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705 Title 5 Documents 2014 P 105 N. rgrm5 Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist (cont.) c) Distribution Box(310 CMR 15.232) All outlet pipes at same elevation per plan Inlet tee min. 1"over outlet D box set on level base Top of D box 36"max depth Number of outlets D box is water-tight D box has a minimum of 2°thick wall and 12• inside dimension d) Pump Chamber(310 CMR 15.231) Tank is set level Proper volume is provided Float elevations set per plan Min. 2'delivery line to D box Number of pumps: Specified pump provided or designers approval for equal pump Correct pump sequence Covers set to grade Electrical permit provided 6°of stone beneath chamber Chamber is water-tight Min. 9'cover provided Correct loading provided per plan Notes: 1ff/cuer — 4 rove/r Check by adding water Number of laterals Visual and w/tape Visual Visual and w/tape Add water Visual and w/level Check plan and tank Measure w/tape Visual Visual Test Visual Visual on tank Approved N/A Problem 3 per plan Lf an ❑ ❑ ❑ ❑ ❑ ❑ 6fr. ❑ ❑ ❑ ❑ Approved N//A// Problem ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Septic System Installation Checklist 11-09doc•date Form Name•Page 3 of 5 Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist (cont.) e) Leaching Facility(310 CMR 15.240) No frozen material used including back fill Visual No clay, tailings or stones larger than 6°for cover material Soil at bottom/sides of excavation matches info on deep holes All impervious layers removed Visual No remaining NB horizons Visual Groundwater conditions match plan and Visual/check plan deep holes Vented if under impervious cover per plan (15.241) Vent is protected from precipitation and animal entry Cover of a minimum of 9"over leach area Pipe slope equal to 0.005 Leach area per design(15.241) Excavation is level and at required depth Removal of 5 ft material and replacement (if in fill) Back fill material is acceptable Final contours correct per plan Surface/subsurface drainage away from leach area Final grade and side slopes are stable Distribution lines are capped, vented, or connected together Impermeable barrier(15.255[2]) Retaining wall inspected by PE Retaining wall is water-proofed Retaining wall/barrier is at correct depth/height Septic System Installation Checklist I1-09.doc•date Check w/transit Visual/check plan Visual/check plan Visual Check with plan N/A Problem Form Name•Page 4 of 6 Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist (cont.) f) Leaching trenches(310 CMR 15.251) Approved N/A Problem Number of trenches: ❑ ❑ Depth of trenches: �71�/ ❑ ❑ Width of trenches: tom' / ❑ ❑ Trench spadng per plan e]- S ❑ Stone is double-washed [3/4"to 1W] (15.247) �❑ ❑ g) Leaching fields(310 CMR 15.242) /' Length of field: LLi�J./ ❑ ❑ Wdth of field: ^ ❑ ❑ Min, of 2 distribution lines [�" ❑ El Separation distance conforms to plan +2 / ❑ ❑ Stone is double-washed[3/4"to 1W] (15.247) Kd ❑ ❑ h) Leaching Pas(310 CMR 15.253) �1 '/ Number of pits: ❑ T ❑ Depth of pits: ❑ ❑ ❑ Stone is double-washed[3/4"to 1W) (15.247) ❑ ❑ ❑ Each pit has min. 1 20"access cover Piping network and configuration of pits/chambers per plan i) Tight Tank(310 CMR 15.260) Tank is set level with 6°stone under Visual and with level ❑ ❑ Tank is proper size per plan Visual with plan ❑ ❑ ❑ Pumping contract has been provided ❑ ❑ ❑ Covers to grade Visual ❑ ❑ ❑ AN alarm set at 3/5 tank capacity Check floats by raising ❑ ❑ ❑ NV alarm test on separate circuit Set off alarm ❑ ❑ ❑ Septic System Installation Checklist 11-0e.doc•date Form Name•Page 5 of 6 Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist (cant) j) Certificate of Compliance(310 CMR 15.021) As Built Plan Submitted Signed by Installer Signed by Designer Certificate of Compliance Issued Notes: / {y/J//�O 45- mow,// k 5✓,‘rkf Date // a u Pis 5 Date Date Date Septic System Installation Checklist 11-09 doc•date Form Name•Page 6 of 6 Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist (cont.) 2. Construction Inspection a) Building Sewer(3W CMR 15 222) All waste pipes tied into building sewer Basement check Schedule 40 PVC 4' or cast iron Verify by reading pipe Minimum slope of C 01-0 02 Visual Pipe laid in continuous straight line Visual Pipe laid on compact,firm base Cleanouts precede all changes in alignment/grade Cleanout provided every 100 ft. Ball material clean b) Septic Tank(310 CMR 15 223) Tank is set level with 6'stone under (15.228) Tank is required sizelloading per plan Inlet and outlet are at proper location (15.227) Tank is water tight(15.226) Outlet tees extend 6' above flow line Visual Verify by visual/tape Verify by visual/tape Visual Check with level Verify with plan Verify with plan Test Verify by visuaUtape Approved filter device placed at outlet DEP list Gas baffle installed at outlet tee Visual Inlet and outlet tees on center line Visual Tank is backfilled with acceptable material Visual Notes: Septic System Installation Checklist t 1-09.doc•date Approved NIA Problem Approved N/A ❑ ❑ Problem Form Name•Page 2 of 6 'ROJECT NO.: :ITV/TOWN: tJRf--1—“,m--y-Mr3 tPPLICANT: G,tt.evy 094 ('S 4DDRESS: r1 OS N DESIGN FLOW: REVIEWED BY: 3W 4 gpd DATE: N/A v15120) 9 OK NO Address Sheet of 13 Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot,tax parcel number and lot number noted on plan [310 CMR 15.220(4)(u)] Locus Provided [310 CMR 15.2204(t)] `/ Plan proper scale? (1"=40' for plot plans, 1"=20'or fewer for components) [310 CMR 15.220(4)] [w= ) ✓ SO- Easements shown [310 CMR 15.220(4)(b)] N-a"Q System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways, parking areas etc.) [310 CMR 15.220(4)(d)] ../ Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] /t`'ro--s. System Calculations [310 CMR 15.220(4)(f)] daily flow septic tank capacity(required and provided) soil absorption system(required and provided) whether system designed for garbage grinder a OT ✓ North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes(existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and(i)] Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] / Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] ✓ Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3)and 310 CMR 1 S 990(41(n11 / Address Sheet of 13 I _ ocation of every water supply,public and private, [310 CMR 15.220(4)(k)] of surface water supplies and gravel packed public water supply wells within 250 feet of the proposed system location in the case of tubular public water supply wells within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)0)] Water lines and other subsurface utilities located [310 M 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system )] components and the bottom of the SAS [310 CMR15.220 4 O(0 Stamp of designer [310 CMR 15.220(1)and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? r310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not>36" deep(unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(1(b)] All system components marked with magnetic tape 15.221(12) Address J Sheet 2 of 13 Size OK? [310 CMR 15.2230)] Mlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees(no less than liquid depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.22280) and 310 CMR 15.232(3)(£)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two for systems>1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.2110)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15 223(1)(b)] First compartment 200%daily flow; Second compartment 100% daily flow [310 CMR 15.224(2)and (3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address I I Sheet 3 of 13 WIRING 'SY ,ANIWTHERTIPINt located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts required/provided ? [310 CMR 15222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] is NIA- ./ Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphon problem/(leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8)and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)0)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] 0 Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity (emergency storage above working—design flow)? [310 CMR 231(2)1 Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible(not too deep wi disconnects accessible) Alarm floats -alarm on circuit Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] Address h piping, t separate from pumps specified? V f Sheet 4 of 13 Address Sheet 5 of 13 ;table Compacted Base [310 CMR 15.221(2)] ./ err 3uoyancy calculations needed ? Provided? [310 CMR 15.221(8)] Dosing chamber capacity(required and provided),pump curves And specifications, number of dosing cycles and depth per cycle? [310 CMR 15.220(4)(r)1 t/ Effluent tee filter provided [310 CMR 15.231(10)] Address Sheet 5 of 13 1OII.AB .. N S' > , (S A OK :alculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15240(1)] / Required separation to groundwater? [310 CMR 15.212)] ✓ Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] J G-f ' d�'., , '. anig. Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole(if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate 1' minimum-4' maximum. [310 CMR 15.253(1)(6)] 2' sidewalk credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] / '. ` Width 2' minimum 3' maximum [310 CMR 15.251(1)(6)] J 100 feet- maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] i j�;s beort SP$;. x. l r minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' [310 CM R15.252(2)(d)] Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10'minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only [310 CMR I5.252(2)(1)] Address Sheet 6 of 13 DID THE PLAN I NVOLYE °1, 1/A Nt] Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Groundwater Separation Per 310 CMR 15.24002) does the groundwater separation take into account mounding. / J Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] / ✓ If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd)or quarterly (>2000gpd) good to note on plan [310 CMR I5.254(2)(d)] / Construction in fill -Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] ✓ Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2)and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] Check DEP Approval letters for credits and design conditions ✓ If used with pressure dosing do not allow pressure discharge to scour soil interface �/d� Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? v Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? agreement? Are the variances listed on the plan? [310 CMR 15.220 (4)(p)] / Address Sheet 7 of 13 RLS Stamp necessary on plan if a component is within five ✓' Feet of property line [310 CMR 15.412(4)] / New construction or increased flow proposed - [Refer to 310 .� CMR 15.414 Address Sheet 8 of 13 Address Sheet 9 of 13 N4ogetq VIA`...,. ,idiveAteas Is the system in a Designated Nitrogen Sensitive Area(Zone IT for a public supply well)? [310 CMR 15.214, 310 CMR 15 215 and 310 CMR 15.216 -also refer to Policy regarding upgrades of such existing systems] / Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] I Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] ,✓ H - c: :'t Pumping to septic tank 9 [310 CMR 15.229] Shared System [310 CMR 15.290] ./ Address Sheet 9 of 13 CITY of NORTHAMPTON PUBLIC HEALTH DEPARTMENT BOARD OF HEALTH MEMBERS: Donna Sal loom, Chair Joanne Levin, MD-Suzanne Smith, MPH, MD William Hargraves- Cynthia Suopis, PhD STAFF: Merridith O'Leary, RS,Director—Daniel Wasiuk Inspector—Edmund Smith, Inspector Lisa Seinhock, RN.Nurse K rly Corbett mock Street s,MA 01053 Ms.Corbett- :rday I met Russ Luce at the property 705 North Farms Road, Florence; I witnessed the soil evaluation that Man s performed in preparation to design the new septic system for the property. Russ asked that I send you a note esting a check for the City's fees that relate to the design of the new septic system. There are two: For the soil evaluation,$200; I am a licensed soil evaluator and concurred with Mr.Weiss'findings; I have started a file here with my notes for the property and will add the design and as-built drawings as we receive them. There were no records for the property from the original system. For the Disposal System Construction Permit,$150;I will review the submitted system plan,checking to see that the design criteria match with the soil evaluation and all aspects of Title 5; I will make a final inspection of the system before it is covered. se remit to our office a check for$3S0 made payable to City of Northampton(please write"705 North Farms Road is Fees" on the check note line). Russ mentioned wanting to try to get the system in this fall,and if the check is when we receive the plans I will review them as soon as possible(should be within 2 days). iu have any questions,please call - nk you, nund Smith 212 Main Street Northampton,MA 01060 Ph(413)587-1214 Fax(413) 587-1221 Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Form 1A 'GO k‘")1 {o Number $ ( St Fee DEP has provided this form for use by local Boards of Health if they choose to do so. Before using the form,check with your local Board of Health to make sure that they will accept it A. Facility Information gout forms Application is hereby made for a permit to ❑Construct a new on-site sewage disposal system leacoompme pall ®Repair or replace an existing on-site sewage disposal system ala only the tab ❑Repair or replace an existing system component to move your or-go not the return 1 Location of Eadlity: Addr N Farms Road Address or Lot 01062 Florence(Northampton) MA crtrrtoan state Zip Code Owner Information CIO Belverly Corbett Name br}BIRmNCR St 4— M cr Address(b different from above) Leeds MA M ORVxn — state 413-584-5807 Telephone Number St 3. Installer Information TOm Wanrych River Drive Excay. Nam Name of Company Name River Drive Address Hadley — — - MA City/Town slate 584-1814 Telephone Number rsformta dec.06103 Zip Cod 01035 Zip Code Designer Information Alan Weiss Cold Spring Environmental Consultants Inc, Name Name of Company 350 Old Enfield Road Address 01007 Belchertown MA - Slate Zip Code ceyrtown 413-323-5957 Telephone Number Application for Disposal System Construction Permit.Page 1 of 3 Commonwealth of Massachusetts City/Town of Northampton Application for Disposal System Construction Permit Form 1A 31) IL( - Eta Number $ Fee fCO A. Facility Information (continued) 5. Type of Building: • Dwelling 3 Bedroom Other:Type of Building ❑ Showers Number of Showers Specify other fixtures: 6. Design Flow: Calculated Daily Flow 7. Plan: 01 Number at Sheets Septic System Repair Plan Title a Plan 8. Description of Soil FS 9 Nature of Repairs or Alterations(if applicable): new septic tank and leach field. 10. Date last inspected'. tSlorm1adoC•IMN3 ❑ Garbage Grinder(check if present) ❑ Cafeteria 330+. Gallons per Day 414 Gallons 11.012014 Dare ofonglnal Revision Date Number of Persons Served ❑ Other fixtures Date Application for Disposal System Construction Permit Page 2 of .C'\ Commonwealth of Massachusetts 0., City/Town of Northampton Application for Disposal System AY Construction Permit Form to 2ot -E - 112 $wmti( B. Agreement The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Tile 5 of the Environmental Code and not to place the s em i operatiop until a Certificate of Compliance has been issued by this Board of Health. -y,c4� •t&nit CrC&M- // ‘,. At ) / Signature Date A lication Approved B y: /y'm'/n/_>-`�`p(1•�_M.'-wlj'a",r'— Daft - Ce "2-0/Y Application Disapproved for the following reasons 5famla.Eec.06103 Application for Disposal System Construction Remit•Page 301 3 City/Town of 1I .' Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information 12,sS! 4r379111-09/� 3ft)erl� (OCba-Pr t. Sy A�49(X ST) Lerci54_ MA ec _ c&y-sgot Owner Name • -05 uJ, cciff#55 _ — StreetAtltlrese. � . Map/Lot# +1 1 OV „°1� \ A City State Zip Code ' B. Site Information 1. (Check one) ❑ New Construction Re n ❑ Upgrade pair 2. Soil Survey Available? L2 Vones El No If yes: Source Soil Map Unit (IAej\\?n' 50 l 1 _I,,}e 11 CD Soil Nam Soil Limitations S ( 4t\1 Ca to1 ,1 `\ Geoogic/Parent Mthefial Landfonn 3. Surficial Geological Report Available? 2 Yes El No If yes: 6, 5 . V SG $ Year Published/Source Publication Map Unit 4. Flood Rate Insurance Map Above the 500-year flood boundary? El Yes ❑ No Within the 500-year flood boundary? ❑ Yes ❑ No If Yes,continue to#5. Within the 100-year flood boundary? ❑ Yes ❑ No • 5. Within a velocity zone? ❑ Yes ❑ No 6. Within a Mapped Wetland Area? El Yes ❑ No MassOlS Wetland Data Layer: __. Wetland Type 7. Current Water Resource Conditions(USGS): Range: ❑ Above Normal ❑ Normal ❑ Below Normal Month/Year 8. Other references reviewed: PercolationTestFormNew.doc•rev.9/14 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8 G ml rn City/Town of fI " Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: I e 2— )01 111 __ z( �.— C (c`Jr Date Time Weather 1. Location Ground Elevation at Surface of Hole: _._ Latitude/Longitude: / nn feet 2. Land Use aura lle S - (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones(e.g.,cobbles,stones, boulders,etc.) Slope(%) Vegetation Landform Position on Landscape(St),SH, BS,FS, 3. Distances from: Open Water Body 1O c_` h Drainage Way SyI r_ Wetlands toot/— feet feet feet Property Line _ )r; 1 4 Drinking Water Well Other feet feet feet 4. Parent Material: ( -NC +( 4 Unsuitable Materials Present: ❑ Yes (9 No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed. ❑ Yes ❑ No If yes: Depth Weeping from Pit Depth Standing Water in Hole 9 Estimated Depth to High Groundwater: Ito __..._ _ _ Inches elevation PercolationTestFonnNew.doc•rev.9114 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 m z 1.ry IcArVil u fl E Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: (__. ( Coarse Fragments Soil Hedozimorphic Features Soll Texture by Volume Soil Horizon/Soil Matrix:Color- Soil Structure Consistence Other �� Depth(In.) Layer Moist(MUnsell) (USDA) Gravel °obbles (Moist) Depth Color Percent g Stones — • �I � I -1'I\1 Citint Cs-36 ` 0-32u C \ _ S ( �PA. 3040 3/A4e AV, it,,t0z X11 y0 4S(," 3b to451e c5 cl W Sn < � _ 5-21t, 50-Ho G , t.cti ` Additional Notes: / / n e- t-em-"-<_ +0 51tr. JAck-' 6 JJ: *- Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 PercolaticnTestFOnnNew.tloc•rev.9/14 City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: Obs. Hole# / Obs. Hole# 2 r Et/Depth observed standing water in observation hole _ lllc() -- — — inches inches ❑ Depth weeping from side of observation hole — -- inches nches III/Depth to soil redoximorphic features (mottles) __ ho it SoCr_ASS--.e9 inches inches ❑ Depth to adjusted seasonal high groundwater(Sh) inches inches (USGS methodology) Index Well Number Reading Date Sh= Sc—[Sr X (OWe—OWmax)/OWrl Obs. Hole# Sc Sr OW, OWm„„ OWr Sh Obs. Hole# Sc Sr OW, OWmax OWr Sh - _ E. Depth of Pervious Material 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 the soil absorp on system? es ❑ No a I/bri b. If yes, at what depth was it observed? Upper boundary: 50_ Lower boundary: incheF inches c. If no, at what depth was impervious material observed? Upper boundary: _ Lower boundary: . inches inches • PercolationTestFon-nNew.doc•rev.9/14 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. I further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. Signature of Soil Evaluator �+ Date ,� Al Cab krc<� �I 3 3 zoik_ Typed o Printed Name of S Evaluator/Lipense# Expiration Date of License 13orf . C Sell/NA N � Name of Board of Health Witness Board of Health Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the properly owner with Percolation Test Form 12. • PercolationTestFormNew.doc•rev.9/14 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of B Commonwealth of Massachusetts City/Town of Percolation Test Form 12 Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the the lintel ation must st bey substantially ally the the same as that sprovided here. Before using this form, check with it:When A• Site Information forms mputer, the tab Dye your Owner Name Jo not eturn 3 Street Address or Lot# State City/Town Contact Pereon Of different from Owner) Telephone Number B. Test Results Zip Code o Time # Date Time Observation Hole# 4 t_ n� Depth of Perc Start Pre-Soak 71 / End Pre-Soak � (3 Time at 12" 2: 2-2— Time at 9" Time at 6" Time (9"-6") Rate(Min./Inch) Test Passed: ❑ Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ A WEISS, RS , SE, Cold Spring Environmental Consultants Inc. _—Test Performed By: Witnessed By Comments: t5fonn 12.doc•06103 Pert Test•Page 1 of 1 — ��---'� LEACH FIELD DETAIL(NTS) SUBJECT 5a _ -� '' x nm 1 SITE �_✓ �� \ a I � 1 ocnno LV BsV �..,�ITAttritrin44)1"Sigiet „- a 4 .:., LP .� A ® A + i \ \!� .. Y n ' O C\\`Y m EFL ENTO GOYLL ARFA omexnvm HES i g \\\ \ ,\• ` L\ may,^ n a xy w eFE Cr nxr ra,m xaoxnvE n.x ■ _ {��y. 3139F-rownravaMCF FFIwi Taps-EEO 00 come.n3 Tom;NOS&BOBFb V• �Pa Pa T a urma ONLP 31145 uxireemmz eouzuis.wvaxnsm� ,wru ;~ rasm ru _s.Ex. ..snx iA ER E. vL .Ai. wE — 13 25E233 MIIMIA 31.Cf0E231.03. MAINTE zwSOTES FOR HoM .,,o .. ' IT. ramaz«vum ,rays. ,_rmE�x 13 soLEv34.3aTiove■3 0•C2.4125 GRA BEx \FEE DEBWD3 KBE es `,��" .F Xw"ssY 1 Rr�rj ._., a.�mrv�r.� 35C:0 SNIOMBIL4PgiRrYDTGRrORDEBY saaues+max DETE SENES&L ... ]cuwiwxanAmrzRwXUkLYA EQUIPPED, ••.'"••°•`."�„� voxnxiarormnrtEmxauw uwm rxs zo Berm.Of sow 5313,3 mmmeuwErten EFFLUENT DISPOSAL SYSTEM A cru. rx r I I I w:I" ,,mw.. TEST PIT LOG an Ones®®°® {{ 5-:--r o °� ..a `T a 1 :t„rrr rw. ' '1® 1 b � 'NMpUS' 'Dj _ ,ry °MP IM s ®� 5�1'. 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