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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 -_gin—