383 Local Upgrade Approvals & Certificate of Compliance BOARD OF HEALTH
MEMBERS
JAY FLEITMAN,M.D.,Chair
SUZANNE SMITH,M.D.
ITHI SCRIMOEOUR,MHEd,CHES
Health Director
ETER J.McERLAIN,R.S.,MPH
Title 5 Inspector
MO
rE:
(413)587-1214
FAX(413)587-1284
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON,MA 01060
Northampton Board of Health
July 29,2009
Review of Application for Local Upgrade Approval and Plans for the construction of a new Soil Absorption System at
383 Westhampton Road-Route 66,Northampton.
,TEM
NER:
Wzorek Family Trust
;IGNER: James Gracia, PE
;TEM
;CRIPTION: Septic System Upgrade—Proposed new system to be gravity fed for a 3 bedroom single family house.
::KGROUND: Title 5,the State Environmental Code,310 CMR 15.000 Standard Requirements for On-site Sewage
Treatment&Disposal Systems authorizes Boards of Health to issue Local Upgrade Approvals(LUA)
when it is deemed necessary to repair/replace failed soil absorption systems on lots where conditions do not
allow full compliance with the Code. An LUA must be voted upon/approved by the Board of Health during
a legally posted meeting and would vary the application of the Code without the need to obtain a formal
variance from DEP.
:AL UPGRADE
'ROYAL: The attached application for the Local Upgrade Approval seeks a one(1) foot reduction in the separation
(from 4 feet to 3 feet)between the estimated seasonal high groundwater elevation and the bottom of the
leach field.
4CLUSION: This is a reasonable and common request which will allow a gravity system to be installed;otherwise a pump
would be required. This request is feasible and allowable. I therefore recommend issuance of the Local
Upgrade Approval.
se feel free to contact me with any questions concerning this review.
Date
Ttant When
out forms
e computer,
only the tab
move your
r-do not
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Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
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 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 15.415.
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 an on-site system constructed in accordance with either the 1978 Code or 310 CMR 1ff 000.
A. Facility Information
Facility Name and Address:
Wzorek Family Trust
Name
383 Westhampton Road - Rte 66
Street Address
Northampton MA 01060
City/Town State Zip Code
2. Owner Name and Address Of different from above): [�
Wzorek Family Trust /917 i/ , I01/ r�Qp/ Dr.
Na - trees Address o
TIM I IWO �iY11
City/Town 1 State
�
2 9C r&as)aa9--9“6
Telephone Number
Zip Code
3. Type of Facility (check all that apply):
® Residential
4. Describe Facility:
4 Bedroom Dwelling
❑ Institutional ❑ Commercial LI School
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, each field, pits, etc):
Existing system unknown
rek LUA1 •rev.7/06 Application for Local Upgrade Approval, Page 1 of 4
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
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:
gpd
710 Gals/Day
gpd
660 Gals/Day
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:
Replace existing system with new 24'x 40' each field and new 1500 gallon, two compartment septic
tank.
date of inspection
3. Local Upgrade Approval is requested for(check all that apply):
❑ Reduction in setback(s)—describe reductions:
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
® Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate
Depth to groundwater
1'Reduction from 4'to 3'
ft.
3 Min/Inch
min/Inch
4 feet
u._.._
k LUA1 •rev.7/06 Application for Local Upgrade Approval* Page 2 of 4
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Form 9A — Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
B. Proposed Upgrade of System (continued)
❑ Relocation of water supply well(explain).
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
❑ Use of only one deep hole in proposed disposal area
❑ Use of a sieve analysis as a substitute for a perc test
❑ 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 Apprved Soil S Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1).
member or agent of the local approving authority.
High groundwater evaluation determined by:
Ernest Mathieu 6-09-04
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:
The reduction in separation above groundwater will allow a gravity system to be installed. An
additional foot higher in elevation would require a pump to be added to the system. The existing
plumbing in the basement shall be raised as much as possible in order to meet the 3'separation above
groundwater. —_. ._.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
N/A
ek LUA1 •rev.7/06
Application for Local Upgrade Approval* Page 3 of 4
Commonwealth of Massachusetts
dity/Town of NORTHAMPTON
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
C. Explanation (continued)
3. A shared system is not feasible:
N/A
4. Connection to a public sewer is not feasible:
No Public Sewer available.
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
® 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."
Print Name
James A. Gracia, PE
Name of Preparer
99 Glendale Street Easthampton
Preparers-address _ __ ....__.. City/Town
413-527-8318
5-08-09
Date
MA 01027
State/ZIP Code
ek LUA1 •rev.7/06
Telephone
Application for Local Upgrade Approval* Page 4 of 4
•
IOARD OF HEALTH
MEMBERS
IEMARIE KARPARIS,R.N.,MPH
XANTHI SCRIMGEAUR
JAY FLEITMAN,M.D.
STAFF
.sit J.Mathieu,R.S.,M.S.,C.H.O.
Director of Public Health
Meczywor,R.S.,Sanitary Inspector
a Abbott,R.N.,Public Health Nurse
August 10, 2009
OFFICE OF THE
BOARD OF HEALTH
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
RE: 383 Westhampton Road/Route 66
Dear Resident of 383 Westhampton Road:
212 MAIN STREET
NORTHAMPTON,MA 01060
TEL(413)567-1214
FAX(413)587-1221
Enclosed is your Local Upgrade Approval for your new septic system that was
approved by this Board of Health.
As indicated on the bottom of page of your approval form, it is the homeowner's
responsibility to submit a copy of this approval to the Massachusetts Department of
Environment Protection. The address to mail it to is listed below:
Massachusetts Department of Environmental Protection
Western Region Office
1000 Dwight Street
Springfield, MA 01020
Please do not hesitate to contact me if you have any questions regarding this mater.
Sincerely,
Ellen Bokina
Title 5 Inspector
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Local Upgrade Approval
Form 9B
, 'ir H
if-to-09
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
it:When
forms 1. Facility Name and Address
rmputer,
the tab
ove your
Jo not
eturn
Wzorek Family Trust
Name
383 Westhampton Road - Rte 66
Street Address
Northampton
City/Town
2. Owner Name and Address(if different from above)
Wzorek Family Trust
Name
MA
State
01060
Zip Code
Street Address
City/Town
State
Zip Code
3. Type of Facility(check all that apply):
Z Residential ❑ Institutional
4. Design flow per 310 CMR 15.203:
5. System Designer:
99 Glendale Street
Address
Telephone Number
❑ Commercial
710 Gals/Day
gpd
James A. Gracia, PE
❑ School
Name
Easthampton
City/Town
Z PE 0 R
MA 01027
State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s)—specify:-._..
❑ Reduction in SAS area of up to 25%:
SAS size,sq.ft.
%reduction
LUA2•rev.7/06 Local Upgrade Approval* Page 1 of 2
'Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Local Upgrade Approval
Form 9B
B. Approval (continued)
® Reduction in separation between the SAS and high groundwater:
1' Reduction from 4'to 3'
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well (explain):
ft.
3 Min/Inch
min./inch
4 Feet
ft
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
❑ Use of only one deep hole in proposed disposal area
❑ Use of a sieve analysis as a substitute for a perc test
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
N ift3-1 a ni Vl la v, 3G )'i
Approving Au Doty /
Si-le al-of $ ID U
Print or Type Name and fe Signature Date
rk LUA2•rev.7/06 Local Upgrade.Approval,Page 2 of 2
i Commonwealth of Massachusetts
e _ City/Town of NORTHAMPTON
1-i Certificate of Compliance
Form 3
tant:When
wt forms
computer,
ity the tab
move your
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DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with
the local Board of Health to determine the form they use.
This Is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
® Repair or replacement of an existing system
❑ Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
DSCP Number DSCP Date
James F.Wzorek,Jr.
Facility Owner
383 Westhampton Road
Street Address or Lot F
Northampton MA 01062
City/ own State Zip Code
Designer Information:
James A. Gracia i James A.Gracia, PE
Name of Company
8-06-09
nature Date
Installer Information:
Paul Truehart
N (T
—
Nam °moony
Signature
Truehart Paving &Construction
Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed:r, ' vT�rctvvl4}avt -36
}q-
Approving Au . /1
Signature
%- 10�0c/
Date
13.doc•06/03 _._Certificate of Compliance•Page 1 of 1
ES A. ' GRACIA, PE
Male Street, Easthampton, YA 01027
NEW
D GALLON
MC TANK
\
\
CONCRETE \\
DRIVEWAY
/ / \■
WATER 1
SERVICE*
IMPERVIOUS
BARRIER
INSPECTION
PORT
AVM3A18O 313210NOO
N
WESTHAMPTON ROAD - ROUTE 66
JAMES f. WZOREK, JR.
383 WESTHAMPTON ROAD
NORTHAMPTON, MA
SEPTIC SYSTEM "AS BUILT"
SCALE 1" = 20' 8/06/2009
£own of
Cc)5T
AMHERST LiUlaachuets
AMHERST HEALTH DEPARTMENT, 70 13OLTWOOD WALK, AMHERST, MA 01002
1413) 256-4077 Environmental Health Services
FAX (413) 256-4053 (413) 256-4033
www_amherst nagov
-A" MAKE SMOKING HISTORY
;22-2009 13:09
TAYLOR AGENCY 14135275424 P.02
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit Fee
Form IA
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Number
'dant:When
out forms Application is hereby made for a permit to El Construct a new on•site sewage disposal system
e computer, IZ Repair or replace an existing on-site sewage disposal system
inly the tab [' Repair or replace an existing system component
move your
-do not
he return
st Of
as
ANTHONY
ORACJA
CML
P
4ffPL
1 Location of Facility:
383 Westhampton Road -Route 66
Address or Lot#
Northampton MA
CIty/Town State
2 Owner Information
James F.Wzorek, Jr.
Name
PO Box 1039
Address(if different from above)
Easthampton
CIty/Town
3 Installer Information
Paul Truehart
Name
25 College Highway
Address
Southampton
City/Town
01060
Zip Code
MA 01027
State Zip Code
413-527-3375 cio Taylor Agency
Telephone Number
Truehart Paving&Construction
Name of Company
4. Designer Information
James A.Gracra
Name
99 Glendale Street
Address
Easthampton
CitylToval
xmlaidoo•36/03
MA
State
413-527-9246
01073
Zip Code
Telephone Number
James A. Gracia, PE
Name of Company
MA
State
413-527-8318
01027
Zip Code
Telephone Number
Application for Disposal System Construction Permit•Page 1 of 3
gown o f
.�/ t7).
1- AMHERST c_Massacfnusetts
OG�O 1
AMHERST HEALTH DEPARTMENT, 70 BOLTWOOD WALK, AMHERST, MA 01002
■4131 256-4077 Environmental Health Services
FAX 14131 256-4053 (4131 256-4033
www.am herstma.gov
c,`r MAKE SMOKING HISTORY
,v„
-22-2009 13:09 TAYLOR AGENCY 14135275424 P.03
t
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form to
Number
$
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other.Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
® Garbage Grinder(check if present)
Number of showers
❑ Cafeteria
Number of Persons Served
❑ Other fixwres
710 Gals/Day
Gallons per Day
660 Gals/Day
Gallons
5-06-09
Date of Original
1
Number of Sheets Revision Date
Septic System Upgrade for Wzorek Family Trust, Dwg#2009-005
TAIe of Plan
8. Description of Soil:
Sandy Loam (See soil logs on plan)
9. Nature of Repairs or Alterations Of applicable),
Replace entire disposal system with new 1500 Gallon, two compartment septic tank and new 241x40'
each field.
10. Date last inspected:
anal teem 06103
Date
Appliwtian for Disposal System Construction Permit•Page 2 of 3
¶owt of
S,Wtt.M
�� AMHERST <Massachusetts
.0 1159
AMHERST HEALTH DEPARTMENT, 70 BOLTWOOD WALK, AMHERST MA 01002
(413) 256-4077 Environmental Health Services
FAX (413) 256-4053 14131 256-4033
www_a mh ers[magov
1:71 MAKE SMOKING HISTORY
r22-2009 13:09
TAYLOR AGENCY 14135275424 P.04
A Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form 9A
Number
$
Fee
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and
not to place the system in operation until a Certificate of Compliance has been issued by this Board of
Health.
rrnta.do •03103
Signature
Application Approved By:
Date
Name Date
Application Disapproved for the following reasons:
Application for Disposal System Construction Peenit•Page 3 of 3
¶ownn of
AMHERST <JUlassaehusetts
Deo n
AMHERST HEALTH DEPARTMENT, 70 BOLTWOOD WALK, AMHERST, MA 01002
(413) 256-4077 Environmental Health Services
FAX (413) 2564053 14131 256-4033
wwwamhersona.gov
MAKE SMOKING HISTORY
.-22-2009 13:09
rirEE
intent:when
out forme
0 computer,
mly the tab
move your
it-do not
he return
TAYLOR AGENCY 14135275424 P.05
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use.
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 fur compliance, as defined in 310 CMR
15.404(1), is not feasible.
System upgrades that cannot be performed in accordance velth 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 15.415.
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 an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000.
A. Facility Information
1. Facility Name and Address:
James F. Wzorek, Jr.
Name
383 Westhampton Road• Rte 66
Street Address
Northampton MA 01060
City/Town State zip Code
2. Owner Name and Address(if different from above):
James F. Wzorek, Jr. PO Box 1039
Name Street Address
Easthampton MA
City/town Stele
01027 413-527-3375 do Taylor Agency
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
4 Bedroom Dwelling
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
® Conventional ❑ Other(describe below):
6. Type of soil absorption system(trenches, chambers, each field, pits, etc):
Existing system unknown
trek LUA1.doc rev.7/06
Application for Local Upgrade Approval.Page 1 of 4
9o(01 of
�� M s
0
AMHERST < assaehusetts
4DED 11 9
AMHERST HEALTH DEPARTMENT, 70 BOLTWOOD WALK, AMHERST, MA 01002
(413) 256-4077 Environmental Health Services
FAX 14131 256-4053 1413) 256-4033
wwwa mherstmagov
MAKE SMOKING HISTORY
L-22-2009 13:10
TAYLOR AGENCY 14135275424 P.06
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
= Form 9A - A pp lication for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
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;
???
gpd
710 Gals/Day
gpd
660 Gals/Day
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is(check one):
S/
Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301:
date of inspection
2. Describe the proposed upgrade to the system:
Replace existing system with new 24'x 40' leach field and new 1500 gallon, two compartment septic
tank.
3. Local Upgrade Approval is requested for(check all that apply):
❑ Reduction in setback(s)—describe reductions:
❑ Reduction in SAS area of up to 25%:
SAS size.sq.rt %reduction
• Reduction in separation between the SAS and high groundwater
1'Reduction from 4'to 3'
Separation reduction
Percolation rate
Depth to groundwater
orek LUAt.doo•rev.7/06
ft.
3 Min/Inch
min/Inch
4 feet
rc
Application for Local Upgrade Approval Page 2 of 4
down o f
C AMHERST UUlassaehusetts
G��ED ll i9
AMHERST HEALTH DEPARTMENT, 70 BOLTWOOD WALK, AMHERST, MA 01002
(413) 256-4077 Environmental Health Services
FAX (413) 256-4053 (413) 256-4033
wwvcamhersona.gov
MAKE SMOKING HISTORY
r22-2009 13:10
TAYLOR AGENCY 14135275424 P.07
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
B. Proposed Upgrade of System (continued)
LI Relocation of water supply well(explain):
(] Reduction of 12-inch separation between inlet and outlet lees and high groundwater
El Use of only one deep hole in proposed disposal area
U Use of a sieve analysis as a substitute for a perc test
9 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)(h)(1). The soil evaluator must be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Ernest Mathieu 6-09-04
Evaluator's Name(type or prxtq Signature bate at 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:
The reduction in separation above groundwater will allow a gravity system to be installed. An
additional foot higher in elevation would require a pump to be added to the system. The existing
plumbing in the basement shall be raised as much as possible in order to meet the 3'separation above
groundwater.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible;
N/A
orek LUA1.doc•rev.7/06
Application for Local Upgrade Approval*Page 3 of 4
Efownn of
ENT M.1
./11/ AMHERST <Massachusetts
4,ED Il9
AMHERST HEALTH DEPARTMENT, 70 BOLTWOOD WALK, AMHERSI, MA 01002
■413) 256-4077 Environmental Health Services
FAX 1413) 256-4053 1413) 256-4033
wwwam herstm a.gov
MAKE SMOKING HISTORY
-22-2009 13:10 TAYLOR AGENCY
14135275424 P.00
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health.Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use_
C. Explanation (continued)
3. A shared system is not feasible:
N/A
4. Connection to a public sewer is not feasible:
No Public Sewer available.
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
® Complete plans and specifications
® Site evaluation forms
LI 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 Owners Signature Date
James F. Wzorek, Jr.
Print Name
James A. Gracia, PE 7-21-2009
Name of Preparer Date
99 Glendale Street Easthampton
Preparers address City/Town
MA 01027 413527.8318
state/ZIP Code telephone
torek LUAI.doc•rev.7/06 Application for Local Upgrade Approval'Page 4 of 4
flown o f
.�i'�.&q
AMHERST UUlassackusetts
4 tED ils9
AMHERST HEALTH DEPARTMENT, 70 HOLTWOOD WALK, AMHERST, MA 01002
{413) 256-4077 Environmental Health Services
FAX (4131 256-4053 1413) 256-4033
wwwa m herstmagav
MAKE SMOKING HISTORY
-22-2009 13:10 TAYLOR AGENCY
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Local Upgrade Approval
Form 9B
14135275424 P.09
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
rtent:When
out forms 1. Facility Name and Address
a computer.
James F.Wzorek, Jr.
m
n the tab
>move your Name
r-do not 383 Westhampton Road - Rte 66
re return Street Address
Northampton MA
City/Town State
2. Owner Name and Address(if different from above):
James F.Wzorek, Jr. PO Box 1039
Name Street Address
Easthampton _ MA
City/Town State
01027 413-527-3375 c/o Taylor Agency
01060
Zip Code
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
710 Gals/Day
4. Design flow per 310 CMR 15.203: gpd
James A. Gracia, PE ® pE ❑ RS
5. System Designer: Name
99 Glendale Street Easthampton MA 01027
Address City/rown State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction In setback(s)—specify:
❑ Reduction in SAS area of up to 25%:
.mek LUA2.doe•rev.7/06
SAS sire,sq.ft %reduction
Local Upgrade Approval*Page 1 of 2
gown of
PST 44
'oLry AMHERST <JUlassacfnusetts
AMHERST HEALTH DEPARTMENT, 70 BOFTWOOD WAI.K, AMHERST, MA 01002
1413) 256-4077 Environmental Health Services
FAX 0131 256-4053 (413) 256-4033
www.amherstma.gov
R, MAKE SMOKING HISTORY
L-22-2009 13:11 TAYLOR AGENCY
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Local Upgrade Approval
Form 9B
14135275424 P.10
B. Approval (continued)
24 Reduction ill separation between the SAS and high groundwater:
V Reduction from 4'to 3'
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well(explain):
ft
3 Min/Inch
min./inch
4 Feet
ft.
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
❑ Use of only one deep hole in proposed disposal area
❑ Use of a sieve analysis as a substitute for a pert test
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
Approving Authority
Pnnt or Type Name and TPla
Izorek LUA2.doc•rev.7/06
Signature Date
Local Upgrade Appeal*Page 2 012
TOTAL P.10