709 Septic Upgrade Application 2001 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF 5
Commonwealth of Massachusetts
NORTHAMPTON , 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 failed or nonconforming system with_a design flow
of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full
compliance, as defined in 310 CMR 15.404(1), 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 Georgianna Flanders
Name
Address
Phone #
Address of facility
•
413-586-2883
2) Applicant (if different from above)
Name
Address
Phone k
Georgianna Flanders
709 Florence Road
Cora -n.- • , •r . Vol
3) Type of facility
xx residential commercial school
institutional
(Specify)
DEP APPROVED FORM-12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 OF 5
4) Type of existing system
privy cesspool(s) xx conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits,etc.)
(Field)
5) Design flow based on 310 CMR 15.203
Unknown?
a) Design flow of existing system
Approved? yes approval date
no why?
gPd
b) Design flow of proposed upgraded system ? gpd
c) Design flow of facility gpd
6) Proposed upgrade of existing system is
a) Voluntary
Required by order, letter, etc. (attach copy)
xx Required following inspection required by 310 CMR 15.301 5pr yid date -
inspection form was submitted to the approving authority) (date)
b) Describe the proposed upgrade to the system
New S. a a
stole at sueel.
oundation duo to
c) Which of the following are applicable to the proposed upgrade'?
xx Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
10-€eet-€ran s k r fnundati
•
Percolation rate of 30-60 minutes per inch (state actual perc rate)
DEP APPROVED FORM-12107/95
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)
Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & pert rate)
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)0)(1). The evaluator must be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
feet
As determined by:
Evaluator's name 4L4' u11 }SS
Evaluator's signature
Date of evaluation G i;ij pl
DPP APPROVED FOCUS-13/07/95
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 N/A Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
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 complianrr with 310 CMR 15.000 is not feasible:
Placement of tank is required due to slope at street.
b) an alternative system approved pursuant to 310 CMR 15283-15.288 is not feasible:
Alternative System would not change grade.
➢EP APPROVED FORM-I2/0Il95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
a shared system is not feasible:
Not Aplicable
d) connection to a sewer is not feasible:
Not with 500 ft.
10) An application fora disposal system construction permit, including all required attachments
(e.g. plans & specifications, site evaluation forms), must accompany this application. Is the
DSCP application attached? rayes no
11) Certification
"l, 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 andior
imprisonment for knowing violations."
i.'
/c /
Fac rty owner s signature / Date
Georgianna Flanders
4
Print Name
Alan E. Weiss, RS Cold Spring Environmental, Inc. 7/02/2001
Date
Name of prepare;
350 Old enfield, Rd. Belchertown, MA 01007
Telephone fi & address of prepares . _(413) 323-5957
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.
DEP APPROVED FORM-12/07/95