547 Septic Repair Forms 2006 Plan to Repair
SEPTIC SYSTEM
for
Charles Gregory
Located at
547 Audubon Road
in Northampton, Massachusetts
Plan Number 393
Thomas S. Leue, R.S.
Homestead Inc.
1664 Cape Street
Williamsburg, MA 01096
413 628-4533
fax: 413 628-3973
Design Date: 6/12/06
Updated:
Contents
Site Plan: 1 page
Site Suitability Form 11.1: 1 page
On-Site Review Form 11.2: 2 pages
Groundwater Form 11.3: 1 page
Perc Test Form 12: 1 page / � S ,_
Specifications: �3 pages
Pump Details 5 pages
Design Calculations: System 2 pages
Plan Drawing: 1 page
Separate To be signed by Owner(sl
Application for Construction Permit: 3 pages
Local Upgrade Approval Form: 5 pages
eerefoi 11,01aamftearl, 44.44/eicaera
212 lac Sweet
72ont44m'rtag, W(4 01060
7d 413-587-1214
?ax 413-587-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE SYSTEM INSTALLER
INSTALLER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Installer of a system is required to sign
this form as a condition for issuance of a Board of Health Certificate of Compliance for the onsite septic
system,
This is to certify that the onsite sewage disposal system that I installed as: /new construction
/� %,� [ /J 'repair(existing system)
at .J /��N rns) �� on 8 6p ,DWCP number 2.0C in°
(Addrss) / (Date)
has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the
original approved plans have been reflected on an as-built plan that has been submitted to the Board of He lti
P a1- r"-9r;7q ,moo Box icy ev;il;it s b14.1-t.
(Pnntlnstaller's name)
(Street,City,and Zip Code)
oi6p
e- `it 9
(Installer's signature) L
(Dam)
NOTE: This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-sae
subsurface disposal system.Rather,the plan and installation are in compliance with all applicable rues and regulations as are
in effect at the time of plan submittal.
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 of 5
co?noNwnET)Ti WAssRcJ-Cush fs
Board of Health, Northampton, MA
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.401(1)
To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or
nonconforming system with a design flow 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 failed or nonconforming system with a design
flow of 10,000 up to 15,000 d and/or of a state or federal facility,where full compliance, as
defined in 310 CMR 15.404(1),is not feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade 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.
1) Facility/system owner
Name: Charles Gregory
Address: 547 Audubon Rd.,
Leeds, MA 01053
Phone # 584-7210
Address of facility: 547 Audubon Road,Northampton
2) Applicant (if different from above)
Name:
Address:
3) Type of facility
X Residential _ Commercial
_ School _ Institutional
Other (specify)
4) Type of existing system
_ privy _ cesspool
X conventional system
_ Other(specify)
Type of soil absorption system(trenches,chambers,pits, etc.)
leach pits
DEP APPROVED FORM 1807/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2of5
5) Design flow based on 310 CMR 15 203
a) Design for of existing system uai—wn lfRf) gpd
Approved? iio y e s
Approval Date aA) k.�m,.,e
If not,why? Joe eitf su0 rnco pQ c
b) Design flow of proposed upgraded system 550 gpd
c) Design flow of facility 550 gpd
6) Proposed upgrade of existing system is
a. X Voluntary
Required by order, letter, etc. (attach copy)
Required following inspection required by 310 CMR 15.301
date inspection was submitted to the approving authority:
b) Describe the proposed upgrade to the system:
New Dump tank and leachfield.
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(state actual perc rate)
_ Up to 25% reduction in subsurface disposal design requirements (state required Sr
proposed size)
Relocation of water supply well (identify well, describe relocation)
X Reduction of required separation between bottom of SAS Sr high groundwater
(specify proposed reduction Sr perc rate)
2 ft. separation at 15 min Der inch
_ 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,require a variance pursuant to 310
CMR 15.410-15.417.
DEP APPROVED FORM 12,07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 of 5
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 groundwater elevation pursuant to 310 CMR
15.404 (1)(i)(1).The evaluator must be a member or agent of the local approving authority.
Distance from soil absorption system to high groundwater: 2 feet
As determined by:
Evaluator's Name: Ernie Mathieu
Evaluator's Signature:
Date of Evaluation:
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 mail 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 notices to abutters must be
completed prior to the date of submission of the application to the Department.
The notices to abutters shall indude a copy of the completed application form and shall
reference the standards set forth in 310 CMR 15.402 through 15.405.
List of Affected Abutters:
Abutter Name:
Address:
Date Notified:
Abutter Name:
Address:
Date Notified:
Abutter Name:
Address:
Date Notified:
Abutter Name:
Address:
Date Notified:
DEP APPROVED FORM 1207/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 of 5
9. Explain why full compliance, as described 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:
Sn order to control cost and to minimize surface disurption
request reduction to groundwater of 2 ft.
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
Not needed. conventional system feasible.
c) a shared system is not feasible:
Not required, lot will swoon system.
d) connection to a sewer is not feasible:
No public sewer in area
10) An application for a disposal system construction permit,including all required
attachments (e.g. plans and specifications, site evaluation forms), must accompany this
application. Is the DSCP application attached? X yes _ no
11) 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."
Fa
1n+
'
s signature
Date
Charles Gregory
Print Name
Thomas S. Leue, Homestead Inc.
Name of Preparer
6/12/06
Date
1664 Cape Street, Williamsburg, MA 01096 (413) 628-4533
Telephone 3 &address of preparer
NOTE:Title 5, 310 CMR 15.403(4),requires the system owner or operator to submit to the
Department a copy of the local upgrade approval upon issuance by the Board of Health
and prior to commencement of construction.
DEP APPROVED FORM 120795
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5of5
coT4T1 INIWTA.LT'V OF TVIssscq-CIISET}TS
Northampton, Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility.system owner: Name: Charles Gregory 547 Audubon Rd Leeds MA 0105-i
Address of Facility: 547 Audubon Road
Type of facility: Residential
design flow per 310 CMR 15.203 550 qpm
System designer: Name: Thomas Leue Address Homestead Inc. , 1664 Cabe St . ,
Williamsburg MA 01096 Phone No. 413 62A-4533
Local Upgrade Ap�ovalgranted for:
reduction in setback(s) (soecifyj
per rate of 30-60 min.Tinch (soecify rate)
reduction in SAS of uo to 25%
Snecifv%reduction&site of SAS).
x reduction in separation between SAS & high groundwater
Lsnecifv reduction&nerc ratel 2 ft. separation at 15 min per inch
relocation of a well (explain)
List local variances aranted (no DEP approval required per 310 CMR 15 412(411
I variances granted requiring DEP approval
Board of Health Approval of proposed upgrade
Name&Title
Sianature
City/town
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION DIVISION OF
WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY&BEFORE
COMMENCEMENT OF CONSTRUCTION.
Mail to: DEP, Western Regional Office, 426 Dwight St., 5th Floor, Springfield, MA 01102
DEP APPROVED FORM 12/07/95
Per Test Wimess Payment Record t i» 9300
Date: 1/30/66 Amount $_ //Z,V
Property Olwner�¢�+�-"'�
Property Address
New Construction
Repair
CHARLES R.GREGORY
ELIZABETH;I. GREGORY
L: 2L187 &Gaa: 01 23 4.5920.
le ;43Q0
EASTERN '
w 110••••••Sabo
d3 O
' R° ii>ig6411m7
PE 7YYGOAY HILL RO s M
A.17.'111111185 0 LAUREL ?°
K\NGSbY
GS
•J gnmant 01111100 _ �.0
WWACPotE 4kba F bin.L
•
N,ydeno111e
AWN..xni MIS
�4 D
y p
UN OUOM()MK PO 547 Audubon Rd.
a
i
F
s awarxunm
s
0
.LOGeO 16mnnPnCaiWAm.bn +O
of
oICZ
om
>I s
m
0U00)4,RD y
0? A
I P ' 4 bed s BE RNA HE
ti
y
9- ska..n.x naa ''ARCH
VY'
F. S I
ePm OIL Vet Salt A04.•USA 40 0 ICI MAC Sall ,P 'P q,
WORK SITE LOCATION
THE COMMONWEALTH OF MASSACHUSETTS
jj BOARD OF HEALTH
e
C..V.T�` OF 1V N !a.
Qlrrhfuatr of Tontottaxur
arg ISS IS TO CERTIFY, That the Individual Sewage Disposal System c ructed ( or Repaired (/)
by..&fiA stt ri 4Ciu7�.,.e/zpat IAA c Pale' r. Lctt ory .ak a r
at 4'.I A"<16ik' AID^ �' _\7a. ;itad1
has been installed in accordance with the provisions of TIT'E 5 ■SS The State Sanitary ode as described in the
application for Disposal Works Construction Permit No._. 6.t_ase dated )57206;6__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A ANTEE THAT THE
SYSTEM IL"""L��,FUNCTION SATI FACTORY.
DATE.. .- ,t_.a01 Inspect°
war 1. flToIEU.
nt =KM