160 Septic Application & Permits 1999 No. 5 7 /
THE COMMONWEALTH OF MASSACHUSETTS
NORTHAMPTON ,MASSACHUSETTS
FEE 43
Application for Disposal System Construction Permit
Application is hereby made for a Permit to Construct(X)or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot.No.
Owner's Name,Address and Tel.No
Mr.John Skibiski
160 Coles Meadow Road
P.O.Box 381
Northampton,MA 01060
Northampton,MA 01060
(413)584-3428
Designer's Name,Address and Tel.No.413-584-7444
Almer Huntley,Jr.&Associates
Kos
30 Industrial Drive East
Northampton,MA 01061
Type of Building: /
Dwelling No.of Bedrooms
Other Type of Building
Other Fixtures
Design Flow 330 gallons per day.
3
Garbage Grinder(X)NO
No.of Persons
Showers( ) Cafeteria( )
Calculated daily flow
3 55
gallons.
Plan Date 10\30\98 Number of sheets 3 Revision Date
Title Plan of Proposed Sewage Disposal System
Description of Soil See Deep Observation Hole Logs—Sheet 3 of 3
Nature of Repairs or Alterations(Answer when applicable) Construction of a 12'x40'(480 SF)Leachfield to be connected to a proposed
1500 gallon septic tank which is to be connected to the existing house.
Date last inspected: 10\08\98
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescrihed 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 Compliance
has been issued by i Board dj{ieal tys / 4 (y
Signed 111 J/ X.� D yt+ Date /l- IFf-9r
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
at
THE COMMO! EALTH OF MASSACHUSETTS
d//\ ,MASSACHUSETTS
Certificate of Compliance
HIS IS TO CERTIF -atthea
Jai
• r S
/lc 'nv riff"; MIng
Sewage Disposal System install
cordonewjlh,j¢Aisyw of Title 5 and
epa
4)
ac
(41 Nov'3v
has been constructed
Disposal System Construction Permit No. dated
Use of systnn is conditioned on compliance with the provisions set forth below.
expires on
DATE
The issuance of this
s I not be construed as a guarantee that the system will function as designed. This Certificate
G°`t-` 5- /7C,
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
No. S3 � ,MASSACHUSETTS FE
Disposal��S::y//st� m� /Co�nsttrrruction Permit
Permission is hereby anted to 'ZJd/W( (�/a-t^i^'—""^�-
to construct( )or repair(peg -site Sewage System_/4 ti s_afXVe kr a t :1 u •• 7 /rte.
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes that his/her duty to comply with
Title 5 and the following local provisions or special conditions.
All construction must be completed within tthhreeyeyears of the date below.
DATE t9�/" /r /9 Y Approved by
F..\cnoerneoxeeoczcrs sae-nasnrs ecous.doc FORM 1255
rocs:Limp- .: A»PRO AL I9SU1D PURSUANT TO 310 cm 15,104_ S 14.445
Facility/aystem owner
Name:
JOHN SKIBISKI
Address:
P.O. BOX 381, NORTHAMPTON, MA 01060
Address of facility 160 COLE'S MEADOW ROAD, NORTHAMPTON MA 01060
Type of facility
residential X institutional _ commercial _ School
design flow per 310 CMR 15.203 gpd
System designer
ALMER HUNTLEV, JR. & ASSO 30 INDUSTRIAL DRIVE E. NORTHAMPTON, MA 01060
Name Address
Phone. d 413 584 7444
Local Upgrade Approval granted for
reduction in setbaCk(e) (specify)
X
Wert rate of 30-60 min./inch
(apecify rate)
reduction in SAS area of up to 25t
(specify F reduction a size of SAS,
reduction in separation between
SAS a high groundwater
(specify reduction a pert rate)
relocation of a well (explain)
FROM 5' to 4' SEPARATION
PERC RATE LESS THAN 2 MIN/IN
List local variances granted (no DEP approval required per 310 CMR 15.412 (4) )
LSst variances granted requiring DE? approval
Board o alth sousl o proposed upgrade
gnature
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A CO?Y OF THIS LOCAL UPGRADE APPROVAL
TO TEE APPROPRIATE REGIONAL OrYICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING
AUTHORITY & BEFORE COMMENCEMENT OP CONSTRUCTION.
Application for Local UPCrade Approval
Title 5 , 310 CMR 15 . 000
DEP Approved form required by 310 CMR 15 .403 (1)
To be submitted to Local ADOrovina_Aushoricv/8nard_of Hea1t : For
the upgrade of a failed or nonconforming system with a design flow
of <10 , 000 gpd, where full compliance, as defined in 310 CMR
15 . 404 (1) , is not seasible .
To be submitted to DEP: For the upgrade of a failed or
nonconforming system with a design flow of 10 , 000 to up to 15, 000
gpd and/or for upgrade of a state or federal facility, where full
compliance, as defined in 310 CMR 15 . 404 (1) , is noc feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade
proposal that includes the addition of new design flow to a
cesspool or privy or the addition of new design flow above the
existing approved capacity of a system constructed in accordance
with either the 1978 Code or 310 CMR 15 . 000 .
1) Facility/system owner
Name JOHN SKIDISKI
Address P.O. sax 381
Phone # 413 584 3428
NORTHAMPTON, MA 01060
Address of facility- "1o0 CDLE`s MEADOW ROAD
NORTHAMPTON, MA 01060
2) Applicant (if different from above)
Name
Address
Phone #
3) Type of facility
x residential commercial _ school
institutional
(Specify)
Tyne of existing system
Privy cesspool (s) conventional system
x Other(describe) SEPTIC TANK AND OUTLET WITH Nn APPARENT SAS
4Y
Type o
soil absorption system (trenches, chambers, pits, etc . )
NONE
5) Design flow based
a) Design flow of
Approved?
b) Design flow of
c) Design flow of
on 310 CMR 15 .203 design flows
existing system gpd UNKNOWN
no yea approval date UNKNOWN
proposed upgraded system 330 gpd
facility 330 god
2
Proposed upgrade of existing system is
a) X Voluntary
Required by order, letter, etc . (attach copy)
Required following inspection required by 310
CMR 15 . 301 (provide date inspection form was submitted to
the approving authority) (date)
b) Describe the proposed upgrade to the system
CONSTRUCTION OF A 12' x 40' (480 SF) LEACHFIELD TO BE CONNECTED TO THE EXISTING
HOUSE VIA A PROPOSED 1500 GALLON SEPTIC TANK.
c) Which of the following are applicable to the proposed
upgrade?
_ Reduction of setback(s) (list setbacks to be
reduced with proposed setback distances)
Percolation rate of 30-60 minutes per inch (state
actual pert zaLe)
Up to 25% reduction in subsurface disposal area design
requirements (state required & proposed size)
Relocation of water supply well (identify well, describe
relocation)
Reduction of required separation between bottom of SAS &
high sgroundE Rater E (specify pro used reduction & pert rate)
Other requirements of 310 CAR 15 . 000 that cannot be
met (specify sections of the Code)
System upgrades that cannot be
310 CMR 15 .404 & 15 . 405 , or
requirements of 310 CMR 15 . 000,
310 CMR 15 . 410-15 . 417 .
performed in accordance with
in full compliance with the
require a variance pursuant to
3
7) 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 ground water elevation pursuant to 310
CMR 15 .405 (1) (i) (1) . The evaluator must be a member or agent
of the local approving authority:
Distance from soil absorption system to high groundwater
feet
As determined by
Evaluator' s name
Evaluator' s signature
Date of evaluation
8) Notice to Abutters
No application for upgrade approval shall be complete
until the applicant has notified all abutters by
certified mail at least ten days before the Board of
Health meeting at which the upgrade approval will be on
the agenda pursuant to 310 CMR 15 . 403 (1) and 15 .405 (2) .
Such notice shall include the date, time and place where
the application will be discussed.
If the Department is the approving authority, then such
notice to abutters must be completed prior to the date of
submission of the application to the Department .
All notices to abutters shall include a copy of the
completed application form and for applications involving
the reduction of a setback from a property line or a
private water supply well shall reference the standards
set forth in 310 CMR 15 . 402 through 15 . 405 .
List of Abutters to facility with proposed upgrade :
Abutter Name Date notified`
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Abutter Name Date notified
Address
9) Explain why full compliance, as defined in 310 CMR 15 .404 (1) ,
is not feasible (each section must be completed) :
a) an upgraded system in full compliance with 310 CMR 15 . 000
is not feasible :
4
b) an alternative system approved pursuant to 310 CMR
15 . 283-15 . 288 is not feasible :
AN ALTERNATIVE SYSTEM IS NOT FEASIBLE FOR THIS SITE DUE TO THE TYPES OF CONSTRAINTS
c) a shared system is no: feasible :
RESIDENTIAL LOT - SHARED SYSTEM NOT FEASIBLE
d) connection to a sewer is not feasible :
NO EXISTING SEWER SYSTEM.
10 ) An application for a disposal system construction permit,
including all required attachments (e .g. plans &
specifications, site evaluation forms) , must accompany this
application. Is the DSCP application attached? yes no
11) 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 knowing
violations . "
(Facility owner' s signature
Nlatih r 5416, h,
/0-30-9Y
Date
Print Name
Name of preparer Date
Telephone # & address of preparer
NOTE: Title 5 , 310 CMR 15 .403 (4) , requires the system owner or
operator to submit to the Depar,.ment a copy of the local upgrade
approval upon issuance by the Board of Health and prior to
commencement of construction .
FORM 3A - CERTIFICATE OF COMPLIANCE
G
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Northampton
, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Contp'onent(s) M Complete System
The undersigned hereby certify that the Sewage Disposal System;
Constructed O, Repaired N, Upgraded O, Abandoned ( )
by: John Skibiski
at: 160 Coles Meadow Road'
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the
approved design rplans/asbuilt plans relating to application No. 63—Fc(
dated ////,y/fr" Approved Design Flow 330 (gpd)
Installer Karl's Excavating
Designer: Huntley Associates Inspector
Date January 7 1999
The issuance of this permit shall not be construed as a guarantee that the system will
function as designed.
DEP APPROVED FORM 5/%
ZA'd LK:6 6661 6E PO
6711-78L-£Iv:xed 610I93d N231S39 d3S
HUNTLEY
ALMER HUNTLEY,JR. &ASSOCIATES,INC.
SURVEYORS •ENGINEERS •LANDSCAPE ARCHITECTS
January 7, 1999
Northampton Board of Health
210 Main Street
Northampton,MA 01060
RE- Installation of Me Repair System, 160 Coles Meadow Road
Huntley No. 98-236
Dear Board of Health:
Based on the inspections performed by our office during the installation of the repair system for John
Skibiski at 160 Coles Meadow Road,Northampton,MA. The system appears to have been constructed
conforming to the Title V, Sanitary Code requirements.
We have enclosed the Certificate of Compliance and request that the Board issue their certificate. Thank
you for your attention to this matter. Please find enclosed one(I)copy of the record plans and the
certificate. Should you have any questions please do not hesitate to contact our office.
Very truly yours,
ALMER HUNTLEY,JR.&ASSOCIATES,INC.
Rebecca Sherer,P.E.
Project Manager
RLS: cjm
cc: John Skibiski
Enclosure
Huntley\projinfo\projects\98-236\TtheV
(800)227-7723 •(413)584-7444 •FAX(413)586-9159 O 30 INDUSIR41L DRIVE Easy •P.O.Box 568 NORTHAMPTON,MA 01061