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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 le return 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 -do not e return 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