446 Septic Upgrade Application 1998 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE I OF s
Commonwealth of ¥assachusetts
Athz-rHA Ta , Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(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
of 10,000 up to 15,000 gpd and/or for upgrade
compliance. as defined in 310 CMR 15.404(1),
failed or nonconforming system with a design flow
of a state or federal facility, where full
is not feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal 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 kr,11.- ,4,u ,t4 6ttaA/
Address 446, c4ES7FY2-FIFL-N Rd /Gth■C r4 0/0S3
Phone # (4,3 ) 5-73 (, _ 996 0
Address of facility
Applicant (if different from above)
Name
Address
Phone It
3) Type of facility
residential commercial school
institutional
(Specify)
DEP APPROVED FORM.12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2OFS
4) Type of existing system
privy _cesspool(s) conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits,etc.)
f- rCL1%
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system SO gpd/&DV-00M,
Approved? yes approval date at -.31i At u 15; /96e
no why?
b) Design flow of proposed upgraded system 5i gpd
c) Design flow of facility 40 gpd
6) Proposed upgrade of existing system is
a) ?C) Voluntary
Required by order, letter, etc. (attach copy)
Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date)
b) Describe the proposed upgrade to the system
Refb1cc- D--LScy cAc4/ a. nib
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 6eid rate) )
DOP APPROVED FORM•13/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF 5
Up to 25% reduction in subsurface disposal area design requirements (state re
& proposed size)
quired
Relocation of water supply well (identify well, describe relocation)
Reduction of required separation between bottom of
(specify proposed reduction & pert rate)
Other requirements of 310 CMR 15.000 that cannot
Code)
SAS & high groundw ter
be met (specify sections of the
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 15.000, require a
variance pursuant to.310 &
CMR 15.410-15.417.
7) If the proposed upgrade involves a reduction in the required separation between
of the soil absorption system and the.high groundwater elevation,
E must determine he bottom
Evaluator valu15.405(1)(i)(1). rmine the high ground water elevation an Approved Soil
The evaluator must be a member or pfrsuano to 310 CMR
agent of the local approving authority:
Dis ce from soil absorption system to high groundwater
feet
As determined by
AEvaluator's name
Evaluator's signature // '
Date of evaluation
DS•APPROVED FORM- Il/4105
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 OF 5
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 notice to abutters must be
completed prior to the date of submission of the application to the Department.
The notices to abutters shall include 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
Abutter Name
Address
Abutter Name
Address
Abutter Name
Address
Date notified
Date notified
Date notified
Date notified
9) Explain why full compliance, as defined 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:
,c r&a b--C /S% Sal--bt1 ■ PR ICE-
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
sor4a.AL CAS i CCNVc-hD+4L O}'srext
DEP APPROVED FORM-trill55
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
c) a shared system is not feasible:
AM' -$V- 41 LA-&(E
d) connection to a sewer is not easible:
10) An application for a disposal system (JAI LQ ISCe-
(e.g. plans & specifications, site evaluation forms), must including all this required attachments
DSCP application attached? ) must accom an hme❑[s
yes P Y this application. Is the
I]) 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 tme, 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,"
WitiCs2,frk
Facility owner's s
W ILL/AM
Print Print Name
111EQLElf
Name of preparer
Hs-
Telephone N & address of preparer
Date
HOWARD ENVIRONMENTAL SERVICES
750 NORTH PLEASANT STREET(REAR)
AMHERST,MA 01002
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.
MP APPROVED FORM-I2/07/95
Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM / R
INFORMATION (continued)
Property Address: 1/
!�
Owner: r'.-lr(µ
Date of Inspection: �, -,2 /—p V
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water V feet
c{.e</
24
Please indicate(check)all methods used to determine the high ground water elevation:
t- Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
—CChecked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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HOWARD ENVIRONMENTAL SERVICES
TITLE 5 SPECIALISTS
750 NORTH PLEASANT STREET, REAR
AMHERST, MA 01002
PHONE: (413)256-8008 FAX: (413)549-1850
Board of Health
City Hall
210 Main Street
Northampton, MA 01060
Dear Board,
July 11 , 1998
On July 8, 1998 a representative of our firm inspected the soil absorption system
installed at 446 Chesterfield Road at the home of Bill Mellen. The system was
installed by Tom Childs of Leeds, MA.
Our representative found the soil absorption system to be installed in accordance
with our approved septic system design dated September 22, 1997 with the
following exceptions:
The D-Box and pipe configuration was modified slightly.
The final grading associated with the breakout fill had not yet been
completed.
See the accompanying as-built sketch for locations of the systems components.
This letter shall serve as engineer and installer certification that the system was
installed in accordance with Title 5 and our approved system design. If there are
any questions, please contact our office.
Sin ata171 / l
I hereby certify that the above
Title 5 and the approved se
Services.
avi e Ph.D., M.P.H., A.S.E.
erenced system was installed in accordance with
stem design prepared by Howard Environmental
Tom Childs
PERC TESTING • SEPTIC SYSTEM ENGINEERING • ENVIRONMENTAL CONSULTING