368 Septic Application 2013 Important:
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only the tab key
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Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
_aoNumber t3 -7
$ I50
DEP has provided this form for use by local Boards of Health if they choose to do so. Before using
the form, check with your local Board of Health to make sure that they will accept it.
A. Facility Information
Application is hereby made for a permit to:❑ Construct a new on-site sewage disposal system
❑ Repair or replace an existing on-site sewage disposal system
Repair or replace an existing system component
1. Location of Facility:
368 Chesterfield Road
00
Address or Lot#
Florence
City/Town
2. Owner Information
Mary Rice
Name
368 Chesterfield Road
Address(if different from above)
Florence
City/Town
3. Installer Information
Mark Lavalley
Name
Sylvester Road
MA.
State
01062
Zip Code
MA
State
(413)587-0963
01062
Zip Code
Telephone Number
Lavalley&Sons
Name of Company
Address
Florence
City/Town
MA
State
(413)695-4782
Telephone Number
4. Designer Information
Timothy E. Maginnis R.S., LSE
Name Name of Company
70 Montague Road
010622
Zip Code
Address
Westhampton
City/Town
MA.
State
1413) 527-5291
01027
Zip Code
Telephone Number
t5forla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3
•
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
_ ?1
Number
$ /57°
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
❑ Showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
❑ Garbage Grinder(check if present)
6
Number of showers
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
330
Gallons per Day
330
Gallons
7. Plan: June 3, 2013
Date of Original
2
Number of Sheets Revision Date
Plan of subsurface sewage disposal system-Presby Patented Sand Filter
Title of Plan
8. Description of Soil:
Sandy loam
9. Nature of Repairs or Alterations Of applicable):
Replace a failing soil absorption system. Install a new distribution box and a Presby Enviro-Septic
SAS. 6 lines @ 35'L each - 1 75'oc
10. Date last inspected:
April 10, 2013
Date
t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
aoi3-
Number
/50 Ca
Fee
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 Title 5 of the Environmental Code and
not to place the system in operation until a Certificate of ompliance has been issued by this Board
7Heal
Signature
t5forml a.doc•06/03
Application Approved By:
Name
G IS i3
Date
6/7/3
Date
Application Disapproved for the following reasons:
;ORTHAMPTON BOARD OF HEALTH
212 MAN STREET
� 0RTHAMPTOIN. MA 01060
Application for Disposal System Construction Permit•Page 3 of 3
361 O(etsi e4/ %
Commonwealth of Massachusetts 7////3 �
City/Town of
Septic System Installation Checklist
• B. Application Checklist(cont)
2 Construction Inspection
a) Building Sewer(310 CMR 15722) Approved- N/A Problem
All waste pipes tied into building sewer Basement check ❑ ❑
Schedule 40 PVC 4' or cast iron Verity 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 ❑ ❑ ❑
Cleanouts precede all changes in
alignment/grade Verify by visual/tape ❑ ❑ ❑
Cleanout provided every 100 ft. Verify by visual/tape ❑ ❑ ❑
Ball material dean Visual 01 ❑
.b) Septic Tank(310 CMR 15.223) 051- oil .i 4
Tank is set level with 6'stone under
(15 226) C heck with level ❑ ❑
Tank is required size/loading per plan Verify with plan ❑ ❑ ❑
not and outlet are at proper location
(15.227) Verify with plan ❑ ❑ ❑
Tart is water tight(15226) Test ❑ ❑ ❑
Outlet tees extend 6'above flow kne Verify by visuaL/tape ❑ ❑ ❑
Approved filter device placed at outlet DEP list ❑ ❑ ❑
Gas baffle installed at outlet tee Visual ❑ ❑ ❑
Inlet and outlet tees on center line Visual ❑ ❑ ❑
Tank is baddilled with acceptable material Visual ❑ ❑ ❑
Approved WA _ Problem
Netes: R : e // NCl/ IL PQ /N
/ : m 4d.
Septic System Installation CMOkMt 11-ee.tloc•date Form Name.Page 2 of 6
A
Commonwealth of Massachusetts
Cityrrown of
Septic System Installation Checklist
B. Application Checklist front.)
c) Distribution Box(310 CMR 15.232)
All outlet pipes at same elevation Check by adding water
Number of outlets -- ---.-- Number of laterals
Per Pion
Inlet tee min. 1'over outlet Visual and w/tape [."
D box set on level base Visual [V"
Approved N/A Problem
❑ ❑
❑ ❑
Top of D box 36'max depth Visual and w/tape ❑
D box is water-tight Add water 2' ❑ ❑
D box has a minimum of 2'thick wall and �. ❑ ❑
IF inside dimension
d) Pump Chamber(310 CMR 15.231) ti/hl Approved
Problem
Tank is set levet Visual and w/level ❑ ❑ ❑
Proper volume is provided Check plan and tank ❑ �" ❑
Float elevations set per plan Measure w/tape ❑ ❑ ❑
Min. 2' delivery line to D box Visual ❑ ❑ ❑
Number of pumps: ❑ ❑ ❑
Specified pump provided or designers
approval for equal pump ❑ ❑ ❑
Correct pump sequence ❑ ❑ ❑
Covers set to grade ❑ ❑ ❑
Electrical permit provided ❑ • ❑ ❑
6' of stone beneath chamber Visual El ❑ ❑
Chamber is water-tight Test ❑ ❑ ❑
Min. g must provided Visual ❑ ❑ ❑
Correct loading provided per plan Visual on tank ❑ ❑ ❑
Notes:
Sept System Installation GsclJisl 11-09.doc•date Form Name•Pepe 3 ale
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist(cont.)
e) Leaching Facility(310 CMR 15240)
Approved_ N/A Problem
No frozen material used including back fill Visual [� u ❑
No clay, tailings or stones larger than 6'for ,-✓
cover material ❑ ❑
Soil at bottom/sides of excavation matches
info on deep holes ❑ ❑
All impervious 'ayers removed Visual [k/ ❑ C
No remaining NB horizons Visual [,� ❑ ❑
Groundwater conditions match plan and
deep holes
Vented if under impervious cover per plan
(15241)
Vent is protected from precipitation
and animal entry
Cover of a minimum of 9'over each area
Visuat/check plan
Q. ❑ ❑
[1;— ❑ ❑
❑4 ❑ ❑
Pipe slope equal to 0.005 Check wltransit % ❑ ❑
Leach area per design(15241) CM ❑ ❑
Excavation is level and at required dep :. plan ' ❑ ❑
Removal
(din fill) of 5 ft material and replacement-• � ❑-- ❑ ❑
Back fill material is acceptable �• ❑ ❑
Final contours correct per plan heck with plan E ❑ ❑
31 s4_e Ek. ❑ ❑
ER- ❑ ❑
17549e9/_[r' ❑ ❑
Impermeable barrier(15.255[2]) hL /��Pr�� ❑ ❑
Retaining wall inspected by PE /470b/CM$ ❑ ❑ ❑
Retaining wall is water-proofed /''V - ❑ ❑ ❑
Retaining waIVbartier is at correct ydd C/Cs
depthmeight ❑ ❑ ❑
eck plan
Surface/subsurface drainage away from
leach area
Final grade and side slopes are stable
Distribution lines are capped, vented, or
connected together
Septic System Installation Checklist I I-09.4oc•date
Form flame•Page 4 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont.)
f) Leaching trenches(310 CMR 15.251)
Number of trenches:
Depth of trenches:
Width of trenches'
Trench spadng per plan
Stone is double-washed[3/4'to 1W] (15.247)
g) Leaching fields(310 CMR 15242)
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 13/41 to 1%1(15 247)
Each pit has min. 1 20'access cover
Piping network and chnfiguraticn of
pits/chambers per plan
i) Tight Tank(310 CMR 15.260)
Tank is set level with 6' stone under
Tank is proper size per plan
Pumping contract has been provided
Covers to grade
NV alarm set at 3/5 tar*capacity
AN alarm test on separate arcuit
Septic System IrmWlebon Checklist 11119.doc•WIe
Visual and with level
Visual with plan
Visual
Check floats by raising
Set off alarm
Approvecj,. N/A Problem
Form Name•Page 5 of 6
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist front)
j) Cartfioate of Compliance(310 CMR 15 021)
As Built Plan Submitted
Signed by Installer
Signed by Designer
Certdicate of Compliance Issued
Notes.
Dale
Date
Date
Data
Sepik System Installation Checklist 11-09 doc•date
Form Name•Pape 6 of 6
Florence-368 Chesterfield Road—Mary Rice-Presby system-July 2013.jpg - City of Northa... Page I of 1
anporten4
Wron AIWA out
forms on the
computer,use
only the tab key
to move your
cursor-eo not
use the return
key
Commonwealth of Massachusetts
City/Town of Norhtampton
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used, but t
information must be substantially the same as that provided here. Before using this form.oho
the local Board of Health to determine the form they use
This Is to Certify that the following worts 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(DSC
DSCP Number CSCP Date
Mary Rice
3aclllry owner
LA3sc Chesterfield Road
- Sheet Address or lot
TeLeatim Lee S
Designer Information.
Timothy E. Maginnis R.S.
Name
ire
Signature
MA
Slate
0Ios3
asesE
Zrp cone
Installer Information:
Michael J
re
Name of Company
July 12,2013
Dare
Execavting Etc.-Montague,MA.
Name of Company
July 12, 2013
Diu
Use of this system is conditioned on compliance with the provisions set forth below:
-This is an Alternative sewage disposal system. It is a Presby Patented Sand Filter. Thereto
deed Notice is required to be registered with the Hampshire County Registry of Deeds.
- No garbage disposal allowed
The issuance of this certificate shall not be construed s a guarantee that the system will funs
d pwaamo hni kkl/� D
Date
ao/3
Mips://mail-attachment.googleusercontent.corn/atC chmenCu,i01?ui=2&ik=6523edbe9e&vie... 7/12/2013
Commonwealth of Massachusetts
City/Town of Florence
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
,?D/3- 7
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 Rice
only the tab key Name
to move your 368 Chesterfield Road
cursor-do not Street Address
use the return
key.
Ma
Florence
City/Town
MA
State
01062
2. Owner Name and Address Of different from above):
Mary Rice 368 Chesterfield Road
Zip Code
Name Street Address
Florence MA
City/Town State
01062
Zip Code
584-0963
Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
Single family home-3 bedrooms-no garbage disposal
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
Z Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Presby Patented Sand Filter is proposed
FM-Local up-grade approval form-Farm 9a•rev.7/06
Application for Local Upgrade Approval*Page 1 of 4
Commonwealth of Massachusetts
City/Town of Florence
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:
330
gpd
330
gpd
330
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:
April 10, 2013
date of inspection
2. Describe the proposed upgrade to the system:
Replace a failing subsurface sewage disposal soil absorbtion system. Install a Presby Patented
Sand Filter with 6-35 lines at 1.75'OC
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.N.
0 Reduction in separation between the SAS and high groundwater:
Separation reduction 2
N.
Percolation rate 30 mph
min./inch
Depth to groundwater 0.5'
FM-Local up-grade approval form-Form 9a•rev. 7/06
A reduction
Application for Local Upgrade Approval Page 2 of 4
Commonwealth of Massachusetts
City/Town of Florence
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
❑ Use of only one deep hole in proposed disposal area
El 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 determin-d by:
Daniel Wasiuk April 10, 2013
Evaluators Name(type or print) Signatu 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 is a very small lot with two wells less than 200 feet from proposed SAS
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
A Presby Patented Sand Filter is proposed
FM-Local up-grade approval form-Form 9a•rev.7106
Application for Local Upgrade Approval Page 3 of 4
S \ Commonwealth of Massachusetts
City/Town of Florence
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:
Neighboring lots are too small and are all served byprivate water supplise.
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
Z Complete plans and specifications
® Site evaluation forms
Z 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).
Z Other(List):
Lab analysis for soil Class-Alternative perc test.
D. Certification
1, 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."
NILVLA� ✓
Facility Owners Sig ature Date
Print Name
Timothy E Maginnis R.S., LSE
Name of Preparer
70 Montague Road
Preparers address
Massachusetts-01027
State/ZIP Code
FM-Local up-grade approval form-Form 9a•rev.7/06
June 3, 2013
Date
Westhampton
City/Town
j413) 527-5291
Telephone
Application for Local Upgrade Approval• Page 4 of 4