839 Site Suitability Massachusetts Department of Environmental Protection
' Bureau of Resource Protection -Wastewater Permitting Program 80 9 YJe,+1e so� �Lo Number
1 ""'W{`�
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
ass or Map; of ryu pet
g posal
C. On-Site Review (minimum of two holes required at every proposed disposal area)
Deep Observation Hole: Date: o1
1 v Time: B
l0 4
/ 5 4 Weather. Oveecas} _.
1. Deep Hole Number I Location (Identify on Plan ): See -Des 9 --
2. Land Use: L^,....., 1". Surface Stones: - Slo
(e.g. woodland, agricultural field, vacant lot,etc -- P- (�) Vegetation �rraSg
Landform: be-140, Position on landscape.
3. Distances from: Open Water Body z o. ft. Drainage Way too+ ft. Possible Wet Area bo 4- R.
Vie-.5).4- Property Line 60 ft. Drinking Water Well ¢ao+ ft. Other ft.
ft.
4. Parent Material: (:),#)-1-,-(:),#)-1-,-(:),#)-1-,-),AsL. Unsuitable Materials Present.. Yes NoR
If Yes: Disturbed Soil❑ Fill Material❑ Im pervious Layer(s) ❑ Weathered/Fractured Rock ❑ Uedi ock ❑
5. Groundwater Observed: Yes ❑ No 3"/
If Yes: Depth Weeping from Pit _ Depth Standing Water in Hole Estimated Depth to High Groundwater:p g I20''
Soil Redoximorphic Features Coarse Fragments T -
Depth Horizon/ Soil Matrix. —Depth Color mottles) %by Volume
(In.) Soil Texture Color-Moist De _
Layer (USDA) (Munsell) Percent Gravel Cobbles - Soil Structure Soil Consistence
& Stones (Moist) Other
0 9
A 5L IO vg 3/z_ - /
/6„5,_ jf cr∎.mb
9 8 j3 L S
o v/2. 4-,74- — moss/lie e y
/8-120" C 5 2,5Y6 /4 cosi eyrer ■ /0OIt m"'r.5-4 nq
•
•
— —
—.— __L .—.
"Si. Additional Notes - -- --- - - — _. —_
1 H/LLTOWN ENVIRONMENTAL CONSULTING I -----
_ Massachusetts Department of Environmental Protection S39 1Ai es}k4V„ptnRa. , Nor--kan^w��
N. Bureau of Resource Protection —Wastewater Permitting Program site Address or Map/Lot Number
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
D. Determination of High Groundwater Elevation 1 ?
1. Method used. ❑ Depth observed standing water in observation hole A. B
Ly Depth weeping from side of observation hole A. > 120" 8. > 120"
Lh Depth to soil redoximorphic features (mottles) A. 7 120 ' B. > 120"
❑ Groundwater adjustment(USGS methodology) A. B.
2. Index Well Number Reading Date Index Well Level
Adjustment Factor Adjusted Groundwater Level_
E. Depth of Pervious Material
1. Depth of Naturally Occurring Pervious Material
a. Does at least four feet of natural) occurring pervious material exist in all areas observed throughout the area proposed for the
soil absorption system? Yes le No❑
b. If yes, at what depth was it observed? Upper boundary: Lower boundary
F. Certification
I certify that 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.
r � Cc4ob tr- [4,7w8 HILLTOWN ENVIRONMENTAL CONSULTING
�� ' r'
Signs ire of Soil E aluator Date P.O. BOX 314
CHESTERFIELD, MA 01012
Mark Thompson April 29, 1997 (413) 296-4499
Typed Printed Nnamerof Soil Evaluator 'Date of Soil Evaluator Exam \
Petc McErlai•- �vor� i nn p}o CQye \
Massachusetts Department of Environmental Protection
, Bureau of Resource Protection — Wastewater Permitting Program 839 4.Je-s+l.., Address �or�-In an-.pia v.
Site Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
aa`M,aP-LntNUmba.
A. Facility Information
PERGORMetk BY%
Owner Name EA wre_ u■,, u�i HILL TOWN ENVIRONMENTAL CONSULTING
Street Address. X39 ��es}-f (2 P.O. BOX 314
Ma p/Lot. CHESTERFIELD, MA 01012
City F1-----="'- _ State. lMA
(413) 296
Zip Oto6'Z
B. Site Information
1. (Check one) New Construction
❑ Upgrade 0/ Repair ❑
_. Published Soil Survey available? Yes 0/ No ❑ If yes. 19s I :1546o Hi A I
H Sail Neme/
y. Surficial Geological Report available? Yes
❑ No ❑ If yes.
Year Published Publication Scale Map Unit
Geologic Material
Land,orm
4. Flood Rate Insurance Map.
Above the 500 year flood boundary? Yes L✓J
No ❑ Within the 100 year flood boundary? Yes ❑ No
Within the 500 year flood boundary? Yes
❑ No ❑ Within a Velocity Zone? Yes ❑ No ❑
5_ Wetland Area National Wetland Inventory Map
Wetlands Conservancy Program Map Map unit Name
Map Unil Name
6. Current Water Resource Conditions (USGS) 9/o8 Range Above Normal [✓i
Month/Year Normal ❑ Below Normal ❑
7. Other references reviewed.
frf-
L Massachusetts Department of Environmental Protection 839 W esl-haw"p4�.- (Zd No����-«-.pin�
Bureau of Resource Protection —Wastewater Permitting Program site Address or Mepaot Number
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (minimum of two holes required at every proposed disposal area)
Deep Observation Hole: Date: ID/I'I-,c?B Time 1 : Z0 Weather: O Vs rc a s A-,_-
1. Deep Hole Number Z Location (Identify on Plan )': Sac-Des 2g t^
2. Land Use: _Los wr-, Surface Stones: -- Slope (%). O Vegetation 6""55
(e.g.woodland, agricultural field,vacant lot,etc
Landfoml: 1D-e Pres Position on landscape.
3. Distances from. Open Water Body 209+ ft. Drainage Way loo+ft. Possible Wet Area loon- ft.
W e_g} Property Line 4o ft. Drinking Water Well am+ ft. Other ft.
4. Parent Material: +was io Unsuitable Materials Present: Yes ❑ No
If Yes: Disturbed Soil(] Fill Materials Impervious Layers)❑ Weathered/Fractured Rock ❑ Bedrock El
5. Groundwater Observed: Yes ❑ No [r'
If Yes- Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater > Iw
Redoximorphic Features Coarse Fragments
Soil Soil Matrix: (mottles) %by Volume
Depth Horizon) Soil Texture Color-Moist Depth Color Percent Gravel Cobbles Soil Structure Soil Consistence
(In.) Layer (USDA) (Munsell) &Stones (Moist) Other
PI
D -9 A sL ID YR3/z- — Iooa Crr,note _.
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9 _Zln �j,x,1 L5 10 YR 4�4 — mass;v� -Tr VA\o k-ZI- IZD" C 5 2.5Y6/4" - I _ S;nyte3 re;v. loos= t„-cSena
Addifinnal Mrdoa I t __ - s.
es awn ss om nl+-�!�^JO
Massachusetts Department of Environmental Protection 839 VAl +L Rd, N 1 k
11 Bureau of Resource Protection—Wastewater Permitting Program sae Address or Map/Lot Number
Form 12 — Percolation Test
HILLTOWN ENVIRONMENTAL CONSULTING
P.O. BOX 314
A. Facility Information CHESTERFIELD, MA 01012
(413) 296-4499
1. Facility Information
Ei"y�r-e I csr.igiw.cky
Owner Name r�
839 WaSa-Law��-�-o Roc-ct Map/Lot _
Street Address
FIovt vsce- MA 0104"z
City State Zip Code •
Percolation Test
Date: Oc-t-. 14, 2oc8
Observation Hole # 'rP- I
Depth Of Pero 36 "
Start Pre-soak 9 ; 03
End Pre-soak IA_ -fn k
Time at 12" 24ywlions 9Mil"
Time at 9"
Time at 6"
Time (r-6")
Rate — Min/Inch < Z M
Minimum of 1 Percolation test must be performed in both the primary area AND reserve area.
Site Passed IY Site Failed Li
Performed By: Mar L I L0w?scr --Witnessed By: Ricer McE,-(a;r. —_
Comments:
Na.
/-/,..11-1,, (bpi
FORM 3A - CERTIFICATE OF COrMPLIAT
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Nnrfl,q,,,Pich MA.
CERTIFICATE OF COMPLIANCE
Description of Work:
The undersigned hereby cc
by 03p 11e5 < 9r p fr4 �o n� �74 nG Nay e S%�at: a�c2/1
has been installed in accordance with the provisions or 310 C,MR 15.00 (Title 5) and th
approved design plans/as-built plans relating to application No.
dated 1 k /S/os _ Approved Design Flow 535 (gpd)
1- (7/ -
Fee_
O Individual Component(s) IComplete Sys-ter
rlify that the Sewage Disposal System;
Constructed O, Repaired O, Upgraded (LAbandoned ( )
�v_rf / Vu9 r_rt1
Installer
Designer: / " /ea-
Inspector
Date /Z/Z /De,
The issuance of this permit shall not be ronslrned as a guarantee that the system will
function as designed.
}es :
rih i5lteck 3 cad ioiq ✓IC-F CompletecJ 44- Aome_ ot- t nspec-rioyn
' Se i(; Wank SlIytculc Le_ IDuW19ecl every -I-krc& year:
ncarai'SItErrila•
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9 )0 a/ I hfSVl SG .--,-5/s ->Litils Lma�ca 2ny °" )- -
Deep Hole Number: #
Location(identify on site plan):
Land Use:
Landform:
Distance from:
Date:
Vegetation:
Position of Landscape:
Open Water Body
Possible Wet Area
Drinking Water Well
Feet
Feet
Feet
Time Weather:
Slope(%).
Surface Stones_
Drainageway
Property Line
Other
Feet
Feet
Feet
Parent Material(geologic)
Depth to Groundwater: Standing Water in the Hole:
Depth to Bedrock:
Estimated Seasonal High Ground Water: ;/2C Weeping from Pit Face:
certification: I certify that in November 1994. I passed the soil evaluator examination approved by the Department of Environmer
Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described
310 CMR 15.017. Mass.Soil Eval.Approval No.5E1543
Signature:
Peter J. McErlain
Date:
TP
DEEP OBSERVATION HOLE LOG
Depth from
Surface
(Inches)
Soil
Horizon
Soil Texture
(USDA)
Soil Color
(Mansell)
Soil
Mottling
_
Other(Structure,
Consistency,
Stones,Bot
% Gravel)
Parent Material
Depth to Groundwater:
(geologic)
Seasonal
Standing Water in the Hole: Depth to Bedrock: % / '� /
High Ground Water: Weeping from Pit Face: i'7 i
Estimated
TP
.1
DEEP OBSERVATION HOLE LOG I
Depth from
Surface
(Inches)
Soil
Horizon
Soil Texture
(USDA)
Soil Color
(Monsen)
Soil
Mottling
Other(Structure,Stones,Boul
Consistency, % Gravel)
_
Parent Material(geologic)
Depth to Groundwater: Standing Water in the Hole:
Depth to Bedrock:
Estimated Seasonal High Ground Water: ;/2C Weeping from Pit Face:
certification: I certify that in November 1994. I passed the soil evaluator examination approved by the Department of Environmer
Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described
310 CMR 15.017. Mass.Soil Eval.Approval No.5E1543
Signature:
Peter J. McErlain
Date:
NORTHAMPTON BOARD OF HEALTH
212 MAIN ST. , NORTHAMPTON, MA 01060
TEL; 413-587-1213
Site Suitability for On-Site Sewage Disposal
Number_
red by h1q .Y4? l'..,,,..
Inspector: { FAtc
Site Address
Date. !
Equipment Operator:
Client Name& Address
New Construction it Repair it
T.P.#
"7
d;r
Office Review
red Soil Survey Available. No It Yes it
ar Published Publication Scale Soil Map Unit Drainage Class Soil Limitations
al Geologic Report Available: No It Yes it
ar Published Publication Scale Geologic Material(Map Unit) Landform
Insurance Rate Map:
eve 500 year flood boundary it Within 500 year flood boundary rz Within 100 year flood boundary it
rd Area'.
aional Wetland Invetory Map(Map Unit) Wetlands Conservacy Program Map(Map Unit)
it Water Resource Conditions(USGS): Month
.nge: Above Normal it Normal it Below Normal it
References Reviewed:
rervvmu....
•....�..----
Time
Measurement
Time
Measurement
Saturation
Begin Saturation
--
End Saturation
aturation
ath
t K'
9"depth
Measurement
arement
pth
-
6"depth
Measurement
urement
eel Time
6"
Elapsed Time
9"to 6"
elation Rate
nn of Percolation Test Hole:
Bottom of Percolation Test Hole'.
Determination for Seasonal High Water Table
rod Used
)epth observed standing on observation hole inches ❑ Depth weeping from side of observation hole inches
)epth to soil mottles inches ❑ Ground water adjustment inches. it,
K Well Number Reading Date Index well level
Adjusted ground water level
stment factor
of N.thrall Occurim Pervious Material
s at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
'rption system?
:s, what is the depth of naturally occurring pervious material? TP# TP#
t,what is the depth of naturally occurring pervious material? TP# TP#
-Site Review
T.P.#