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75 Applications & Perc Tests 2004 Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. MOP 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 1. Facility Name and Address Name 75 Dunphy Radakvi Street Address Northampton City MA State 01062 2. Owner Name and Address: Linda Wheeler 75 Dunphy Road Name Street Address Northampton MA City State 01062 413-586-3853 Zip Telephone Number 3. Type of Facility(check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: Single family dwelling 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) Zip Code Z Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Proposed: raised bed each field t5form9a•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 gpd 330 gpd gpd 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: Install new leach field in raised bed, repair existing 1250 gallon septic tank with new inlet baffle and outlet if possible otherwise install new 1500 gallon septic tank,and remove garbage grinder date of inspection 3. Local Upgrade Approval is requested for: ❑ Reduction in setback(s)—describe reductions: ❑ Percolation rate for 30 to 60 min./inch: mint/inch ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction Z Reduction in separation between the SAS and high groundwater: from four feet to three feet, one foot reduction Separation reduction ft, 7 Percolation rate mtn.nnch 2 Depth to groundwater ft_ ❑ Relocation of water supply well(explain): t5formga•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)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determ••1 b Ernest Mathieu Evaluators Name(type or pent) June 7, 2004 Si.nature - 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: Fill soil absorption system required, if located in front yard with impervious baffler, even at 3 ft. separation, system located at street line, if in back yard, located at set back, system fill eliminates functional use of back yard if in back yard. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: no alternate available 3. A shared system is not feasible: all lots are small in vicinity of site, likely all have high groundwater 4. Connection to a public sewer is not feasible: Public sewer does not serve Dunphy Road t5form9a•rev.5/02 Application for 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 Z Complete plans and specifications Z Site evaluation forms ❑ 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 "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 deliberate violations." Facility Owner's Signature Date Print Name Paul B. Hatch, PE June 7, 2004 Name of Preparer Date 57 Munn Road Monson Preparers address City/Town MA 01057 413-267-3696 State/ZIP 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. t5form9a•rev.5/02 Application for Local Upgrade Approval*Page 4 of 4 9 24" pine septic o 98.32 tank 98.140 9 3 l 9 2 deep hole #2 'retaining wo I for- pool.' . • Existing contour DUNPHY ROAD SPRUCE LANE No. FORM 11 -SOIL EVALUATOR FORM Pagel of 3 Commonwealth of Massachusetts Northampton Performed By: Paul B. Hatch , Massachusetts Witnessed By: Ernest I.Mathieu Date. 6/7/04 Date: 6/7/04 Location Addess or Lot N 75 Dunphy Road New Construction ❑ Repair N Owner's Name Linda Wheeler Address and 75 Dunphy Road Teleolorep 413-586-3853 Office Review Published Soil Survey Available:No ❑ Yes N Year Published 1981 Publication Scale 1:15840 Soil Map Unit 118A Drainage Class A Soil Limitations none Surficial Geologic Report Available: No N Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) Landform Flood Insurance Rate Map: Above 500 year flood boundary: No N Yes ❑ Within 500 year flood boundary: No ❑ Yes ❑ Within 100 year flood boundary: No ❑ Yes ❑ Wetland Area- none observed National Wetland Inventory Map(map unit) Wetlands Conservancy Program Map(map unit) Current Water Resource Conditions (USGS): Month Range: Above Normal N Normal ❑ Below Normal ❑ Other References Reviewed. 493pg1 FORM 11 -SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No 75 Dunphy Road,Northampton On-site Review Deep Hole Number -I— Date:6/7/04 Location (identify on site plan) Land Use homestead Vegetation grass Landfortn glacial outwash Time: 9:00 Slope (%) 6 Weather: sunny Surface Stones none observed Position on landscape (sketch on the back) Distances from: Open Water Body >100 feet Drainage way >100 feet Possible Wet Area >100 feet Property Line 25 feet Drinking Water Well>100 feet Other DEEP OBSERVATION HOLE LOG* Depth from Surface(inches) Soil Honzon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure,Sbnes, Boulders,Consistency, Gravel) 0-11" A LS 7.5YT3/2 11"-22" B LS 7.5YR5/6 22"-60"+ C LS 10YR5/1 10YR6/8 mottles>5%at 22" 'MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material(geo agic) glacial outwash Depth to Bedrock: none observed Depth to Groundwater. Standing Water in the Hole: none observed Estimated Seasonal High Ground Water 24" 493pg2 Weeping from Pk Face:none observed FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. DH#1 - 75 Dunphy Road,Northampton Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole inches ® Depth to soil mottles 24 inches ❑ Ground water adjustment feet Index Well Number Reading Date Index well level Adjustment factor Adjusted ground water level Depth of Naturally Occurring Pervious Material 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 If not, what is the depth of naturally occurring pervious material? Certification 493pg3 I certify that on July 27, 1995 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 CMR15.017. Signature a Date June 7.2004 FORM 12 - PERCOLATION TEST Location Address or Lot No. 75 Dunphy Road COMMONWEALTH OF MASSACHUSETTS Northampton Massachusetts Percolation Test* Date: June 7,2004 Time: 10:20 Observation Hole# -t- Depth of Perc 54„ Start Pre-soak 10:20 End Pre-soak 10:35 Time at 12" 10:35 Time at 9" 10:51 Time at 6" 11:10 Time (9"-6") 19 Rate Min./Inch 7 min.per inch *Minimum of 1 percolation est must be performed in both the primary area AND reserve area. If repair,only one test is required. Site Passed ® Site Failed ❑ Performed By: Paul B. Hatch. PE Witnessed By Ernest J.Mathieu Comments: 493pg4 operty lines shown are assumed from field obs ions conducted June Z 2004, and a plan prepared y.Almer Huntley, Jr. & Assoc., Northampton titled " ine Meadow" Definitive Definitive Subdivision Pla , —11-72, no assumptions of property line T street line locations are to be mode from data-Shur< this plan. vent GRAPHIC SCALE 0 20' ( w rur) I inch 20 n New "0" box with in baffle Dosing chamber screened porch house . 'tbm=100.00 hinge side door sill retaining wa l for pool I/^ atchbasin DUNPHY ROAD SPRUCE LANE znk efjuippe with filter no gra der allowed As Built Plan REPAIR On—site Sewage Disposal System 75 Dunphy Road Northampton, MA prepared for Linda Wheeler 75 Dunphy Road Northampton, NA 01062 scale: 1"=20' horizontol date:Sept. 15, 2004 P. B. Hatch Consulting Engineers 57 MUNN ROAD MONSON, MASSACHUSETTS 1 of 1