589 Septic Upgrade Application Approval & Compliance 2003 FORM 9A - Application for Local Upgrade Approval
Commonwealth of Massachusetts
Nor{Aan p%.n ,Massachusetts
(City/own)
Application for LOCAL UPGRADE APPROVAL
Title 5, 310 CMR 15.000
DEP Approved Form 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 15.404(1),is not feasible.
System upgrades that cannot be performed in accordance with 310 ChIR 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 v
cordance with either the 19718'Code or 310 CMR 15.000.
Facility Address: 5b9 Florence Road City/Town: / crfhannp "
Facility/System owner: Ke .Vrisc°I I
Address: 6-89 Fc,ev to Rd. Hcrc cs MA 0 i Vz
City/Town: State: Zip:
Telephone: ( 413 ) Sin-7- IDZia
Type of Facility(check all that apply): ❑ Residential ❑Institutional ❑Commercial ❑ School
Describe facility
Type of existing system: ❑Privy ❑Cesspool(s) Eonventional System
❑ Other(describe)
Type of soil absorption system(trenches,chambers,leach field,pits,etc)
Design Flow per 310 CMR 15.203:
Design flow of existing system N. A, gpd
Design flow of proposed upgraded system 410 gpd
Design flow of facility —/ 440 gpd
Proposed upgrade of system is: E voluntary ❑Required by order,letter,etc.(attach copy)
❑Required following inspection pursuant to 310 CMR 15.301
Provide date of inspection / /
7
Department of Environmental Protection
FORM 9A - Application for Local Upgrade Approval
Page I of 3
DEP Approved Form-3/20/02
Describe the proposed upgrade to the system
Reo z, i ',it fyz irevn . (•le,,; isoo3c16n-3c n i— L 4' ■2:x 40'x It,"5,44.
Local Upgrade Approval is requested for:
❑ Reduction in setback(s) (Describe reductions)
❑ Percolation rate for 30 to 60 min/inch Percolation rate min/inch
❑ Reduction in SAS area of up to 25%
(SAS size and%reduction) SAS sq ft Reduction %
❑ Reduction in separation between the SAS and high groundwater
Separation reduction I R Percolation rate 5 min/inch
Depth to groundwater 3 ft
❑ Relocation of water supply well(Explain)
❑ 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 elevation determined by: 4. / 3 /03
(Print or type evaluator's Name) (Signature of evaluator) (Evaluation Date)
Explain why full compliance,as defined in 310 CMR 15.404(1),is not feasible.
(Each section must be completed)
1. An upgraded system inIfulll compliance with 310 CMR 15.000 is not feasible:
Excessive f1I glif,Ctily - 4,\a: QN S.IC�r4 C4 h,0,
2. Alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
(co Cx eons,vc No+ viecAnt
Department of Environmental Protection DEP Approved Fonn-3/20/02
Page 2 of 3
FORM 9A - Application for Local Upgrade Approval
3. A shared system is not feasible: Noroc- vleettitt3 iv, c+ren,
/
4. Connection to a public sewer is not feasible: N out A JCL lAble-
The Application for Local Upgrade Approval must be accompanied by all of the following:
(Check the appropriate boxes)
LJ Application for Disposal System Construction Permit
13 Complete plans and specifications
Site evaluation forma
❑ 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)
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
'/`J/C�f°i' Print name eav� ture ll
Date (n/Y/ 61
Name of preparer /!-low^ Env/rcnvt,en-fa/ Date 6 /l2 /03
Preparer's Address: P0. 13os 226
City/Town: (■ar{{. State: MA Zip: OIC& 2
Preparer's telephone: ( 4-13 ) 247 —5464
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.
L-I
Department of Environmental Protection
Page 3 of 3
DEP Approved Form—3/20/02
FORM 9B - Local Upgrade Approval
Commonwealth of Massachusetts
J�lor i-I,cr n., -4v,.. ,Massachusetts
(Cit rrsva)
LOCAL UPGRADE APPROVAL
Issued Pursuant to 310 CMR 15.404 and 15.405
Facility/System owner: ♦ 'I/ Dr co( Address: ,rl/ f/P PN re kV
State: MA-- Zip: 0 / ac 1--
City/Town: r/024'N
Facility Address: 7D r F(OteNal-Z f`c-• City/Town: r4,eNt'
Type of Facility: .Residential ❑ Institutional ❑Commercial ❑ School
Design flow per 310 CMR 15.203 gpd
System Desi• �-r:__ _gf/`/( ❑PE RS
Address: -F. O K . Z-C∎ �n
City/Town: . : h 1 ire State: /144-
Zip: Ca/CC
Local Upgrade Approval is granted for:
❑ Reduction in setback(s) (Specify)
❑ Percolation rate for 30 to 60 min/inch Percolation rate min/inch
❑ Reduction in SAS area of up to 25%
(SAS size and%reduction) SAS sq ft Reduction
OKI Reduction in separation between the SAS and high groundwater
Separation reduction / ft Percolation rate 5- min/inch
Depth to groundwater 3 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:
lL ' / Board hfa 064,
(Print or type name and Title) t ignature) (Date)
CThe 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
aWit by: n111town environmental Gonsultl; 413 247 5464;
J40 K�
A MILLTOWN ENVIRONMENTAL CONSULTING
P.O.BOX 226
NORTH HATFIELD.MA 01066
(413)247-5464
Jul-10-03 4:41PM; Page 2
n �rlstoil say F/occ„c“ Road
SHEET No
CALCULATED BY
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A I DATE
DATE
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•
•
BOARD OF HEALTH
MEMBERS
RICHARD P.BRUNSWICK, M.D.,MPH,
Chair
ROSEMARIE KARPARIS,R.N.,MPH
MY FLEITMAN,M.D.
PETER 3.McERLAIN,Health Agent
(413)587-1214
FAX(413)587-1264
MEMO
TO:
FROM:
DATE:
SUBJECT:
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
Kevin Driscoll
589 Florence Rd.
Florence, MA 01062
OFFICE OF THE
BOARD OF HEALTH
Peter McErlain, Health Agent
July 2. 2003
Local Upgrade Approval at 589 Florence Rd..
210 MAIN STREET
NORTHAMPTON,MA 01060
On June 26, 2003, the Northampton Board of Health issued the Local Upgrade Approval,
which will allow the repair of your septic system at 589 Florence Rd. Florence.Enclosed
please find your disposal system repair permit and an approved septic system construction
plan.
Please contact me with any questions.
Thank you.
Sent By: H1lltOWn Environmental consult"; 413 29/ 5404;
No.
Jul-10-03 4:41PM; Page 1
FORM 3A - CERTIFICATE OF COMPLIANCE
F-
COMMONWEALTH OF MASSACHUSETTS
Board of Health, /Uor1hgr.tp*n , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) El2tomplete System
The undersigned hereby certify that the Sewage Disposal System;
Constructed ( 1, Repaired {-)!Upgraded N, Abandoned I )
by: R obe.+ W44t //
at: 5-69 Fio/enc0 Rogg / revi,n Dr ro//J
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the
approved design plans/as-built plans relating to application No.
dated aunt 19 ,24,03 . Approved Design Flow 470 (god)
Installer
Inspector
Date 77(0(03
The issuance of this permit shall not be construed as a guarantee that the system will
function as designed.
12/ —C—
e sileacLed sk-e-L L
Or•APPROVED(ORM S/OR