140 Applicatio for Local Upgrade 2015 •
Commonwealth of Massachusetts di/51/
- -� City/Town of 0Y+Ino lnp ton
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 15415.
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 1.out FacilityName and Address:
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2. Owner Name and Address(if different from above):
OxoName Street Address
City/Town State - -
Zip Code Telephone Number
3. Type of Facility(check all that apply):
fzi Residential 9 Institutional ❑ Commercial ❑ School
4. Describe Facility: 1�
3 ie�Obr" llirkq ' one pe, oro t : cent
5. Type of Existing System:
9 Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below):
6. Type of soil absorption system(trenches, chambers, leach field, pits, etc):
5ep4 c kwtiK - i-Vw4-h 1-each p;
t5formga.doc•rev.7/06 Application for Local Upgrade Approval,Page 1 of 4
Commonwealth of Massachusetts
City/Town of ucr - n- ptnn
-'741-4=1-1 Form 9A - Application for Local Upgrade Approval
C®C
- y/ 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:
Unknown
Design flow of existing system: god
U4O
Design flow of proposed upgraded system gpd46
Design flow of facility: god 4-
B. Proposed Upgrade of System
1. Proposed upgrade is(check one):
❑ 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:
1 e p,ro osrap± 5_tv .n 1 s_--\-t, be— cam I eSerd e_ ®nthe
-event "k3/4. Zus lw - work-Lr�q S'HS±ern is f�arnaSeh
QInC 4 SA-r1/4.6% I tla. on pro jest' gl0Y\.9 11.4 river banK
3. Local Upgrade Approval is requested for(check all that apply):
®
Reduction in setback(s)—describe reductions: r�
_ r7Dri1 10' *o S 'kb +1,•& fro c
\` n -ProrsA - -
e-4e Of 5rts . .
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction ft
Percolation rate -min inch
Depth to groundwater ft - _
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 2 of 4
•
Commonwealth of Massachusetts
- City/Town of No(} 'orr'..?+"ofl
r44 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 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:
Evaluator's 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:
aa
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
�,1/,:‘536 ht ,W05ed SSS -erN_w J)_. pNvi d.-
a-Lecti"oA _—_
form9a.doc•rev.7/06
t5Application for Local Upgrade Approval,Page 3 of 4
P.A. Commonwealth of Massachusetts
City/Town of Morl'hawtp+or
kForm 9A - Application for Local Upgrade Approval
y, 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:
Kok Ga.
4. Connection to a public sewer is not feasible:
Mot avoU-10o ie
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
156 Complete plans and specifications
V) Site evaluation forms
9 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).
9 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."
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Fac IN Owner's ignalure Dat
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P intNzme
nIL /O
Jr of Prreoaren. Date
C it?-)P0016 ley') bit _ W; 1.brahaLvw
Preparers address City/Town
vw k wools-S -- — 413 454 515'
State/ZIP Code Telephone
t5torm9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4
Commonwealth of Massachusetts ,,�/��c'/i
m f` City/Town of Northampton umber
t Application for Disposal System
$150.06
t 9 - Construction Permit Fee
Form 1A
A. Facility Information (continued)
5. Type of Building:
® Dwelling ❑ Garbage Grinder(check if present)
Other: Type of Building - Number of Persons Served
❑ ShowersNumber of mowers ❑ Cafeteria ❑ Other fixtures
4 Bedrooms
Specify other fixtures:
440
6. Design Flow: canons per Day
450
Calculated Daily Flow: Gallons
8/1/15
7. Plan: Date of Original
Number of Sheets Revision Date
Proposed Septic Design
Title of Plan
8. Description of Soil:
see attached soil log _.-
9. Nature of Repairs or Alterations(if applicable):
The purpose of this plan is to show that a system can be installed on this site in the event the current
system gets damaged during slope stabilization work.
10. Date last inspected: Date
t5fonnl a.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3