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417 Application Local Upgrad Approval 2018 Commonwealth of Massachusetts — City/Town of Northampton ;^"-1 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 15.000. A. Facility Information Important: When filling out 1. Facility Name and Address: forms on the computer,use Mary Cadorette only the tab key Name to move your 417 Westhampton Road cursor-do not Street Address use the return key. Northampton _ MA _ 01060 City/Town State Zip Code 2. Owner Name and Address Of different from above): O YO Mary Cadorette _ _ 417 Westhampton Road Name Street Address Northampton _ _ _ MA City/Town State 01060 413-588-8462 Zip Code Telephone Number 3. Type of Facility (check all that apply). C ® Residential LI Institutional Li Commercial El School Capp 4. Describe Facility: 7 bedroom multifamily home 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): 1000 gallon tank with 1 trench of unknown length TITLE 5 FORM 9a.doc•rev.7/06 Application for Local Upgrade Approval Page 1 of 4 Commonwealth of Massachusetts City/Town of Northampton 'Ma: I— ; 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 15203: unknown - no records available 9P Design flow of existing system: -_d ---- - _- --- 770 Design flow of proposed upgraded system - -- -_-- -- _ _- - gptl 770 Design flow of facility: gptl 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 dale of inspection 2. Describe the proposed upgrade to the system: install complete new system withh 2000 gallon tank, effluent filter, 1000 gallon pump chamber and 25' x 55' stone 8 pipe leach field — 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%I MS size,sq.ft. - %reduction Z Reduction in separation between the SAS and high groundwater: from 4' to 3' �_ Separation reduction fr 15 mpi a) Percolation rate min/inch C 1 Depth to groundwater --- --- _— - - TITLE 5 FORM 9a.doc•rev.7/06 Application for Local Upgrade Approval*Page 2 of 4 Commonwealth of Massachusetts -,_— City/Town of Northampton 3 V- Form 9A - Application for Local Upgrade Approval yV ` 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 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. * Ron Laurin October 13, 2017 /1 Evaluator'sfName(type orprint) '1`, SlgnaWr/e/' - ( Date of evaluation *Coi 4'tcaLr 4 n- 1yH� ,'pprovtcl 6 D I .J C. Explanation / I / 8):a# I Explain why full compliance, as defined in 310 CMR 15.404( ), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: Additional fill required would create a need for a slope easement onto abutting property and the additional cost is also more than the homeowner can afford 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasibl . TITLE 5 FORM 9a.doc•rev.7/06 Application for local Upgrade Approval* Page 3 of 4 Commonwealth of Massachusetts ,_z City/Town of Northampton 11 :a'Mt _ g Form 9A - Application for Local Upgrade Approval ter 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: 4. Connection to a public sewer is not feasible: 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): Z 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." Cador,cCty k-11_ , I Facility is Signature Date Mary Cadorette_ Print Name Edward T. Berry, P.L.S., SE#153 August 16, 2018 Name of Preparer Date 113 Main Street Athol Preparers address City/Town MA 01331 978-249-8811 State/ZIP Code Telephone TITLE 5 FORM 9a doc•rev.7/06 Application for Local Upgrade Approval, Page 4 of 4 Commonwealth of Massachusetts _a _ City/Town of Northampton :St_` Local Upgrade Approval f m h Form 9B DEP has provided this form for use by local Boards of Health if they choose to do so. eG(//� ''1� The Local Upgrade Approval is to be completed by the local Board of Health and a signed— ovided to the system owner. /I A. Facility Information Important: When filling out 1. Facility Name and Address forms on the computer,use Mary Cadorette _ only the tab key Name to move your 417 Westhampton Road cursor-do not - - - _- -- _ -- use the return Street Address key. Northampton MA 01060 irCity/Town State Zip Code e 2. Owner Name and Address (if different from above): Mary Cadorette 417 Westhampton Road /innName Street Address Northampton MA City/Town State 01060 413-588-8462 Zip Code Telephone Number 3. Type of Facility(check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Design flow per 310 CMR 15.203: 7704 gpd 5. System Designer Paul O. Hadsel & Edward T. ® PE ❑ RS Berry, PLS, SE 113 Main Street _ Athol _ MA 01331 Address City/Town 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 TITLE 5 FORM 9b.doc•rev.02/2014 Local Upgrade Approval Page 1 of 2 Commonwealth of Massachusetts a_ c4 City/Town of Northampton a, Local Upgrade Approval 'owe Form 9B B. Approval (continued) ® Reduction in separation between the SAS and high groundwater: From 4'to 3' Separation reduction 15mpi_ Percolation rate min./inch - 1 Depth to groundwater n -- -- - - - ❑ 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 List local variances granted: AIv "'t?jili reduction in accor n,n dr lathy- ViolTitle S Reg. 15.405(1)LL__ /VO/7L/YJ J{!A_� /741/ „_ *A- n..., gAutho / l / / � not or Type ame and Title / Signatu Date l/e`/H 1,u oect -- kr thk edge 71- NORTHAMPTON BOARD OF HEALTH _ // // 212 MAIN STREET � ry70� NORTHAMPTON, MA 01060 ) TITLE 5 FORM gb.doc•rev.02/2014 Local Upgrade Approved Page 2 of 2 * : 71 " j .