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75 Disposal System Construction Permits 2004 NoB 1f 31 FORM 1A - APPLICATION FOR DSCP Fee Or at COMMONWEALTH OF MASSACHUSETTS Board of Health, ,MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to: Construct ❑ Repair ® Upgrade❑Abandon ❑ ❑ Complete System Individual Components Location 75 Dunphy$e28`pQ ter C- Owner's Name Linda Wheeler Map/Parcel*/ Address 75 Dunphy Road,Northampton Lot# Telephone s 413-586-3853 p ✓O Installer's Hanle'LnournvFaa ft(OUnArir;vn.z Ery Designers Name Paul Hatch,PE Address Q 30 «tsscvmx Cam✓L ysmNed,A7d.VAddress 57 Munn Road,Monson,MA 01057 Telephones ' is — S a7_swey 'MR Telephone./413-2. 67-3696 Type of Building:single family home Dwelling-No. of Bedrooms-3- Other-Type of Building No.of persons_ Showers (), Cateteria () Other Fixtures Lot Size 15,037 Garbage grinder sq.ft. yes ❑ na PAUE Design Flow(min. required)330 gpd Calculated design flow qpd Design flow provided 350 gpd Plan: DateJune 7, 2004 Number of sheets-3- Title Repair, On Site Sewage Disposal System Revision Date HATCH No 2901 clvr Description of Soil(s)0-11"=A=LS, 11"-22"=B=LS, 22"-60"+=C=LS Soil Evaluator Form No. Name of Soil Evaluator Paul Hatch, PE Date of Soil Evaluation June 7, 2004 DESCRIPTION OF REPAIRS OR ALTERATIONS Relocate or replace existing septic tank, new dosing chamber, nstall new soil absorption system in fill with impervious barrier,waiver for depth to groundwater from four feet to three feet. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed of /-C1Z-4.4 Date '-47_ Oy Inspections DEP APPROVED FORM 5196 FORM 2A - DSCP No. Fee COMMONWEALTH OF MASSACHUSETTS Board of Health,Northampton MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to: Construct ❑ Repair Upgrade Abandon pan individual sewage disposal system at75 Dunphy•ReedDR i vet as described m the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Date Board of Health DEP APPROVED FORM 5196 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 75 Dunphy Road cursor-do not Street Address use the return key. Northampton City MIR MA State 2. Owner Name and Address: Linda Wheeler 75 Dunphy Road 01062 Zip Code 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) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Proposed: raised bed leach field t5for9a•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): Z 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: ❑ Reduction in MS area of up to 25%: min./Inch SAS size,sq.fl. °/0 reduction ❑ Reduction in separation between the SAS and high groundwater: from four feet to three feet, one foot reduction Separation reduction Percolation rate Depth to groundwater ❑ Relocation of water supply well(explain): 7 minJinch 2 ft. t5form9a•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)(i)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by: Ernest Mathieu June 7, 2004 Evaluators Name(type or print) Signature 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 barrier, 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): Z Application for Disposal System Construction Permit ® Complete plans and specifications ® 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 Preparer's address City/Town 4 413-267-3696 MA 01057 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 FORM 11 -SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. 75 Dunphy Road.Northampton On-site Review Deep Hole Number -1— Date:617104 Time 9:00 Weather Sntlt1Y Location (identify on site plan) Land Use homestead Slope (%) 6 Surface Stones none observed grass Vegetation glacial outwash Landform Position on landscape (sketch on the back) Distances from: Open Water Body >100 feet Drainage way >100 feet >100 Possible Wet Area — feet Property Line 25 feet Drinking Water Well>100 feet Other DEEP OBSERVATION HOLE LOG' Depth from Surface(inches) Soil Horizon Sol Texture (USDA) Soil Color (Mansell) Soil Mottling Other (Structure,Sbnes,Boulders,Consistency, Gravel) 0-11" A LS 7.5YT3/2 B LS 7.5Y125/6 11"-22" 22"-60"+ C LS 10YR5/1 10YR6/8 mottles>5%at 22" 'MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) glacial outwash Depth to Bedrock: none observed Weeping from Pit Face.none observed Depth to Grounder Standing Water in the Hole: none observed w Estimated Seasonal High Ground Water 24 493pg2 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 irides ❑ 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 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 DateJune 7,2004 493pg3 Location Address or Lot No. 75 Dunphy Road FORM 12 - PERCOLATION TEST COMMONWEALTH OF MASSACHUSETTS Northampton Massachusetts `Minimum of 1 percolation est must be performed in both the primary area A reserve area. If repair,only one test is required. Site Passed ® Site Failed ❑ Performed By: Paul B. Hatch. PE Witnessed By: Comments: 493pg4 Ernest J.Mathieu Percolation Test* Date: June 7,2004 Time: 10:20 Observation Hole# _t Depth of Pere 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 7min.per inch `Minimum of 1 percolation est must be performed in both the primary area A reserve area. If repair,only one test is required. Site Passed ® Site Failed ❑ Performed By: Paul B. Hatch. PE Witnessed By: Comments: 493pg4 Ernest J.Mathieu e • w 1J .f<,I b'r 1 \ 'rr clWatS/\ ort1'::: ; ; Clf �� A zJS BF8'9/Olr w r \ ��/ \ nr ?f]9M- Por/MAX \ \ rf« ff[y \ I army A✓ ccono ^ :JC 99l \�a I Irar row N7d0 f % /��t7/H it N ^-4JC'Ibc I t 4.'' \ sir r ro °1 .<a r i 8�4 \. \ \ 4,45 �- — 4A oco'si $ o` / �. ... iv \•<r I Qj \ ? �/ .« ^ CObZY ti 4`i / 1 i \ - "--- ^ /� �ava .00,.. \ / ri • f]CVwa qy ^ ti Pow, \ \/ °.... w 4 � M N. __��acr \ �� �, .Di r .W4y OYi� rJi LE0��1�� �.`° fr% at '�<.;D R \\\1 ,p• �_8 4 .4C i—� Halal -le '-�` / — ^ . ID N\�o0 4��/—\NN \ \ �n nr N wr a _ / I \ \ -;X c0o�\E 4 \ � ry\_� \ COON ,, !�� ` Nor [w x \ I 1 \:df-00011—.N 9 �'wai \ \ a�zSC 00r $e _ \\.7CWwar f e p wry i ..lot: N.'"" liar_ _ / j I d Zan/Y/7 7 d��W -\—� t 1 - --pc- _ l — NUMBER THE COMMONWEALTH OF MASSACHUSETTS (9-041 of ciama-Pe r gel Board of Health � /�/f Cc-1/4-45- This is to Certify thatK � .�-f.>.!L't(�.�-i-c 'rt NAME 3 0 g� s LC o f �` `� Ct tine o (pa ADDRESS IS HEREBY GRANTED A"DISPOSAL WORKS INSTALLER'S PERMIT'TO CONSTRUCT,ALTER,INSTALL or REPAIR, Individual Sewage Disposal Systems FEE y s' This permit is granted in conformity with the State Sanitary Code Title V, Regulation 2.2, and expires December 31, a 60$ unless sooner suspended or revoked.n WHITE COPY-Original Board YELLOW COPY-Board of Health of PINK COPY-Mailed immediately to Regional Environmental Engineer, - Health :Department of Environmental Protection. FORM EMS AM.SOMME CO.•BOSTON.MA NUMBER THE COMMONWEALTH OF MASSACHUSETTS of (isf "2-3 This is to Certify that 2-0 0-..32.5 Board of Health FA ht 41 FEE 25, Cam 51 L r)c td.J ODRESS IS HEREBY GRANTED CONSTRUCT, ALTER, INSTALL o REPAIR,INSTALLER'S PERMIT TO ° Individual Sewage Disposal Systems in conformity with the State Environmental Code Title V. Regulation This permit is granted 9,cr,tt, 2.2, and expires December 31, L.r_unless sooner suspended or revoked. Original - --> unaee a WARSEN 9' Board of Health BOARD OF HEALTH MEMBERS ROSEMARIE KARPARIS,R.N.,MPH XANTHI SCRIMGEOUR,tli1Ed,cHES JAY FLEITMAN,M.O. STAFF ErnatJ.Mathieu,P.S.,MS.,C.H.O. DWstW of Public Health Rbhrd Mxaywor,R.S,Sanitary Inspector Patricia Abbott,R.N.,Public Health Nurse Madeline Han,Clerk OFFICE OF THE BOARD OF HEALTH CITY OF NORTHAMPTON MASSACHUSETTS 01060 Board of Health, Northampton 212 MAMNSTREEf NORTHAMPTON,MA 01060 (419)557-1214 FAX(413)5$7-1221 CERT1FICATE OF COMPLIANCE Description of Work 0 Individual Component(s) C.* Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed C1 Repaired L7 Upgraded 0,Abandoned❑ by Linda Wheeler 75 Dunphy Road at has been installed in accordance with the provisions of 31 0 CMR 1 5.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow 338 (.013d)Installer• Dave Loven, Loven Excavating & Construction// Designer ��� I9/or Inspector ay� Date l)� The issuance of this permit shall not be construed as a guarantee that the system will function as designed.