1031 Septic Inspection 2014 Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Form 9A — Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health_ Other loans 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)
T Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility:
B. Proposed Upgrade of System
t. Proposed upgrade is(check one):
0
unknown
°Pd
571
gad
550
gpd
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 entire system per approved design
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%: SAS size.sq.ft.
f
t5form9a•rev.7/06
Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate
Depth to groundwater
from 4'to 3'
fl.
7
min
3
R.
date of inspection
%reduction
Application for Local Upgrade Approval* Page 2 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
Ron sT
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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 for 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
1. Facility Name and Address'.
Lorraine Clapp-O'Keefe
Name
1031 Chesterfield Road
Street Address
Florence
Ciry:Town
2. Owner Name and Address (if different from above)
Name
City/Town
Zip Code
3. Type of Facility (check all that apply):
Residential ❑ Institutional
4. Describe Facility:
single family dwelling
MA
State
Street Address
State
413-586-7581
Telephone Number
❑ Commercial ❑ School
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ❑ Conventional
unknown
01062
Zip Code
❑ Other(describe below)
6. Type of soil absorption system(trenches, chambers, leach field, pas, etc):
unknown
t5forrn9a•rev. 7/0a
Application for Local Upgrade Approval• Paget of 4
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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:
none available
4. Connection to a public sewer is not feasible
none available
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
O Application for Disposal System Construction Permit
E 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."
tsform9a•rev.7/06
dtetcdtete raalay owners sgea e Dare
Lorraire_ X C�iartt r Keiek
Print Name
Hililown Environmental
Name of Preparer
Date
P. O. Box 314 Chesterfield
Preparer's address City/Town
MA 01012 (413)296-4499
State/ZIP Code Telephone
Application for Local Upgrade Approval* Page 4 of 4
N
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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 pert test
❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREEP-------
NORTi1AMPTON, MA 01060
If the proposed upgrade invo yes 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 15405(1)(h)(1)- The soil evaluator must be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Daniel Wasiuk 5/21/2014
EvaluatorsName(type orprint) 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:
additional 611 required would be difficult to contain with property boundaries
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
expensive 0&M agreements would create financial hardship
t5form9a•rev. 7/06
Application for Local Upgrade Approval( Page 3 of 4
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
from 4'to 3'
Separation reduction fl
Percolation rate
Depth to groundwater
❑ Relocation of water supply well (explain):
7
3
finch
❑ 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 pert test
List local variances granted not requiring DEP approval per 310 CMR 15412(4):
List variances granted requiring DEP approval:
/' ✓� �N 444-4 p?,
4 ,
gAyth ity L /
&arid W66f✓L
Print or Type Name and Title
Date/ #2,3'/V�
Sign
t5form9b•rev.7/06 Local Upgrade Approval Page 2 of 2
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
■ Local Upgrade Approval
J Form 9B
DEP has provided this form for use by local 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
Important:
When filling out 1. Facility Name and Address
forms on the
computer,use Lorraine Clapp-O'Keefe
only the tab key Name
to move your 1031 Chesterfield Road
cursor-do not Street Address
use the return
key. Florence
CiryTown
a H
15form9b•rev.7z06
2. Owner Name and Address (if different from above):
Name...—._
City?own
Zip Code
3 Type of Facility (check all that apply):
Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15203: 550
gpd
Hilltown Environmental
Name
MA
State
Street Address
State
413-586-7581
Telephone Number
5 System Designer:
01062
Zip Code
❑ PE 0 RS
P. O. Box 314 Chesterfield MA 01012
Address CilyTourn 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,sp.ft. %reduction
Local Upgrade Approval* Page 1 of 2
wyriN
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form IA
Number
$
Fee
A. Facility Information (continued)
5. Type of Building:
Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
Number of showers
Number of Sheets
Sewage Disposal System Upgrade
Title of Plan
8. Description of Soil:
SEE FORM 11
9. Nature of Repairs or Alterations (if applicable):
Replace entire system per approved design
10_ Date last inspected:
❑ Garbage Grinder(check if present)
❑ Cafeteria
571
Gallons per Day
550
Gallons
June 18, 2014
Date of Original
Revision Date
Date
Number of Persons Served
❑ Other fixtures
t5formla doc•06/03 Application for Disposal System Construction Permit Page 2 of 3
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form 1A
Numr4gy-
Number
$ Pa)
Fee C
DEP has provided this form for use by local Boards of Health if they choose to do so
the form, check with your local Board of Health to make sure that they will accept it
A. Facility Information
Important:
When tilling out Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system
forms on the ® Repair or replace an existing on-site sewage disposal system
computer,use El
only the tab key Repair or replace an existing system component
to move your
cursor-do not 1. Location of Facility:
use the return
key 1031 Chesterfield Road
nth
Address or Lot#
Northampton
CitylTown
♦ I
2_ Owner Information
MA 01060
State Zip Code
Lorraine Clapp-O'Keefe
Name
1031 Chesterfield Road
Address(if different from above)
Florence MA 01062
cifyrrorn State Zip Code
413-586-7581
Telephone Number
3 Installer Information
Cliff Clark
Name
P_ o_ Box 224
Address
Williamsburg_
dey/Town
4. Designer Information
MARK THOMPSON
Name
P. O. BOX 314
Address
CHESTERFIELD
City/Town
t5tonnla doc•06/03
Clark's Excavating
Name of Company
MA
State
413-268-7968
Telephone Number
01096
Zip Code
HILLTOWN ENVIRONMENTAL
Name of Company
MA 01012
State Zip Code
(413) 296-4499
Telephone Number
Application for Disposal System Construction Permit-Page 1 of 3
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Application for Disposal System
Construction Permit
Form IA
,70/V 6
N umber
Fee Pi
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site
sewage disposal system in accordance with the provisions of Tine 5 of the Environmental Code and
not to place the system in operation until a Certificate of Compliance has been issued by this Board
of Healt_h - � '' �/ �'"�
N�CA�uZ (��uxky_ Cv/d3/lq
Signature 0 bate
Application Approved By:
Name � )
4/44.,e/ Was.rK
Application Disapproved for the following reasons:
Date
t5forml a doe 06/03 Application for Disposal System Construction Permit Page 3 of 3
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
Disposal System Construction Permit
Form 2A
Number
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 for they use.
Permission is hereby granted to:
Cliff Clark
Name
P. O. Box 224
Address
Williamsburg
cityfown
Clark's Excavating
Name of Company
MA
State
to perform the following work on an on-site sewage disposal system:
❑ Construction
® Repair or replacement
❑ Repair or replacement of system components
1031 Chesterfield Road
Facility Address
Northampton
City/Town
01098
Zip Code
MA
State
Lorraine Clapp-O'Keefe 413-586-7581
Owner Telephone Number
01060
24p Code
The work to be performed is further described in the Application for Disposal System Construction
Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions
or special conditions:
g 01,7
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON, MA 01060
All construction must/be completed within three years o the ate below.
2,L/h/2S, 6 /
Ap oved b �' Date
tle
t5form2a.doc•06/03 Disposal System Construction Permit•Page 1 of 1
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
DEP has provided this form for use by local Boards of Health. Other fors 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):
110/3/41 gni
DSCP Number DSCP Date
Lorraine Clapp-O'Keefe
Facility Owner
1031 Chesterfield Road
Street Address or Lot#
Florence
City/Town
Designer Information:
Mark Thompson 7 Signe
lusthller Information:
MA
State
Hilhown Environmental
Name of Comp
7 Z3 any
Da
01062
Zip Code
Cliff Clark Clark's Excavating
Na Name of Company
Signal Date
7/21/ '!
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designee ' e L v/ / �f
Approving Authority I /,Us/ �/
Sig r_ifSlGj'(/NJ/c)
t5form3 doc•06/03 Certificate of Compliance•Page 1 of 1
/03/ (Xes4JeJ icf
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont.)
2 Construction Inspection
a) Building Sewer(310 CMR 15 222)
All waste pipes led 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 one Visual
Pipe laid on compact, firm base Visual
Cleanouts precede all changes in Verify by visualftape P7 ❑
align menVgrade
Cleanout provided every 100 ft Verify by visual/tape Li{/ ❑
(/
Backfill material clean Visual y' ❑ Li
7/9-3/Li
72
Approved N/A Problem
L s Li
❑
J
T
J
b) Septic Tank(310 CMR 15.223) '7 WA Problem
Tank is set level with 6'stone under Check with level ❑ D
(15.226)
Tank is required size/loading per plan Verify with plan
Inlet and outlet are at proper location ,,-/ ri --r
(15227) Verify with plan / �. l-]
Tank is water tight(15226) Test it El
Outlet tees extend 6' above flow line Verify by visuaUtape �e/ ❑ ❑
ILW
Approved filter device paced at outlet DEP list S S
Gas baffle installed at outlet tee Visual F, ❑ ❑
Inlet and outlet tees on center lire Visual WJ ❑ ❑
P....-.
❑ ❑
Tank is bad sled with acceptable material Visual
Notes.
Septic System InstallaMon CrroklNt t 1-09.eoc•Este
Form Name•Pipe 2 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist(cont.)
c) Distribution Box (310 CMR 15.232) Approve WA Problem
All outlet pipes at same elevation Check by adding water ❑
Number of outlets ----- Number of laterals Per Wen--- -----
Pa Pttm Inlet tee min. 1' over oat Visual and w/tape ❑+- J ❑
D box set on level base Visual r7-7
Top of D box 36' max depth Visual and w/;ape ,__ "
D box is water-tight Add water l,� _
D box has a minimum of T thick wall and --1
12'inside dimension
d) Pump Chamber(310 CMR 15 231)
Approved N/A Problem
Tank is set level Visual and w/level ❑ ❑
Proper volume is provided Check plan and tank ❑
Float elevations set per plan Measure wttape ❑ U ❑
Min. 2'delivery line to D box Visual ❑ ❑ ❑
Number of pumps: - ... - - ❑ ❑ ❑
Specified pump provided or designers ❑ ❑ ;_J
approval for equal pump
Correct pump sequence ❑ ❑ ❑
Covers set to grade ❑ ❑ L]
electrical permit provided ❑ ❑ ❑
6'of stone beneath chamber Visual ❑ ❑ El
Chamber is water-light Test ❑ ❑ ❑
Min. 9' cover provided Visual ❑ ❑ ❑
Correct loading provided per plan Visual on tank ❑ [' 1
Notes
Septic System II-Y6tlon Checklist 1I-OS doc•date Form Nome.Pepe 3 of e
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist(cont)
at Leaching Facility (310 CMR 15.240)
No frozen material used including back fill Vlsua.
No Gay, tailings or stones larger than 6' far
cover material
Soil at bottom/sides of excavation matches
info on deep holes
All impervious ayers removed Visual
No remaining NB horizons Visual
Groundwater conditions match plan and
Visual/check plan
deep holes
Vented if under impervious cover per plan
(15.241)
Vent is protected from precipitation
and animal entry
Cover of a minimum of 9'over leach area
Approved WA Problem
W'�
(7
u
Pipe slope equal to 0 005 Check w/transit �,�� ❑ ❑
Leach area per design(15.241) rD� ❑ ❑
Excavation is level and at required depth Visual/check plan ❑
Removal of 5 ft material and replacement Vlsuajcheclk plan i� '.�_J �,❑
(if in fill) WV-
Back
fill material is acceptable Visual ❑ _J
Final contours correct per plan Check with plan `I ❑
Surface/subsurface drainage away from �. ❑
• teach area
Fins grade and side slopes are stable (y' ❑ ❑
Distribution lines are capped, vented, or ! / ❑ ❑
connected together L-Y/
Irrlpemleable bamer(15.255(2)) LAS ❑ ❑
Retaining wall inspected by PE ❑ ❑ ❑
Retaining wall is water-proofed ❑ ❑ ❑
Retaining waWbarrier is at correct ❑ ❑
depth/height
Wee System Instele9un Ch.c&Mt 11-09 dm•date Form Neme•Pepe 4 of e
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont)
f) Leaching trenches (310 CMR 15 251; Approved Problem
Number of trenches - --- - — — / 7
Depth of trenches Y 7 Piet [3K ❑ ❑
Width of trenches. -_ -.. . .._- _. . =!t" ❑
Trench spa^ng per Dian ,L/ : J
Stone is double-washed 1314"to 1X`1;'5.24?) '4/
9) Leaching fields (310 CMR 15.242) �,
Length of field _ _ __.___ E4 ❑ L!
V.Stlth of field. -__ _______.__ . S ❑
Min. of 2 distribution lines ❑ ❑
Separation distance conforms to plan .IV ❑ ❑!
Stone is double-washed(3/4'to 11S1 (15247) L� ❑ ❑
h) Loathing Pits(310 CMR 15.253)
Number of pits.
Depth of pits.
Stone is double-washed[3V'to 1 W I(15.247)
Each pit has min. 1 20"access cover
Piping network and configuration of
pits/chambers per plan
i) Tight Tank(310 CMR 15260)
Tank is set level with 6`stone under
Tank is proper size per plan
Pumping contract has been provided
Covers to grade
AN alarm set at 3/5 tank capacity
• AN alarm test on separate circuit
34/004 System Installation Checker I I-09.4oc•dote
Visual and with level
Visual with plan
Visual
Check floats by raising
Set off alarm
Fmn tame•Pape 5 of 6
Commonwealth of Massachusetts
City/fawn of
Septic System Installation Checklist
B. Application Checklist(cons)
Certificate of Compliance(310 CMR 15.021 i
As Built Plan Submitted
Signed by Installer
Signed by Designer
Certificate of Compliance Issued
Notes
Fbfer_"eJ
Dee
Date
Date
Date
Sp*Syetam Ine.Yepn CMckMt 11-09.6oc•date Form Nave-Page 6 o16