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124 Septic Upgrade Application 2002 BOARD OF HEALTH MEMBERS CYNTHIA DOURMASHKIN,R.N.,Chair ROSEMARIE KARPARIS,R.N.,MPH RICHARD P.BRUNSWICK,M.D.,MPH PETER].MtERIAIN,Health Agent (413)587—1214 FAX(413)587-1221 CITY OF NORTHAMPTON MASSACHUSETTS 01060 OFFICE OF THE BOARD OF HEALTH To: Barbara Smith, 124 Cross Path Rd. From: Peter McErlain, Health Agent Date: May 22, 2002 Re: Septic Repair Permit— 124 Cross Path Rd. 210 MAIN STREET,Room 8 NORTHAMPTON,MA 01060-3167 On May 20, 2002, the Northampton Board of Health issued the Local Upgrade Approval allowing the septic system repair at 124 Cross Path Rd. Your Septic system repair permit and a copy of the upgrade approval are enclosed Please contact the Board of Health office with any questions concerning this permit. Thank you. FORM 9B - Local Upgrade Approval Commonwealth o Massachusetts ND2 �k.1 ,Massachusetts (City/Iown) LOCAL UPGRADE APPROVAL Issued Pursuant to 310 CMR 15.404 and 15.405n Facility/System owner: /�(frhalBt 5w t6 Address: /3Y ` 7-po;S .a-r-� City/Town: �fp /.J ((C��htS, /4154 {ei City/Town: /1%0/2-i,/i y�ytq 1‘1-7 Facility Address: Type of Facility: System Designer: Address: City/Town: State: 04+ Zip: O esidential ❑Institutional Design flow per 310 CMR 15.203 ❑Commercial gpd ❑ PE -RSA^ State: /1/)�-s. Local Upgrade Approval is granted for: ❑ Reduction in setback(s) (Specify) ( n. ❑ School Zip: 6/07 ❑ Percolation rate for 50 to 60 minfinch Percolation rate min/inch ❑ Reduction in SAS area of up to 25% (SAS size and%reduction) SAS sq ft Reduction ,g 27 Reduction in separation between the SAS and high groundwater Separation reduction rj ft Percolation rate ?. minrinch Depth to groundwater_' ft Relocation of well(Explain)_ List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: Ap Jowed by the t Dis /TOaf/ Board of ucalt j ci.Mee •(Print or type name and Title) (Signature) (Date) 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. Department of Environmental Protection DEP Approved Form—3/20/02 z E E f a,:: 2 E ait TOPO! map panted on 04/22/02 from"NorteasGtpo"and"UnUUedtpg" 69400om E. 69500 mE. 696000mE. 6970oamE. WGS84 Zone 18T 698000mE NicrAtine 699000m E. MN 695000mE, 696000m E, •I NET 0 697000m E. WGS84 Zone 187 698180m E. i saE m r ETO Slanted 6®TOPOI 02001 National Geographic Holdings(wwwtopo corn) 0 0 0 CO co 2 m cI 5 )CPC 5B`- I 37. -t31'± ■ l65'_* - �- C2L 5 ) I hereby report that a portion of the premises on this plan is located within Flood Hazard Area (Zone/} ) and it appears that the improvements shown aretare located within a Flood Hazard Aron as shown on Department of ILU.D.. Federal Ins Administration Maps, Community Number Identificatio s. to By; 250167 0002A April 3, ' 8 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE I OF 5 Commonwealth of Massachusetts Norati_Asproo , Massachusetts Application for Local Uo rade Aonroval Title 5, 310 CMR 15.000 DEP Approved form required by 310 CMR 15.403(1) To be submitted to Local A rovin• Authori /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 design flow of a state or federal facility, where full is not feasible. NOTE: Local upgrade addition of new design flow to approval cesspooltorr be granted for an privy or the addition of new design flow o includes bo the existing approved capacity of a system constructed in accordance with either the 1978 Code eor,310 CMR 15.000. 1) Facilityisystem owner Name Address Phone if Address of facility tQ 2A 5•t j- 12J truss 1)-41.r sCy- 37 50,8e 2) Applicant (if different from above) Name =E Address Phone Ai 3) Type of facility ✓residential commercial institutional (Spec i fy) DEP APPROVED FORM-12/07/9S school FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 2OF5 4) Type of existing system privy esspool(s) conventional system Other (describe) Type of soil absorption system (trenches, chambers, pits,etc.) 5) Design flow based on 310 CMR 15.203 a) Design flow of existing system `? gpd Approved? yes approval date — ooh no why? b) Design flow of proposed upgraded system *a—. c) Design flow of facility 3gpd gpd 6) Proposed upgrade of existing system is a) //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 ai S 2 OM1IL t L"R et- 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) DEP APPROVED FORM-12/07/95 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 3 OF 5 Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) 7es Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & pere rate) 3 Cy ( S-% MiU )c.u\ 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 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 the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater `3 feet As determined by: Evaluator's name Evaluator's signature Date of evaluation DFP APPROVED FORM-U/07/95 Ate- t ( -QLd-O P4rr tit IE1Cl4+U 8) Notice to Abutters FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL. PAGE 4 OF 5 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 [nail 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 15A05. 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: — Iso..tR frre IC MOJACQ 9n nord Ara- b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible: woo Qlsv arinivtn nR 5ftp /ad.' DO'APERO VEO roLM-12/%/95 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 5 OF 5 c) a shared system is not feasible: No-1- udn/ate d) connection to a sewer is not feasible: /Ja{—ad„r lrt VC 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? es no Il) 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. 1 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.” Facility owner's signature Date as - Print Name Aka. Lit ' s, Qs I Name of preparer (o'2 col clSer.As PM. nnnuxlr+4l ,Lsic Dale `phone 3-595} eoF,0cfi Ralcf-� Telephone # & address of preparer �'touu, hN • c,t NOTE: Title 5, 3I0 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-12/07/95