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1023 DSCP & Local Upgrade & Certifiactes of Compliance FORM 1 A - APPLICATION FOR DSCP Fee . ?0�' coM'MOT1wEACTITfoP wss?tc7-('usia-ts Board of Health. Northampton, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to: Repair mplete System ( X ) Individual Components 3cription of Soil(s) sandy Soil Evaluator Form No. 191 Name of Soil Evaluator Thomas Leue Date of Soil Evaluation 9/28/01 SCRIPTION OF REPAIRS OR ALTERATIONS new hump tank and leachfield undersigned agrees to Install the above described Individual Sewage Disposal System In accordance with provisions of TITLE 5 and further agrees not to place the system In operation until a Certificate of Compliance been i. : ed b d of Health. ned - . •41 pecti Date 7// DEP APPROVED FORM 5/96 w � anon 1023 Westhampton Road Owner's Name Joseph Dacri ,/Parcel Address 1023 Westhampton Rd. Florence, MA 01062 Telephone # 584-1214 aller's name it ---.M.‘ I ress Designer's Name Thomas Leue, Homestead Inc. Address 1664 Cape St., Williamsburg MA phone # Telephone 413 628-4533 'ding Type: Dwelling Bedrooms: 3 Other - Type of Building No. of persons Other Fixtures sign Flow (min. required): culated design flow: sian flow provided: Lot Size (sq. ft.) 30 000 Garbage grinder YES Showers ( ), Cafeteria ( ) 495 gpd 495 gpd 497 Bpd_. 3cription of Soil(s) sandy Soil Evaluator Form No. 191 Name of Soil Evaluator Thomas Leue Date of Soil Evaluation 9/28/01 SCRIPTION OF REPAIRS OR ALTERATIONS new hump tank and leachfield undersigned agrees to Install the above described Individual Sewage Disposal System In accordance with provisions of TITLE 5 and further agrees not to place the system In operation until a Certificate of Compliance been i. : ed b d of Health. ned - . •41 pecti Date 7// DEP APPROVED FORM 5/96 FORM 2A - DSCP 2 Fee- - r 7//?-10)- Co'M'MO9v1WEAL'�4-COE `A4ASSACWIISO'PJ S Board of Health, Northampton, MA DISPOSAL SYSTEM CONSTRUCTION PERMIT sion is hereby granted to. Repel ran individual sewage disposal system at Westhampton Road Northampton as described in the application for Disposal System uction Permit No. /r0)— dated 1/7.2/0>- led: Construction shall be completed within three yehe date this per it. All local conditions must be met. --f/33/9? Board of Health DEP APPROVED FORM 596 FORM 3A - CERTIFICATE OF COMPLIANCE Fee CO%`?4O`MWEgliTl't(OT 'M'ASSACTPUST'TtS Board of Health, Northampton, MA CERTIFICATE OF COMPLIANCE Iption of Work: ( ) Complete System ( X ) Individual Components idersigned hereby certify that the Sewage Disposal System: a it 1023 Westhampton Road. Northampton Ben installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved 7 plans/as built plans relating to application No. / n /1/01 Approved Design Flow 497 (gpd). ler: per: !ctor: Thomas S Leue. Homestead Inc. Date: Date: Date: issuance of this permit shall not be construed as a guarantee that the system will function :signed. DEP APPROVED FORM 596 FORM 3A - CERTIFICATE OF COMPLIANCE Fee co`M'NOWIW` ALT"}coa ? 91.SSAACJh1SfTts Board of Health, Northampton, MA CERTIFICATE OF COMPLIANCE iption of Work: ( ) Complete System ( X ) Individual Components Idersigned hereby certify that the Sewage Disposal System Repair _River Drive Excavating 1023 Westhampton Road. Northampton stead Inc. Project#: 191 =en installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved t plans/as built plans relating to application No. 5/18/02 , Approved Design Flow 497 (gpd). ler Iner: actor: Date: X-- P‘1--- Date: 7/26/02 Date: issuance of this permit shall not be construed as a guarantee that the system will function ?signed. cc: Joseph Dacri, 1023 Westhampton Rd., Florence, MA 01062 DEP APPROVED FORM 5/96 r tri 1 y p1 X a(? � 5 L 9 A w v0i It d 7 Z N < c O S a w 5 d co co - - in N o • 7 cc O d o O N E N 16' k X I Z ['Ii �� ° Ik ja le }z� al 2� 6 1 6' ^2i N N to W O fr • 9 1 D = PL v 'rt „ leachfield O j 9 �11 1/2 �. - �, .um control O 0 9 Cr, O_ �i N 'bump chamber Pa w 0. "as. 0 1 septic tank 5 3/4' -1, ,.. N of distribution box Deck Porch 18.-- 8 Z OMMONyF Deck Fence Y S Y m • m� an mp Existing 3 bedroom house s',4 N�oa5 Call • X 3 ;, p) �r/rJ� city water in WPA cn V• d to 1 90 o- r) :It Note: No known drinking water sources within 150' radius. i ro d ° `V X PL p .., .. . • FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 5 ofj Co o9WECLO n-CoP ASSACq-CLISFJ7tS Northampton, Massachusetts CAL. UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405 ity.system owner: Name: Joseph Dacri, 1023 Westhampton Rd. J3orence, MA 01062 Address of Facility: 1023 Wes thamot on Road of facility: em designer: Residential design flow per 310 CMR 15.203497 qpm Name: Thomas Leue Address Homestead Luc . . 1669 Cape St . . Williamsburg, MA 01096 Phone No. 413 628-4533 al lJnarade Approval granted for: reduction in setback(s) (specify) per rate of 30-60 min./nch (specify rate) reduction in SAS of up to 25% fspecify % reduction & size of SAS) x reduction in separation between SAS & high groundwater reduction to 9 (specify reduction & oerc rate) <2 min/in. relocation of a well (explain) &oal variances wanted (no DEP approval reauired per 310 CMR 15.412(411 variances Granted requiring DEP approval [rd of Health Approval of proposed upgrade E14/1/11Aleged Name&Title natur ' City/town SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL THE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION DIVISION OF TER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY& BEFORE MMENCEMENT OF CONSTRUCTION. Mail to: DEP, Western Regional Office, 426 Dwight St., 5th Floor, Springfield, MA 01102 DEP APPROVED FORM 12/07/95 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 1 of.5"- coqtq4O1TWPADf'J-ToT WIssscTRISE fs Board of Health, Northampton, MA Application for Local Upgrade Approval Tile 5, 310 CMR 15:000 DEP Approved form required by 310 CMR 15.401(1) be submitted to Local ApprovingjAuthority/Board of Health: For the upgrade of a failed or iconforming system with a design flow of<10,000 gpd, where full compliance, as defined in CMR 15.404(1), is not feasible. be submitted to DEP: For the upgrade of a failed or nonconforming system with a design w of 10,000 up to 15,000 gpd and/or of a state or federal facility,where full compliance, as fined in 310 CMR 15.404(1), is not feasible. ATE: Local upgrade approval shall not be granted for an upgrade that includes the addition new design flow to a cesspool or privy or the addition of new design flow above the existing proved capacity of a system constructed in accordance with either the 1978 Code or 310 4R 15.000. Facility/system owner Name: Joseph Dacd Address: 1023 Westhampton Rd.. fence.MA 01062 Phone It 584-1214 Address of facility: 1023 Westhampton Road,Northampton Applicant (if different from above) Name: Address: Type of facility X Residential _ Commercial _ School _ Institutional _ Other (specify)_ Type of existing system _ privy _ cesspool .1 conventional system _ Other (specify) Type of soil absorption system (trenches, chambers, pits, etc.) leach aalieries DEP APPROVED FORM 12107/95 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 2 ofd" Design flow based on 310 CMR 15.203 a) Design for of existing system unknown gpd Approved? no Approval Date _ If not,why? too old b) Design flow of proposed upgraded system 4 9 7 gpd c) Design flow of facility 495 gpd Proposed upgrade of existing system is _ Voluntary _ Required by order, letter,etc. (attach copy) Required following inspection required by 310 CMR 15.301 date inspection was submitted to the approving authority: b) Describe the proposed upgrade to the system: New pump tank and leach fields c) Which of the following are applicable to the proposed upgrade? _Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) _ Percolation rate of 30-60 minutes per inch(state actual perc rate) Up to 25% reduction in subsurface disposal design requirements (state required & °posed size) Relocation of water supply well (identify well, describe relocation) X Reduction of required separation between bottom of SAS &high groundwater Jecify proposed reduction&perc rate) existing perc rate <2 min Der inch. Request reduction of jfield bottom to 4 ' above groundwater _ Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the xie) /stem upgrades that cannot be performed in accordance with 310 CMR 15.404 &15.405,or full compliance with the requirements of 310 CMR,require a variance pursuant to 310 MR 15.410-15.417. DEP APPROVED FORM 12/07/95 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 3 off 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 15.404 (1)(i)(1).The evaluator must be a member or agent of the local approving authority. Distance from soil absorption system to high groundwater: 4 feet As determined by: Evaluator's Name: Peter McErlain Evaluator's Signature: Date of Evaluation: 9/28/01 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 notices 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: )utter Name- ddress: ate Notified. butter Name ddress: ate Notified. butter Name: ddress: ate Notified- butter Name- ddress: gate Notified. DEP APPROVED FORM 12/07/95 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL PAGE 4 ot3- Explain why full compliance, as described in 310 CMR 15.404(1), is not feasible(each section must be completed): a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible: • • • • . . . • • • _ • • grade. Tn order to reduce costs . avoid need for a Dumped system and equalize local finish grade, request reduction to 4' separation from groundwater. b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible: Not needed, conventional system feasible. c) a shared system is not feasible: Not required. lot will support system. d) connection to a sewer is not feasible: No public sewer in area. )) An application for a disposal system construction permit,including all required attachments (e.g. plans and specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? X yes _ no L) 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 knowing violations." Facility Owner's signature Date Joseph Dacri Print Name Thomas S. Leue. Homestead Inc. 11/1/01 Name of Preparer Date 1664 Cape Street, Williamsburg, MA 01096 (413) 628-4533 Telephone # &address of preparer DOTE: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