414 Septic Applications Compliance & Checklist 2012 Commonwealth of Massachusetts
City/Town of Leeds
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 Frank&Nancy McNulty
only the tab key Name
to move your 414 Chesterfield Road
cursor-do not Street Address
use the return
key
C
Leeds
City/Town
MA
State
2. Owner Name and Address Of different from above):
Frank& Nancy McNulty 414 Chesterfield Road
Name Street Address
Leeds MA
City/Town State
01063
Zip Code
(413) 584-1876
01063
Zip Code
Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
4 bedroom house with no garbage disposal.
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
® Conventional ❑ Other(describe below):
Existing septic tank and leaching field
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Leaching field
Leedsr-414 Chesterfield Rd-McNulty-local up-grade approval form-
Form 9a•rev.7/06
Application for Local Upgrade Approval• Page 1 of 4
Commonwealth of Massachusetts
City/Town of Leeds
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 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility:
Unknown -installed in 1968 (approx.)
gpd
440 gpd
gpd
440 gpd
gpd
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:
2. Describe the proposed upgrade to the system:
Replace existing sewage disposal system. Install new 1,500 gallon 2 compartment septic tank, a
new distribution box and an Infiltrator leaching trench system, 27 Infiltrators required. Two trenches
with 14 Infiltrators per trench =28 Infiltrators provided.
date of inspection
3. Local Upgrade Approval is requested for(check all that apply):
® Reduction in setback(s)—describe reductions:
a. 3 foot separation to from ESHW to bottom of Infiltrator bed.
b. Use of one deep hole in disposal area.
❑ Reduction in SAS area of up to 25%:
N/A
SAS size,sq.ft.
® Reduction in separation between the SAS and high groundwater:
3
Separation reduction
Percolation rate
Depth to groundwater
Leedsrd14 Chesterfield Rd.-McNulty-local up-grade approval form-
Form 9a•rev.7/06
/o reduction
7.33 mpi
min./inch
3.5'
Application for Local Upgrade Approvals Page 2 of 4
Commonwealth of Massachusetts
City/Town of Leeds
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):
N/A
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
Z 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:
N/A
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:
Edward Smith, BOH, LSE July 5, 2012
Evaluators 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:
This new system will provide better environmental protection than the existing failing one. A 4'
separation is more expensive and may be too large for the front lawn. This constitutes maximum
feasible compliance with an economic consideration.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
An alternative system is not beingproposed. An Infiltrator bed is being proposed.
Leedsr414 Chesterfield Rd.-McNulty-local up-grade approval form-
Form 9a•rev.7/06
Application for Local Upgrade Approval Page 3 of 4
Commonwealth of Massachusetts
City/Town of Leeds
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.
C. Explanation (continued)
3. A shared system is not feasible:
Adjacent lots are too far away.
4. Connection to a public sewer is not feasible:
No public sewer available
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
® 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):
Application for a Local up-grade approval Form 9A- Local up-grade approval Form 9B- locus plan -
Certificate of Compliance
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."
Facility Owner's Signature
Frank McNulty
Print Name
Timothy E. Maginnis R.S
Name of Preparer
70 Montague Road
Preparers address
Ma. 01027
State/ZIP Code
Leedsr-414 Chesterfield Rd.-McNulty-local up-grade approval form-
Form 9a•rev. 7/06
Date
Jul 12, 2012
Date
Westhampton
City/Town
413 527-5291
Telephone
Application for Local Upgrade Approval* Page 4 of 4
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
Commonwealth of Massachusetts
City/Town of Leeds
Local Upgrade Approval
Form 9B
DEP has provided this form for use by I cal Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
i.
Facility Name and Address
Frank& Nancy McNulty
Name
414 Chesterfield Road
Street Address
Leeds
City/Town
2. Owner Name and Address(if different from above):
Frank& Nancy McNulty
Name
Leeds
City/Town
01063
Zip Code
3. Type of Facility(check all that apply):
® Residential ❑ Institutional
4. Design flow per 310 CMR 15.203:
5. System Designer:
70 Montague Road
Address
MA
State
01063
414 Chesterfield Road
Zip Code
Street Address
MA
State
(413)584- 1876
Telephone Number
❑ Commercial ❑ School
440 gpd
gpd
Timothy Maginnis RS
Westhampton
City/Town
❑ PE ® RS
MA 01027
State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
Z Reduction in setback(s)—specify:
a. Applicant requests a 3 foot separation to the estimated seasonal hl�h water
❑ Reduction in SAS area of up to 25%:
Leeds-414 Chesterfield Rd:Local Up-grade Approval-Form 9b•rev.
7/06
N/A
SAS size,sq.ft.
%reduction
Local Upgrade Approval• Page 1 of 2
Commonwealth of Massachusetts
City/Town of Leeds
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
3
ft.
7.33
min./inch
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well (explain):
N/A
❑ 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 not requiring DEP approval per 310 CMR 15412(4):
N/A
List variances granted requiring DEP approval:
N/A
Approving Authority �� ,,�
000 G " .Txrc �,i� KVLU, fr7zNNL
Print or Type Name and Tale ignature ' `� Date f
WEAytt fNSpFc/zu-
Leeds-414 Chesterfield Rd.-Local Up-grade Approval-Form 9b•rev.
7/06
Local Upgrade Approval Page 2 of 2
flis
Important:When
filling out forms on
the computer,use
only the tab key to
move your cursor-
do not use the
return key.
Commonwealth of Massachusetts
City/Town of Northampton
Certificate of Compliance
Form 3
NORTHAMPTON BOARD OF HEALTH
212 MAN STREET
NORTHAivIPK: . :diA 01060
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 the local Board of
Health to determine the form they use
This is to Certify that the following work on an On-Site Sewage Disposal System
❑ Construction of a new system
❑ Repair or replacement of an existing system
❑ Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
f0/o7
DSCP Number DSCP Date
Fw Ik s#c,y /l e/v%)/J"//j J
Facility ee
/q oreCAZ,C J R, /
Street ddressr}ot#
°e }5 Stn Tin Cnde
Designer Information:
RJe%
ame
!, TJame of Company
Signature
Installer Information:
Date
—,405Th/%/ 5/1/1.) —.0/E1 ON jei Name of Company
Name
Signature
Date
Use of this system is conditioned on compliance with the provisions set forth below:
t5form3.doc-06/03 Certificate of Compliance• Page 1 of 2
Commonwealth of Massachusetts
City/Town of Northampton
Certificate of Compliance
L Form 3
The issuance of this certificate shall not be construed as a guarantee that the system will function as
teed" 5,✓�, /2„/„Lan. „,� P�/M
a
Approving Authority
Signal
t5form3 do •06/03
7//7
:a
DAte
Certificate of Compliance Page 2 of 2
Lc�.'tet 6j 71enth c4tatot, ?&1acte udett4
212ltA& S6teet
Znacuitfrag, 111,4 01060
Tel. 413-517-1214
?ax 415-517-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE SYSTEM DESIGNER
DESIGNER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Designer of a system is required to sign
this form as a condition for issuance of a Board of Health Certificate of Compliance for the onsite septic
system.
This is to certify that the onsite sewage disposal system that I designed as: new construction
X Repair
at 414 Chesterfield Road—Leeds, MA. on, July 12, 2012 DWCP number
(Address) (Date)
has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the
original approved plans have been reflected on an as-built plan that has been submitted to the Board of Health.
Timothy E. Maginnis R.S 70 Montague Rd. — Westhampton MA.
(Print Designer's name) (Address)
Jul 17 2012
(Date)
NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system.Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the time of plan submittal.
Vent pipeee��� Utility Pole
(imitation boulder
L500 gallon Pumpout man-hole ('C') n ��`�°�4 �E/T /
U F/T
septic tank • • --8.5' r/
(2 compartment) v� 4' • • I.. • •- ,D— a E/ o°I
O
. h
.\\4, Distribution box ('D') 4.
.. _ �'3' Pvc solid PIPe -E/ +l11 .h - . ^I /�
i 'A' p/T/ 'r, _ ..p Overhead utilities
`ice; E/ - 'z I1tl
f N _ T
m -C
Existing v
4 bedroom Si ..� I.., Q
house Title-5 sand o _ "
•---III g -
16..^ Q
CO
� lI _ N
. .111,17-
F•11 q
. 0 "ft.- I
W
en J
/ ,
fence
Existing well 2 Infiltrator Trenches I
with 14 Infiltrators ct
per Trench Cv
Dye
/
As—built dimensions -J
II >y
"A" to "C" = 18,_6•• "B" to "C" = 26'-D' Q.
10 W
AS—BUILT PALN /,
Subsurface sewage disposal system ,a 611
414 Chesterfield Road 4 'gym I
Leeds, MA. 01053 v V
"E" to "F" = 62'_9• "E" to "G = 72•_3" July 17. 2012 /
e4 06 ?kith Son, ltL 62eh 4ett4
212 ?16aiva Skeet
ZvettinntAtaa, 7164 01060
lee. 413-517-1214
?ax 413-517-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE SYSTEM INSTALLER
INSTALLER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage, Section 15.021 (3),the Installer of a system is required to sign
this form as a condition for issuance of a Board of Health Certificate of Compliance for the onsite septic
system.
This is to certify that the onsite sewage disposal system that I installed as: _ new construction
X repair
414 Chesterfield Rd. Leeds MA. on July 17 2012 DWCPnumber
(Address) (Date)
has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the original
approved plans have been reflected on an as-built plan that has been submitted to the Board of Health.
James Dimos
Fair Street Extension —Northamptom, MA. 01060
(Print Installer's name) (Street,City,and Zip Code)
July 17 2012
(Date)
NOTE:This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system.Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the time of plan submittal.
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont.)
2. Construction Inspection
a) Building Sewer(310 CMR 15.222) Approved N/A Problem
All waste pipes tied into building sewer Basement check ❑ ❑
Schedule 40 PVC 4" or cast iron Verify by reading pipe ❑ ❑ ❑
Minimum slope of 0.01-0.02 Visual ❑ ❑ ❑
Pipe laid in continuous straight line Visual ❑ ❑ ❑
Pipe laid on compact, firm base Visual ❑ ❑ ❑
Cleancuts precede all changes in Verify by visual/tape ❑ ❑ ❑
alignment/grade
Cleancut provided every 100 ft. Verify by visual/tape ❑ ❑ ❑
Backfill material clean Visual ❑ ❑ ❑
b) Septic Tank (310 CMR 15.223) Approved N/A Problem
Tank is set level with 6" stone under Check with level Q ❑ ❑
(15.228)
Tank is required size/loading per plan Verify with plan Q• ❑ ❑
Inlet and outlet are at proper location Verify with plan Ly ❑ ❑
(15.227)
Tank is water tight(15.226) Test ❑ ❑ ❑
Outlet tees extend 6" above flow line Verify by visual/tape ❑ ❑ ❑
Approved filter device placed at outlet DEP list —❑ ❑ CI
baffle installed at outlet tee Visual Ly j ❑ ❑
Inlet and outlet tees on center line Visual 17
Tank is backfilled with acceptable material Visual uN ❑ ❑
Notes
sepsyscl•date Form Name•Page 2 of 6
Commonwealth of Massachusetts
Important:When
filling out forms
on the computer,
use only the tab
key to move your Address
cursor-do not
use the return
key.
City/Town of
Septic System Installation Checklist
DEP has provided this form for use by local Boards of Health if they wish to do so.
A. Applicant Information
f/Je cy Nc 'O i
4/P/ CAeSkr-7P.t/] a7
2eeJs /14.
Name
sepsyscl•date
City State
Zip Code
Disposal System Construction P rmit#
C Ca.rick../
if j
Installer
U
Designer �� JJ
Board of ahh Representative
Inspection Dates:
Tank:
Map
Lot
—777/2.
Date
Final: Date Other:
Leach Area:
Date
Date
B. Application Checklist
1. Pre-Construction Conference Approved N/A Problem
Sieve analysis supplied for sand ❑ ❑ ❑
Current approved plans (3 copies) ❑ ❑ ❑
System staked prior to construction ❑ ❑ ❑
On-site check for tank water-tightness ❑ ❑ ❑
Abandonment of existing system (repairs) ❑ ❑ ❑
Plan revision(s) ❑ ❑ ❑
Conditions/Approvals ❑ ❑ ❑
O/M Plan on file ❑ ❑ ❑
DEP approval on file ❑ ❑ ❑
Form Name•Page 1 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont.)
e) Leaching Facility(310 CMR 15.240)
No frozen material used including back fill Visual
No clay, tailings or stones larger than 6"for
cover material
Soil at bottom/sides of excavation matches
info on deep holes
All impervious layers removed Visual
No remaining NB horizons Visual
Groundwater conditions match plan and
deep holes
Vented if under impervious cover per plan
(15.241)
Vent is protected from precipitation
and animal entry
Visual/check plan
Cover of a minimum of 9"over leach area
Pipe slope equal to 0.005 Check w/transit
Leach area per design (15 241)
Excavation is level and at required depth
Removal of 5 ft material and replacement
(if in fill)
Back fill material is acceptable
Final contours correct per plan
Surface/subsurface drainage away from
leach area
Final grade and side slopes are stable
Distribution lines are capped, vented, or
connected together
Impermeable barrier(15.255[2])
Retaining wall inspected by PE
Retaining wall is water-proofed
Retaining wall/barrier is at correct
depth/height
Visual/check plan
Visual/check plan
Visual
Check with plan
sepsyscl•date Form Name•Page 4 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont.)
c) Distribution Box (310 CMR 15.232)
Approved N/A Problem
All outlet pipes at same elevation Check by adding water ❑ El
Number of outlets - p lan Number of laterals
per p per plan
Inlet tee min. 1" over outlet Visual and w/tape
D box set on level base Visual
Top of D box 36 max depth Visual and w/tape
D box is water-tight Add water
D box has a minimum of 2"thick wall and
12" inside dimension
d) Pump Chamber(310 CMR 15 231) Approved N//A// Problem
Tank is set level Visual and w/level ❑ El
Proper volume is provided Check plan and tank ❑ ❑ El
Float elevations set per plan Measure w/tape ❑ ❑ El
Min. 2" delivery line to D box Visual ❑ ❑ ❑
Number of pumps: ❑ ❑ ❑
Specified pump provided or designers ❑ ❑ ❑
approval for equal pump
Correct pump sequence ❑ ❑ ❑
Covers iset to grade ❑ ❑ ❑
Electrical permit provided ❑ ❑ ❑
6" of stone beneath chamber Visual ❑ ❑ ❑
Chamber is water-tight Test El ❑ ❑
Min. 9"cover provided Visual ❑ ❑ ❑
Correct loading provided per plan Visual on tank ❑ ❑ ❑
Notes:
sepsyscl•date Form Name•Page 3 of 6
sepsyscl•date
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont.)
Certificate of Compliance (310 CMR 15.021)
As Built Plan Submitted
Signed by Installer
Signed by Designer
Certificate of Compliance Issued
Notes:
Date
Date
Date
Date
Form Name•Page 6 of 6
sepsysd•date
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont.)
f) Leaching trenches (310 CMR 15.251) Approved N/A Problem
Number of trenches: ❑ ❑ ❑
Depth of trenches: r-- E ❑
Width of trenches: [15 —#E❑ ❑
Trench spacing per plan ❑ ❑ ❑
Stone is double-washed [3/4" to 11/2") (15.247) ❑ ❑ ❑
g) Leaching fields (310 CMR 15.242)
Length of field: ❑ ❑ ❑
Width of field: ❑ ❑ ❑
Min. of 2 distribution lines ❑ ❑ ❑
Separation distance conforms to plan ❑ ❑ ❑
Stone is double-washed [3/4" to 1W] (15.247) ❑ ❑ ❑
h) Leaching Pits (310 CMR 15.253)
Number of pits: ------ - - - - ❑ ❑ ❑
Depth of pits: ❑ ❑ ❑
Stone is double-washed [3/4" to 1%"] (15.247) ❑ ❑ ❑
Each pit has min. 1 20" access cover ❑ ❑ ❑
Piping network and configuration of ❑ ❑ ❑
pits/chambers per plan
i) Tight Tank (310 CMR 15.260)
Tank is set level with 6" stone under Visual and with level ❑ ❑ ❑
Tank is proper size per plan Visual with plan ❑ ❑ ❑
Pumping contract has been provided ❑ ❑ ❑
Covers to grade Visual ❑ ❑ ❑
AN alarm set at 3/5 tank capacity Check floats by raising ❑ ❑ ❑
AN alarm test on separate circuit Set off alarm ❑ ❑ ❑
Form Name•Page 5 of 6