625 Application Disposal System 2018 Commonwealth of Massachusetts ,t1g-10
1 v=rbc City/Town of Northampton Number 1/
_ Application for Disposal System
Ee ice° Construction Permit Fee rt.
1 Form 1A '
DEP has provided this form for use by local Boards of Health if they choose to do so. Before • g
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Important:When
filling out forms Application is hereby made for a permit to:❑Construct a new on-site sewage disposal system
on the computer. Z Repair or replace an existing on-site sewage disposal system
use only the tab ❑ Repair or replace an existing system component
key to move your
cursor-do not
use the return 1. Location of Facility:
key.
-� 625 Westhampton Road
Address or Lot#
Northampton MA _ 01062
[Jaw'X. City/Town - - State Zip Code
2. Owner Information
Thomas Malsbury and Tina Mcelmoyl
Name
Address(if different from above)
City/Town - _ - State - - Zip Code
530-2408
Telephone Number
3. Installer Information
River Drive Excavating Tom
Name Name of Company
"4"... Address
--` `'a ssgc . HadleyMA 01035
�0CirylTown State Zip Code
A '+ 10, 896-5576
c.,,,,i.
Telephone Number
17 i ile
\ r"` 4. Designer Information
/ Alan Weiss - _. Cold Spring Environmental Consultants Inc. -
Name Name of Company
350 Old Enfield Road - - - -
Address
Belchertown _ _ MA 01007 City/Town State Zip Code
413-323-5957 -
Telephone Number
t5fonn1a.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts 'lois-)O
=s a City/Town of Northampton Number
.°
• —tt" Application for Disposal System f5o�
.• Construction Permit Fee
•
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
3 Bedroom
Other: Type of Building -- _. - Number of Persons Served
❑ ShowersNumber or showers ❑ Cafeteria ❑ Other fixtures
Specify other fixtures: — - - - -
6. Design Flow: Gallons per Day
Calculated Daily Flow: Goons
05.24.2018
7. Plan: Date of Original
01
Number of Sheets - Revision Date
Septic System Plan
Title of Plan
8. Description of Soil:
9. Nature of Repairs or Alterations (if applicable):
New 1500 gallon septic tank, leachfield (14' x 35')with distribution box and risers. Water line to be
relocated_
10. Date last inspected: Date
t5forml a.doc•06/03 Application for Disposal System Construction Peri•Page 2 of 3
Commonwealth of Massachusetts ao)8-Jo
l� _.. `t City/Town of Northampton Number
Application for Disposal System o0
-..= 7,0"l " Construction Permit Fee
Form 1A
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 Title 5 of the Environmental Code and
not to place the system in operation until a Certificate of Compliance has been issued by this Board of
527f20Ig
Signature Date
Application Approved B
s /g
Name Date
Application Disapproved for the following reasons:
ILII I ItYYLLC
l
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON, MA 01060
Conditions.
1).System Designer must Inspect and verifyIn renting
Thal the sewage disposal system was installed
In accordance with the approved plans and Title 5.
2).If this is a system with the S.A.S.constructed in
Title 5 fill the System Designer must conduct a bottom
inspection of the excavated arca prior to the placement
of the fill.
3).No changes cm be made during construction by the
Installer without prior approval by both the System
Designer and the Boaad of Health Agent.
4 Other emditionna:
t5for nla.does 06/03 Application for Disposal System Construction Permit•Page 3 of 3
a Commonwealth of Massachusetts
•t City/Town of Northampton
id--tj �y Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
A. Facility Information
T Malsbury &T Mclemoyl
Owner Name
625 Westhampton road
-
Street Address Map/Lat#
Northampton MA _
City State Zip Code
B. Site Information
1. (Check one) ❑ New Construction ❑ Upgrade ® Repair
Cal web USDA Hinkcley
Soil SurveyAvailable? ®
Source Yes ❑ No If yes: _ _ Soil Map ap U
Unh
Hinkley LS - _ _ SW Well Drained
Soil Name Soil Limitations
3. Surficial Geological Report Available? ® Yes 0 No If yes: USGS current Pis
Year Published/Source Publication Scale Map Unit
outwash _ glacial outwash terrace
Geologic/Parent Material Landform
4. Flood Rate Insurance Map
Above the 500-year flood boundary? ® Yes ❑ 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: Wetlands Conservancy Program Map Map Unit - Name - -
6. Current Water Resource Conditions (USGS): Month/YearRange: ❑ Above Normal ® Normal ❑ Below Normal
7. Other references reviewed -- - - _-- - - - - - - _
t5fonn1 l.doc•rev.3/13 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8
Commonwealth of Massachusetts
0 City/Town of Northampton
LIForm 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area)
DeepObservation Hole Number: 1 and 2 05.10.2018 145 - -
Date Time Weather
1. Location
-
Ground Elevation at Surface of Hole: shown Location (identify on plan): - --
2. Land Use
grassy _ no _. _ 2
(e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%)
decidous mix terrace shown
_
Vegetation Landform Position on Landscape(attach sheet)
1001+ 100'+ 50'+
3. Distances from: Open Water Bodyfeet -- Drainage Way (set Possible Wet Area fast
Property Line 100+
- Drinking Water Well 15
Drinking
Other feet
4. Parent Material: Outwash Unsuitable Materials Present: ❑ Yes ® No
If Yes: ❑ Disturbed Soil G Fill Material 0 Impervious Layer(s) 0 Weathered/Fractured Rock 0 Bedrock
84 84",
5. Groundwater Observed: ® Yes ❑ No If yes:
Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater: 84"
P 9 inches elevation
t5forml1.doc•rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8
Commonwealth of Massachusetts
4-' Citylfown of Northampton
� Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
kl
C. On-Site Review (continued)
Deep Observation Hole Number: 1 &2 _ —
Redoximorphic Features Coarse Fragments
Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil
Depth(in.) Layer Moist(Munsell) (USDA) Cobbles 8 Structure Consistence Other
Depth Color Percent Gravel (Moist)
Stones
0-54 A 10 YR 3.2 FSL FRIABLE
54-140" Cl 10 YR 5.6 not S m-c SAND
Additional Notes:
t5forml 1.doc•rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8
Commonwealth of Massachusetts
VR City/Town of Northampton
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
D. Determination of High Groundwater Elevation
1. Method Used:
® Depth observed standing water in observation hole in 140"+ B. 140_+_
nches inches
AEl Depth weeping from side of observation hole in Bs i
n,
ncheses
IDDepthDepth to soil redoximorphic features (mottles) AB. 94
inches inches
A❑ Groundwater adjustment(USGS methodology) in --- - - inches
---
inches in
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 naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
El Yes ❑ No
b. If yes, at what depth was it observed? Upper boundary: inches Lower boundary:s
t5fonnl I doc•rev.3/13 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal *Page 6 of 8
Commonwealth of Massachusetts
City/Town of Northampton
V. _ 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.
5/10/2018
Sig atur of Soil Evaluator Date
ALAN WEISS, RS#933, SE#2568, Cold Spring Env. Inc. _ 9/1995
Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam
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 80 days of the date of field testing, and
to the designer and the property owner with Percolation Test Form 12.
t5fonn11doc•rev.3/13 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8
Commonwealth of Massachusetts
City/Town of Northampton
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