165 Application for Local Upgrade Approval FORM 9B - Local Upgrade Approval
Commonwealth of/Massachusetts
/170/ 6
244iQ4QR/ t Massachusetts
(City )
LOCAL UPGRADE APPROVAL
Issued Pursuant to 310 CMR 15.404 and 15.405
Facility/System owner: ICS t- �i,L LI Address. /-1515-1147110-4/0161)/�
City/Town: (.lei +-a-we State: 4.. Zip9 a'/01]
Facility Address: /1,, 5 tilt f City/Town:
Type of Facility: Residential ❑ Institutional
D25ign flow per 310 CMR 15.203
System Designer: 77141 {4f
Address: O
City/Town:
❑Commercial ❑School
Bpd
❑ PE ORS
State: /141--O
Zip: O/O .%
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 %
War Reduction in separation between the SAS and high groundwater
Separation reduction / ft Percolation rate min/inch
Depth to groundwater Y 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:
/
Al . oved by the l al,4.w Add Board e h
(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-320/02
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF 5
Commonwealth of Massachusetts
t-v, ,y\ ,or-∎ , 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 Aoprovine AuthoritvBoard of Health: For the upgrade of a failed or
nonconforming system with a design tlow of < 10,000 gpd, where full compliance, as defined in
310 CMR 15.404(1), is not feasible.
To be submined 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) Faciliry/system owner
Name CEt.L,vRA
Address 13'3 56 311-tA RD — t r> l,u pi?1�7 AAA-.
Phone # ("4v3) Star) /coo
Address of facility 1,66-; ICSS- WC 5T cp,"v^75t) RtD (Q-T.h�)
NdLItii PO-( ,v0 MA . 0ler)a
2) Applicant (if different from above)
Name 4',a10-
Address
Phone #
3) Type of facility
sG residential commercial school
institutional) n
(Speclty) y VZNDP-ce_AN tAcJ.i E
h c & -e J O1tPoSA-L
DEP URPOO D FORM- 12 0"95
FORM 9A - APPLICATION FOR LOCAL UPGRADE AFPr O .
PAGE : ;
4) Type of existing system
privy cesspool(s) )C conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pitsf�c.)
Gh-0p'i,mL- LcPc-- ( .�5'c x 2s w)
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system ()LIE gpd
Approved? yes approval date (hUK-
no why?
b) Design flow of proposed upgraded system(o49,'gpd
c) Design flow of facility 33° gpd
6) Proposed upgrade of existing system is
a) x 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)
h) Describe the proposed upgrade to the system
Rcp acs a sOCTauPA(24) ni$Oos.Pc, Syf=N
ti ALL uEU 150zsce;C(aK\ ;e t1,C -TA LAC p15112_4 ,c (fix
P"-sr) A e61) X 2S ) Lett a41/4,_,G gtJp
c) Which of the following are applicable to the proposed upgrade?
Nit Reduction of setbacks) (list setbacks to be reduced with proposed setback distances)
!" Percolation rate of 30-60 minutes per inch (state actual perc rate)
DtP APPROVED FORM-11 0115
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF 5
Up to 25% reduction in subsurface disposal area design requirements (sate required
& proposed size)
N/. Relocation of water supply well (identify well, describe relocation)
✓ Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & perc rate) 4.0
Id/A 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 Sod
Evaluator must determine the high ground water elevation pursuant to 310 CMR
15.405(1)(i)(1). The evaluator must be a member or agent of the local approving authority:
Distance from soil absorption system tis high groundwater
4 feet
As determined by
Evaluator's name t C(2tmor1 LA-tAc 4
F.valuatnr•s signature
Date of evaluation 8�2-s-o3
DEP APPROVED PORN- tl O1•"
FORM 9A - APPLICATION FOR LOCAL UPGRADEAPPROVF L
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
include a
in 310 CMR completed 5 402 throug application
5 405.. and
List of affected Abusers:
U1 A
Abuner 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 hill compliance with 310 CMR 15.000 is not feasible:
)ley skukct. Fa[RjAC, S tzJC7L,PoAc;DC f1/4aN RoP
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible
/3l,i-N tv S'iy (;:?7`. Is opc) sip,
Drr AflRO'ID FOIM•11/0/11
c)
d)
FORM 9A - APPLICATION FOR LOCAL UPGRADE Appaov
PAGE 5 OF 5
a shared system is not feasible Ps.Pc-_A c, T>U
PR `t 42A.A.3 i 5 Too "?..4.41
connection to a sewer Is not feasible.
UO Cjow°e.
F3JA�t,fl f3Lc
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? X yes no
11) Certification
1, the facility owner, certify under penalty of law that this document entand all
attachments, to the best of my knowledge and belief, are we,
complete. I am aware that there may be significant consequences for submitting
false information, including, but not limited to, penalties or fine artd/or
imprisonment for knowing violations,'
Facility owner's signature
0 0RA
Print Name
lv o 6,-,= k‘--AP
: .. J / Fill`=1
Telephone 0 & aidress (,t prepare(
Date
—i3 6--on
Date
5v;) - SD9I
NOTE: Tole 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.
DO APPROVED FORM- ❑.Pr.H
Garage
Driveway
AS—BUILT DIMENSIONS
'A' to '6' = 29 ft.
'3' to t 14 ft.
'A' to 'D' = 53 ft.
Existing
3 bedroo
house
kg dlstrIbution box
teach nem
Ex ls Mg septic tank
/65 Westhampton Road Northampton, MA.
Notes
1. The septc tank should be pumped
at least every 3 years.
2. pump the septic tank from the
pump-out cover and not at the
the meet or outlet cover.
As—built plan
155 Westhampton Road
Northampton, MA.
Excavator: John Tautznic & Son
Easthameton, MA.
AS-BUILT DIMENSIONS
'A' to 'C' = 29 ft.
'B' to 'C = 14 ft.
'A' to '1)' = 53 ft.
Driveway
pIGN xlsSin B distribution
box
I I1J1S(1=111-1
E 11l tl nD EL
Leach fled Ili
Existing septic tank
II—III-11i--11
166' Westhampton Road Northampton, MA.
Notes
1. The septic tank should ,e puryeS
at least every 3 years.
2. faro the septk tank fron the
pu,p-out cover end not of the
the llet or outlet cover.
As—built plan
155 Westhampton Road
Northampton, MA.
Excavator: John Toutznic & Son
Easthampton, MA.
500 GALLON TIGHT TANK — BOUYANCY CALCULATIONS
ITE: LOT # 165 — WESTHAMPTON ROAD — NORTHAMPTON, MA.
DR: TODD CELLURA
ATE: AUGUST 28, 2003
WEIGHT OF 1500 GALLON TANK = WT(tank)
Sides: ( 11'L x 5.08'H )2 = 101 .60 sq ft. x 0.5' = 50.80 cu. ft.
Top/Bottom: (111 x 6'W )2 = 66.00 sq. ft.
Ends: ( 5.08'H x 5'W )2 = 50.80 sq. ft. x 0.5 = 25.40 cu. ft.
So: 50.80 cu. ft. + 66 cu. ft. + 25.40 cu. ft. = 142.20 cu. ft.
Then: 142.20cu. ft. x 150 Ibs/cu. ft. (cement) = 21,330 lbs. = WT(tank)
VOLUME OF 1500 GALLON TANK
OUTSIDE DIMENSIONS:MENSIONS: ( 111 x 6.08'H x 5'W ) = 310.678 CU. FT.
N3301bs. WT(tank) > 18,833 bs aWT(w 18,833 Ibs.
WT(water)
Now:ow: 21 ,, b
THEREFORE: COUNTER WEIGHTS ARE NOT NEEDED TO SECURE THE PROPOSED
1500 GALLON SEPTIC TANK.
Lkao
Name:EASTHAMPTON
Date:8/26/103
Scale: 1 inch equals 2000 feet
Location: 04T 18'03.6' N 07T 40'47.2" W
Caption:Septic system repair
Lot#165-Westhampton Rd.
For Todd Cellura
Copyright(C)1997.MaPtecL,Inc.
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