS)
reduction in separation between
SAS & high groundwater
(specify reduction & perc rate)
telocation of a well (explain)
Sep ,arol no
3 niu, /tmc-h
List local valances granted (no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval
Board ofaf calm Approval of plot sed upgrade
n' ki_ ALA
Lrgnatme - City/to
rItkZu-:,
Name & Tiii
ate
THE SYSTEM OWNER-OR OPERATOR SHALL PROVIDE A COPY OP THIS LOCAL UPGRADE APPROVAL
TO THE APPROPRIATE REGIONAL OFFICE OF TIIE DEPARTMENT OP ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
& BEFORE COMMENCEMENT OF CONSTRUCTION.
DEl'Arrnovrn FORM. 12/07/95
'EE
Sr.0.02 min
gq r'
—' VA('
trefrO GALLON
SEPTIC TANK
S
1
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. /7 7 A20) 1-�) /-4 4/1)/3 r■ci
On-site Review
p l area
Deep Hole Number//- 43 Date:510 /C/ Time- frf°N(Ot (--
Location (identify on site plan) �? P- ct,of� f
Land Use ICU-J Slope (%I n --V Surface Stones h-r.
Vegetation 91.-mss•
Land form
Position on landscape (sketch on the back)
Distances from:
Open Water Body 5/60 feet Drainage way %ST' feet
Possible Wet Area -7S feet Property Line 1/o feet
r.R
Drinking Water Well ›/Co feet Other
DEEP OBSERVATION HOLE LOG'
Depth from
Surface(Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
IMunselll
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency, %
Graven
,�
x -60 y)
i_
_
e7,9 /3
nn.mn
I-
SYeld�
— (20 "0
ca's y•,), 4
(a0
n n„ n..•-..
As,.,—/rc-f iprcr7S;.Are i/F.,?,
100
• MINIM(IAA
a
(lr a rani ti nmhi
---
� �
IDCll K. i„re ■
Parent Material(geologic) CI,/]( )(0C))1 (”] g�p DepthtoBedrockr— 130' 1 2 /O , //
-/
Depth to Groundwater: Standing Water in the Hole- (0 /nr� �r Weeping from Pit Face: )) r/00"
6C) Cco"
.)
Estimated Seasonal High Ground Water:
DEP APPROVED FORM-11/07/95
No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
Date: `j/V 99
Commonwealth of Massachusetts
N-t/a , Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By:
Witnessed By:
is/c'/ 20G' nye
@ I C'r nicer/ cynQ
Date:6---1° -99
Lam AEbu
La I
•
4' /Vorfh Forms /24
Vew Construction ❑ Repair gj
��'.W.nt.Uaa3 Lo[lam me
A" " a /3-P"cchc.�c a at.e
ivkpMV
GHQ Sfh4.rnp inr 1 mfg/Ocy%
Office Review
Published Soil Survey Available: No ❑ Yes ❑
Year Published
Drainage Class
Publication Scale
Soil Limitations
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 El 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 Normal ❑
Other References Reviewed:
DEP APPROVED FORM 12107/95
FORM 12 - PERCOLATION TEST
Location Address or Lot No. LA/ ,Ucnw1 het Y\t�
COMMONWEALTH OF MASSACHUSETTS
Massachusetts
1
Minimum of 1 pe colation test must be performed in both the primary area AND
reserve area.
Site Passed .® Site Failed ❑
Performed By: N\ C\Cc1 p./ LCct 7 9-KS
Witnessed By: R"kJ3-.Qr- m cP^ ic&�rn j
Comments:
DFP APPROVED FORM.12/07/95
Percolation Test*
Date: 5//O/ 79
Time:44ft
-moc/il
Observation Hole #
P /
Depth of Perc
il
Start Pre-soak
/ S?
. End Pre-soak
Time at 12"
a- OP
Time at 9"
n
/ /`)
Time at 6"
1 93
�(�i
Time (9"-6")
D
Rate Min./Inch
.7)172(;7v)(.7)Ch
1
Minimum of 1 pe colation test must be performed in both the primary area AND
reserve area.
Site Passed .® Site Failed ❑
Performed By: N\ C\Cc1 p./ LCct 7 9-KS
Witnessed By: R"kJ3-.Qr- m cP^ ic&�rn j
Comments:
DFP APPROVED FORM.12/07/95
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. 2/V /On to j r t7Yl.s I?(/
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 mottlese;'60 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 -C/ (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.
DEP APPROVED FORM•13/07/95
Date6/`x9
uvc3
'
I
yass s 8
•
i -a
s
2022 .
•
2.
12C-93
uvs
#41" 10
I vv 4m
•
•
•
•
<./14 Nov-fk b H.- nus -o
•224.0 ( twr 5 rid. m .en n B•
(2(C44 44r�wK e v(,q
se
s.
124.15 444.15 swv
.. ▪ .!
t44(<P ( c0J`!l la-6T PI 14-6'< YCZ Gu"jet/C''' S
t. 7,lhK1n,, A _ . clifA9
Y fl
1-26
FORM II - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. kJ # / k20,
On-site Review
Deep Hole Number t Date:
5-i l Q-() Timeik {-f r it-a%) Weather
Location (identify on site plan) �-'L$_� CL/10
Land Use (0.!U!`- Slope (%) 0 —2 Surface Stones
Vegetation
Landform _.
Position on landscape (sketch on the back) 3FR -T(°--tC F)
Distances from:
Open Water Body >/CO feet Drainage way �S (1 feet
Possible Wet Area —`yam feet Property Line -726 feet
Drinking Water Well >/OC' feet Other
-Pi, - - n1
oP?J
DEEP OBSERVATION HOLE LOG.
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munselll
Soil
Mottling
Other
(Structure,Stones, Boulders, Consistency, %
Gravel)
C) - 73 "
72"- 136"
Is
C
S
Si.
1-
«s•V,yh
aiSY7/3
L.
7,54 Rqk
isY v V
/0 V5 y
' ), -9 //
L7j,l
, c-l-c,CThj ,-.0-.-bveFtFill
I F,I
lr
6'"- Imoii
6
v. 1-1 1y
SL
Parent Material(geologic) �X //Y7 V�
Depth to Groundwater:
Dep htoBedrock:, 1c b" > / -O//
VStanding WeteTi the Hole:�v ) Vq y Weeping from Pit Face: I _r D r�
Estimated Seasonal High Ground Water: �r3 ) �(i f�
DEP APPROVED FORM- l2/07/95
No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
Date: 5- (-1-Cj Cf
Commonwealth of Massachusetts
No -2i40stpJer.. , Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By: nil c / Lau i 71.12_Witnessed By: 1)-44-e V MC EA 10A.11-)
Date
5-10-99
mr mens 2rc1- . V"S
L9
New Construction gj Repair ❑
,v
mans' a (,e chwocd
Telephone I
Q e
Eostlna nip tzm rn oiayi
Office Review
Published Soil Survey Available: No ❑ Yes ❑
Year Published
Drainage Class
Publication Scale
Soil Limitations
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No El Yes ❑
Within 500 year flood boundary No EYes ❑
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 Normal ❑
Other References Reviewed:
DEP APPROVED FORM-11/07195
FORM 12 Rd.
PERCOLATION TEST
Location Address or Lot No. Lot #- / AJCJ r ) o rm `� Rd.
COMMONWEALTH OF MASSACHUSETTS
/l/ -./LZJ 1»t'w,; Massachusetts
Percolation Test'
Date: ,�J10/ 9 9 Time:( It') CJ00N
Observation Hole #
P- 1
P-a
Depth of Perc
,(/ II
D
O �J ,r
Start Pre-soak
g- 30
q�/
End Pre-soak
1
Time at 12"
Time at 9"
.3 : 061
Time at 6"
Ck
3 ; /o
Time (9"-6")
Dt-i9i li< lst'lu
67
Rate Min./Inch
<)17L/n) /( --)��i
,) ry, Ir /0ch
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed ® Site Failed ❑
Performed By: (l l C hCt ? L / cu) I
l
Witnessed By: _('��' r VU r`fli ict /yL_
Comments:
DEP APPROVED FORM-121 61195
•
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. /0i Dor+li '-n rf'1'c !!ter
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole inches
❑ Depth weeping from sides of observation hole. inches
Depth to soil mottles ' ) 'Lu 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? ,4,17)
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on 11 -9V (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.
DEP APPROVED FORM•12/07195
Date
PERCOLATION TEST(S)
Time: I I Time:
Observation Hole #1 Observation Hole #2
2 – .)– —
Depth of Perc 9 9/ It Depth of Perc g(jl If = <,(
Start Pre-soak ^ J Start Pre-soak - q Y' '
ti
End Pre-soak End Pre-soak
'"y Time at 12" Time at 12"
IlA _,
V- r Time at9' Time at9" 3 ' Li
Time at 6° Time at 6" ( 0
1
Time(9"-6°) Time(9°-6") 3
Rate Min./Inch Rate Min./Inch /.Gt - ,
'minimum of 1 percolation lest must be performed in both the primary area AND reserve area. I r
performed iii
• • • • ; ,
Performed b p�,,;. ,,." Performed b j% a -G, C
Witnessed by �1 -11 — Witnessed by , /, lAI
Comments:
NORTHAMPTON BOARD of HEALTH- Title 5- Site Review
/
Owner
Date /ii°4
I Time
Soil Holton
Owner's
Address
Soti Color
(MUnsell)
Irn
Engineer
��
Weather a(24,/l Phone ft
Land Use
± / \
%Slope
I Surface Stones
Landfonn
Ve•etation Start Time
Position on Landsape(sketch on thebade)
Distances Stop Tins
Open Water Body
feet
Drinking Water Well
feet Property Line
feet
Possible Wet Area
feet
Drainage Way
feet Other
feet
DEEP OBSERVATION HOLE LOG*
ttp mom 11. (J. j MIIVIMUM Vr I MV masa TNURLU RI LYLRI rwJYWCU WaruaAL MTA
Depth from
Surface(Indies)
Soil Holton
Soil Texture
(USDA)
Soti Color
(MUnsell)
Sol
Moiling
Other
(Structure.Stones,Boulders.Con sistency,%Gravel)
D 69"
e
P_i2
-v.• Ir +_./.—
/ Fir e /
SI
akS—yS.i
Parent Mabial(geologic) I Depth to Bedrock
Depth to groundwater. Standing Water in the Hob
01,0 x 4, I Weeping from Pit Face I /I✓0;X TT
Estimated Seasonal High Ground Water
-7 a I+
DEEP OBSERVATION HOLE LOG*
Deep Hole It ) ——)--- 'MINIMUM OF TWO HOLES REQUIRED ATEVERYPROPOSED DISPOSAL AREA
Depth from
Surface(Inches)
Sol Horizon
Soft Tedure
(USDA)
Seater. Standing Water in the H
Sal Color
Norwell)
Soil
Mottling
Other
(Structure,Stones,Boulders,Consistency.%Gravel)
G 7� co-ter,;
leasoal High Ground Water
Depth to Bedrock
Weeping from Pit Face
7) "
LTo< irrl l'`C C1 7 if E0 si 91y No-) LI
PERCOLATION TEST(S)
Time: I Time:
Observation Hole #1 Observation Hole #2
Depth of Perc Depth of Perc
Start Pre-soak / S 2 J Start Pre-soak
End Pre-soak End Pre-soak
., 0
Time at 12" 0 c"/ Time at 12"
Time at 9" a : � ( Time at 9"
Time at6" • 's. Time at 6°
Time(9"-6") cb/j Time(9"-6°)
Rate Min/Inch -} /_. Rate Min./Inch
"minimum of 1 percolation test must be performed in both the primary area AND reserve area.
Performed by Performed b
Witnessed by by
Y Wtnessed- (Mt - by
Comments:
4
NORTHAMPTON BOARD of HEALTH- Title 5- Site Review
Location Address or Lot# Owner
11 A ai-4 7D ',,, DG -4-, (1 F i 2 NLli1' '-2_
Date /
Jr/w �
Time
/53o
Owner's
Address
Ini�$C /)
o� l�-�-W° G� -`ter'^
Engineer I
Weather
CQo 0-1 '(may-' Phone ft j J -% 20a9y:
Land Use
c> /-I+i"■
%Slope
Surfac: Stones
Landfonn
Parent Mahal(geobgr1 I I Depth to Bedrock I > /s&-c°
V=relation
Start Time ///S 5 -■
Distances Stop Time 3 '
Position on Landscape(sketch on the back)
Open Water Body
feet
Drinking Water Well
iii feet Property Line
feet
Possible Wet Area
7 7 feet
Drainage Way
feet Other
feet
DEEP OBSERVATION HOLE LOG*
Deep Hole#: / •MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Depth from
Surface(IM,ies)
Sol Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Molding
Other
(Structure,Stones,Boulders,Consistency,%Gravel)
U
L.,...4_------------
t yl
/
i
0
/ /,4
,l�
Parent Mahal(geobgr1 I I Depth to Bedrock I > /s&-c°
Depth to groundwater. Standing Water In the Hole
29- ^ I Wee ping from Pit Face I
Estmated Seasonal High Ground Water
/,J
Deep Hole IS:
Depth from
Surface(Inches)
DEEP OBSERVATION HOLE LOG*
'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Soil Horizon
n Texture
(USDA)
Son Cola
(Mussel)
Soil
(S
re,Stones,BouHas,Cons6lency,%Gravel)
9 , Ij ,
0, 5r-
Parent Mahal(geologic) _
Depth to groundwater Standing Water in the Hole
Estimated Seasonal High Ground Water
0
Depth to Bedrock
Weeping from PftFaa I /0 }-
6D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
w6) OF /Oorffr1rnpkk)
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Vpple r t ry Pcmmll Cmnvuci 1 HcI Liu fu] l pceWe 1 dbnnJon I 1 -xf plL•la>,acm I I,IOU I[Conphnnl.
yy Cc 1 Far MS OCiCI_
tiii
iit
■
Dcw Lea m�
LQe_e-SAu cLall€-„Ea s_thurnpikn,
O /Dam
I h) OA.2Erl-e 'trc0 1 )€ I4 Sprl>icf
3S an id et /J/2L-1 1orny10>li
s&6- Ogee 06(00
n
Type of Building: art) -e hR ✓n/l�
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow (min.re
Mari: 1)' t
No of per,
1nt Size Sy-fcet
Garbage Grinder ( )
Showers 1 ). Cafeteria
Lured)i vo gpd Calculated deS'ipn flow —arid Design flow provided 6/4Vgpd
9 Number of sheet. j Recision Date
n5 e lei S sc.l pair - ro-mf-
S er Ln
Tida �Pf ,2
Description of Soil(s)AC)a Yf'hj Sc SQL -1 — e �/� �� pOf r-
Soil l_.aluator Form No._ Name of Soil Evaluator/7),L 6Ui 9 e. Date of[valuation '5),.nj99
DESCRIPTION OF REPAIRS OR ALTLRAIIONS a 1J-tt LC I $o0 9a) S-PJ -h ±L
(n� I ��- tea /X r-)0' Xlol/ LkCC 1PIr�
The undersigned agrees to install fh
TITLE 5 and further agrees not • ace
Sigre I
Inspectins
above described Individual Sewage Disposal System in accordance with the provisions of
min operation until a Certificate of Compliance has been issued yy the Board of Health.
9
Date
zb 9
FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
A
Na. cP
-y�
THE OM,MONWEAL,TH OF MASSACHUSETTS
' G,Y�y�Jfi.SI,r. cN BOARD OF HEALTH
CERTIFIdATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑Complete System
The undersigned hereby canifi that th we Sewage Disposal Sta m;Constructed l ). RLeiredXL. Upgraded l 7. �A Rind( ed I 1
{ /
hs.. q Jl [ . 1!"ti' C�_jL-•i,. l4 i �r.4. S O r I C1 it l tt C
at 't Lf A I /' 41( i'[c�l li 20
has been installed in accordance with theyrovisions of 3 0 C,MR I5.1)() (Iit]e 5) and the approved design plans:as-built
plans relating to application No di ?_[ dated
7 l :f- Approed Design Flo y4L/ (epd)
T / h
Installer
7
Designer / v Y(2 8.i e— Inspector (-.- "Rite l7 /
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
/21/(
No THE COMMONWEALTH OF MASSACHUSETTS FEE.
/04%(? /4,lN-22, ,+i BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ) Repair ((/j Lpgrade ( ) Abandon ( ) an individual selvage
disposal system at /V• P •,(it / 7 as d scribed
in the application for Disposal System Construction Permit No. `/-74/ ,dated L�i-) 'T/J
Provided: Construction shall he completed within three years of the dale of this permit- All local conditions must Ile met
Date
FORM 2 - DSCP / DEP APPROVED FORM 5/96
_'i_' '2M .± lam:'r
[ _ i -i 7— l%% Board uC Health �� ' ! - -
IletV Hoaas a WARREN T"
PUBLISHERS - BOSTON