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 .