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
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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- -
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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
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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