52 Septic Appication Form A/B Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
septic system with a design flow of less than 10,000 gpd,where full compliance, as defined in 310 CMR
5.404(1), is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405,or in full
compliance with the requirements of 310 CMR 15.000,require a variance pursuant to 310 CMR 15.410
through 15.417.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
a new design flow to a cesspool or privy,or the addition of a new design flow above the existing approved
capacity of a septic system constructed in accordance with either the 1978 Code or 310 CMR 15.000.
A. Facility Information
Important:
When filling out 1. Facility Name and Address
forms on the
computer,use
only the tab key Name
to move your 52 Autumn Drive
cursor-do not Street Address
use the return
key.
Florence
City
2. Owner Name and Address:
Ellen Reardon
Name
Florence
City
01062
Zip
MA 01062
State Zip Code
52 Autumn Drive
Street Address
MA
State
(413) 586-2560
Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
Single Family Home
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
® Conventional ❑ Other(describe below):
6. Type of soil absorption system(trenches, chambers, leach field, pits, etc):
Trenches?
reardon aa.doc•rev.5/02
Application for Local Upgrade Approval• Page 1 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility
unknown
and
346
9Pd
346
aryl
B. Proposed Upgrade of System
1. Proposed upgrade is(check one):
® Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301:
2. Describe the proposed upgrade to the system:
System consists of a new 1500 gal septic tank, a new D-Box and a 36'x 16'leach field
date of inspection
3. Local Upgrade Approval is requested for.
❑ Reduction in setback(s)—describe reductions:
❑ Percolation rate for 30 to 60 min./inch:
❑ Reduction in SAS area of up to 25%:
minlinch
SAS size,sq.ft. %reduction
® Reduction in separation between the SAS and high groundwater.
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well(explain):
1 foot(from 4 feet to 3 feet)
ft.
7 min/inch
min/inch
2.5 feet
ft.
reardon 9a.doc•rev.5/02
Application for Local Upgrade Approval* Page 2 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
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 15.405(1)(](1). The soil evaluator must be a member
or agent of the local approving authority.
High groundwater evaluation determined by:
E. Matthew
Evaluator's Name(type or print)
Signature
12-13-06
Date of evaluation
C. Explanation
Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
Full compliance is not feasible due lot constraints
2. An altemative system approved pursuant to 310 CMR 15.283 to 15 288 is not feasible:
An alternative system would eliminate the lot constraints
3. A shared system is not feasible:
no neighbor to share with
4. Connection to a public sewer is not feasible:
No sewer is existing or contemplated.
reardon 9a.doc•rev.5(02 Application fa Local Upgrade Approval* Page 3 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection-Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
® Application for Disposal System Construction Permit
® Complete plans and specifications
Z Site evaluation fors
❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other(List):
D. Certification
1,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 deliberate violations.°
at-
Facility Owner's Signature
Ellen Reardon
Print Name
Littletree Envimomental Consulting
Name of Preparer
P.O. Box 503
Preparer's address
MA 01012
State2IP
April 17,2008
Date
Chesterfield
City/Town
(413)537-0344
Telephone
NOTE: 310 CMR 15.403(4) requires the system owner to provide a copy of the local upgrade
approval to the appropriate Regional Office of the Department of Environmental Protection, Bureau of
Resource Protection, Division of Watershed Management, upon issuance by the local approving
authority and before commencement of construction.
reardon 9a doc•rev.5/02 Application for Local Upgrade Approval, Page 4 of 4
_ Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number
11 Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
A. Facility Information
Owner Name: Ellen Reardon
Street Address: 52 Autumn Drive Map/Lot: Map 43, Lot 042
City: Northampton State: MA Zip Code: 01060
B. Site Information
1. (Check one) New Construction ❑ Upgrade Z Repair ❑
2. Published Soil Survey available? Yes Z No ❑ If yes: 1981 1:15.840 AmA Amostown
Year Published Publication Scale Soil Map Unit Soil Name
Soil limitations severe. wetness, peres slowly
3. Surficial Geological Report available? Yes ❑ No Z If yes:
Year Published Publication Scale Map Unit
Geologic Material Landfomi
4. Flood Rate Insurance Map:
Above the 500 year flood boundary? Yes Z No ❑ Within the 100 year flood boundary? Yes ❑ No Z
Within the 500 year flood boundary? Yes ❑ No Z Within a Velocity Zone? Yes ❑ No Z
5. Wetland Area: National Wetland Inventory Map
Map Unit Name
Wetlands Conservancy Program Map
Map Unit Name
6. Current Water Resource Conditions (USGS) December, 2006 Range: Above Normal ❑ Normal ❑ Below Normal Z
Month/Year
7. Other references reviewed:
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 1 of 4
Massachusetts Department of Environmen
Nic 1
Bureau of Resource Protection-Wastewater Permitting tal Protection Program site Address or Map/Lot 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: December 13.2000 Time: Weather: _
1. Deep Hole Number 1 Location (Identify on Plan):
2. Land Use: lawn Surface Stones: no Slope (%): <1 Vegetation: grass
Landform: Glacial Laksbed Position on landscape: - X -
3. Distances from: Open Water Body ASfl. Drainage Way >25 ft. Possible Wet Area >100 ft.
Property Line 10 ft. Drinking Water Well Jjgft. Other NA ft.
4. Parent Material:Lacustrine Unsuitable Materials Present: Yes❑ No ISI
If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s)❑ Weathered/Fractured Rock ❑ Bedrock ❑
5. Groundwater Observed: Yes ® No ❑
If Yes: Depth Weeping from Pit 44" Standing Water in Hole 70" Estimated Depth to High Groundwater: 30"
Redoximorphic Features Coarse Fragments
Depth Soil Soli Matrix: P (mottles) %by Volume
P Horizon/ Soil Texture Color-Moist Depth Color Percent Gravel Cobbles Soil Structure Soil Consistence
(In.) Layer (USDA) (Munsell) i &Stones (Moist) Other
0-16 Ap sl 10 YR 3/3 0 weak friable
granular
18-30 Bw sl 10 YR 6/8 0 massive friable
30-72 C sl 2.6 Y 6/3 30" 7.5 YR 5/8 5% massive friable
2.5Y8/2 7%
Additional Notes
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 2 of 4
Massachusetts Department of Environmental Prot
Bureau of Resource Protection-Wastewater Permitting ection Program Otte Address or Map/Let Number
Nyc\ 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: December 13.2006 Time: Weather:
1. Deep Hole Number 3 Location (Identify on Plan):
2. Land Use: lawn Surface Stones: c: Slope (%): <1 Vegetation: grass
Landform: Glacial Lakebed Position on landscape:
3. Distances from: Open Water Body NA ft. Drainage Way >26 ft. Possible Wet Area >100 ft.
Property Line 10 ft. Drinking Water Well N&ft. Other NA ft.
4. Parent MaterlaI i..acustrine Unsuitable Materials Present: Yes❑ No
If Yes: Disturbed SOIIU Fill Materials] Impervious Layer(s)❑ Weathered/Fractured Rock ❑ Bedrock ❑
5. Groundwater Observed: Yes ® No ❑
If Yes: Depth Weeping from Pit 44" Standing Water In Hole 82" Estimated Depth to High Groundwater: 30
Redoximorphic Features Coarse Fragments
Depth Soil Soil Matrix: (mottles) %by Volume
Horizon/ Soil Texture Color-Moist Depth Color Percent Gravel Cobbles ' Soil Structure Soil Consistence
(In.) Layer (USDA) (Munsell) &Stones (Moist) Other
0-20 Ap sl 10 YR 3/3 0 weak friable
granular
2040 Bw sl 10 YR 6/8 0 massive friable
90-94 C sl 2.6 Y 6/3 30" 7.6 YR 6/8 6% massive friable
2.6 Y 6/2 7%
•
Additional Notes
DEP Form 11 Soil Suitability Assessment for On-She Sewage Disposal•Page 3 of 4
wl
Lik Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Wastewater Permitting Program Stte Address or Map/Lot Number
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 A. B.
❑ Depth weeping from side of observation hole A. B.
El Depth to soil redoximorphic features (mottles) A. 30" B. 30"
❑ 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 Occuning 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? Yes S No❑
b. If yes, at what depth was it observed? Upper boundary: 20" Lower boundary: 72+"
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.
Signature of Soil Evaluator Date
J. Mustain
Typed or Printed Name of Soil Evaluator 'Date of Soli Evaluator Exam
E. Matthews Northampton Health Aaent
Name of Board of Health Wane, Board of Health
Note:This form must be submitted to the approving authority with Percolation Test Form 12
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 4 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Wastewater Permitting Program Ste Address or Map/Lot Number
■ Form 12 - Percolation Test
A. Facility Information
1. Facility Information
Ellen Reardon
Owner Name
52 Autumn Drive Map/Lot Map 43, Lot 042
Street Address
Northampton, MA 01060
City State Zip Code
Percolation Test-
Date: August 30, 2007
Observation Hole# 1
Depth Of Perc 40"
Start Pre-soak 9:47
End Pre-soak 10:02
Time at 12" 10:03
Time at 9" 10:12
Time at 6" 10:31
Time (9"-6") 19 minutes
Rate — Min/Inch 7 min per inch
•Minimum of I Pemolatlon test must be performed I h the rimary//area AND reserve area.
Site Passed ® Site Failed ❑
Performed By: M. SDOkas� //1*(I2 �L L�" 1
Witnessed By: Ellen Bokina for E. Matthew
Comments:
DEP Form 12 Percolation Test•Page 1 of 1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Wastewater Management Program
Form 9B -Local Upgrade Approval
Issued Pursuant to 310 CMR 15.404 and 15.405
This form is to be completed by the local Board of Health and a signed copy provided to the system
owner. The system owner shall provide a copy of this local upgrade approval to the appropriate Regional
Office of the Department of Environmental Protection, Bureau of Resource Protection, Division of
Watershed Management, upon issuance by the local approving authority and before commencement of
construction.
A. Facility Information
Important:
When racing out 1. Facility Name and Address
farms on the
computer.use
only the tab key
to move your
cursor-do not
use the return
key.
Name
52 Autumn Drive
Street Address
Florence MA 01062
City State Zip Code
2. Owner Name and Address:
Ellen Reardon 52 Autumn Drive
Name Street Address
Florence MA
City State
01062 (413) 586-2560
Zip Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15.203: 346
9pd
5. System Designer Littletree Environmental Consult. ❑ PE 0 R
Name
P.O. Box 503 Chesterfield MA 01012
Address City/Town State.ZIP
B. Approval
1. Local Upgrade Approval is granted for.
❑ Reduction in setback(s)—specify:
❑ Percolation rate for 30 to 60 min./inch:
❑ Reduction in SAS area of up to 25%:
min./inch
SAS size,sq.ft. %reduction
reardon 9b.dac•rev.5/02 Local Upgrade Approval, Page 1 at2
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Wastewater Management Program
Form 9B -Local Upgrade Approval
Issued Pursuant to 310 CMR 15.404 and 15.405
B. Approval (continued)
® Reduction in separation between the SAS and high groundwater.
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well(explain):
1 foot,from 4 feet to 3 feet
ft.
7 min per inch
min./inch
2.5 feet
ft.
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval
Approved by the Huntington Board of Health:
reNe
mele -.
riot or Type Name and The
-77.fie `J Cbf "f01L
reardon 9b.doc•rev.902
Local Upgrade Approval Page 2 of 2
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
A. Facility Information
Owner Name: Ellen Reardon
Street Address: 52 Autumn Drive Map/Lot: Map 43, Lot 042
• City: Northampton State: MA Zip Code: 01060
B. Site Information
1. (Check one) New Construction ❑ Upgrade ® Repair ❑
2. Published Soil Survey available? Yes ® No ❑ If yes: 1981 1:15.840 AmA Amostown
Year Published Publication Scale Soil Map Unit Soil Name
Soil limitations severe, wetness, percs slowly
3. Surficial Geological Report available? Yes ❑ No ® If yes:
Year Published Publication Scale Map Unit
Geologic Material Landfom,
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: National Wetland Inventory Map
Map Unit Name
Wetlands Conservancy Program Map
Map Unit Nene
6. Current Water Resource Conditions(USGS) December, 2006 Range: Above Normal ❑ Normal ❑ Below Normal
Month/Year
7. Other references reviewed:
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 1 of 4
L 1Massachusetts Department of Environmental Protection
Bureau of Resource Protection-Wastewater Permitting Program Site Address or Map/Lot 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: December 13,2008 Time: Weather:
1. Deep Hole Numbers Location (Identify on Plan):
2. Land Use: lawn Surface Stones: no Slope (%): <1 Vegetation: prase
Landform: Glacial Lakebed Position on landscape:
3. Distances from: Open Water Body NA ft. Drainage Way >25 ft. Possible Wet Area >100 ft
Property Line 10 ft. Drinking Water Well _A_ft. Other NA ft.
4. Parent Material:l..acustrine Unsuitable Materials Present: Yes❑ No igi
If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s)❑ Weathered/Fractured Rock ❑ Bedrock ❑
5. Groundwater Observed: Yes ® No ❑
If Yes: Depth Weeping from Pit 44" Standing Water In Hole 82" Estimated Depth to High Groundwater: 30"
Redoxlmorphic Features Coarse Fragments
Depth Soil Soli Matrix: (mottles) %by Volume
P Horizon/ Soli Texture Color-Moist Depth Color Percent Gravel Cobbles Soil Structure Soil Consistence
(In) Layer (USDA) (Munsell) &Stones (Moist) Other
0-20 Ap al ' 10 YR 3/3 0 weak friable
granular
20-30 Bw al 10 YR 6/8 0 massive friable
30-84 C sl 2.5 Y 6/3 30" 7.6 YR 6/8 6% massive friable
2.5Y6/2 7%
Additional Notes
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 3 of 4
DMassachusetts Department of Environmental Protection
Bureau of Resource Protection—Wastewater Permitting Program sae Address or Map/Lot 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: December 13.2006 Time: Weather:
1. Deep Hole Number,_ Location (Identify on Plan):
2. Land Use: lawn Surface Stones: Slope(%): <1 Vegetation: grass
Landform: Glacial Lakebed Position on landscape:
3. Distances from: Open Water Body NA ft. Drainage Way >26 ft. Possible Wet Area >100 ft.
Property Line 10 ft. Drinking Water Well ft. Other NA ft.
4. Parent Material:}acustnne Unsuitable Materials Present: Yes ❑ No
If Yes: Disturbed SollD Fill Material'] Impervious Layer(s)❑ Weathered/Fractured Rock ❑ Bedrock ❑
5. Groundwater Observed: Yes ® No ❑
If Yes: Depth Weeping from Pit 44" Standing Water In Hole 70" Estimated Depth to High Groundwater: 30"
Redoximorphic Features Coarse Fragments
Soil Soil Matrix: (mottles) %by Volume
Depth Horizon/ Soil Texture Color-Moist Depth Color Percent Gravel Cobbles Soll Structure Soil Consistence
(In.) Layer USDA
( ) (Munsell) &Stones (Moist) Other
0-16 Ap si 10 YR 3/3 0 weak friable
granular
1640 Bw al 10 YR 6/6 0 massive friable
30-72 C si 2.6 Y 5/3 30" 7.6 YR 6/8 6% • massive friable
2.6Y6/2 7%
Additional Notes •
DEP Form 11 Soll Suitability Assessment for On-Site Sewage Disposal•Page 2 of 4 -
I 'Inial to r...,...r„ fIn^^H..- .... r• r- .:ronmrnf.^.I Protection
� Bureau of Resource Protection—Wastewater Permitting Program sne Address or Map/Lot Namber
� Form 12 — Percolation Test
A. Facility Information
1. Facility Information •
Ellen Reardon
Owner Name
52 Autumn Drive Map/Lot Map 43, Lot 042
Street Address
Northampton, MA 01060
City Stale Zip Code
Percolation Test
Date: August 30, 2007
Observation Hole# 1
Depth Of Pere 40"
Start Pre-soak 9:47
End Pre-soak 10:02
Time at 12" 10:03
Time at 9" 10:12
Time at 6" 10:31
Time (9"-6") 19 minutes
Rate—Min/Inch 7 min per inch
•Minimum or t Percolation test/must be performed th the glma�rea AND reserve area.
Site Passed ® Site Felled ❑ G
Performed By: M. Spokes elf" 1�' /�L C
q
witnessed By: Ellen Bokina for E. Matthews
Comments:
DEP Form 12 Percolation Test•Page 1 of 1
I AI Massachusetts Department of Environmental Protection
°c.-.0 of i r7urco Protection—Wastewater Permitting Program Site Address or Map/Lot Number
I1 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 A. B.
❑ Depth weeping from side of observation hole A. B.
CO Depth to soil redoximorphic features (mottles) A. 30" B. 30"
❑ 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 naturally occurring pervious material exist In all areas observed throughout the area proposed for the
soil absorption system? Yes Ei No❑
b. If yes,at what depth was It observed? Upper boundary: 20" Lower boundary: 72+"
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.
Signature of Soil Evaluator Date
J. Mustain
Typed or Printed Name of Soil Evaluator 'Date of Soil Evaluator Exam
E. Matthews Northampton Health Agent
Name of Board of Health witness Board of Health
Note:This form must be submitted to the approving authority with Percolation Test Form 12
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 4 of 4