235 Septic Upgrade Application 2004 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
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Board of Health, Northampton, MA
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.401(1)
To be submitted to Local Approving Authority/Board of Health 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 feasible.
To be submitted to DEP:For the upgrade of a failed or nonconforming system with a design
flow of 10,000 up to 15,000 gpd and/or of a state or federal facility, where full compliance, as
defined in 310 CMR 15.404(1), is not feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade 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: Steve Mongeon
Address- 235 Coles Meadow Rd.,
Northampton, MA 01060
Phone # 413 586-0254
Address of facility: 235 Coles Meadow Road,Northampton
2) Applicant (if different from above)
Name:
Address:
3) Type of facility
X Residential _ Commercial
School _ Institutional
_ Other (specify)
4) Type of existing system
privy _ cesspool
X conventional system
_ Other (specify)
Type of soil absorption system (trenches, chambers, pits, etc.)
leachfield
DEP APPROVED FORM 12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 of 5
5) Design flow based on 310 CMR 15.203
a) Design for of existing system unknpown gpd
Approved? no
Approval Date 2LP.r Is 15)c ` s P
If not,why? too old -11a + ;,O3cE( F;lei
b) Design flow of proposed upgraded system 330 gpd
c) Design flow of facility 330 gpd
6) Proposed upgrade of existing system is
_ Voluntary
_ Required by order,letter, etc. (attach copy)
X Required following inspection required by 310 CMR 15.301
date inspection was submitted to the approving authority:
b) Describe the proposed upgrade to the system:
New septic tank and leachfield.
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 perc rate)
Up to 25% reduction in subsurface disposal design requirements (state required&
proposed size)
_ Relocation of water supply well (identify well, describe relocation)
X Reduction of required separation between bottom of SAS&high groundwater
(specify proposed reduction&perc rate)
3' separation at 5 min per inch
_ Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the
Code)
System upgrades that cannot be performed in accordance with 310 CMR 15.404&15.405,or
in full compliance with the requirements of 310 CMR,require a variance pursuant to 310
CMR 15.410-15.417.
DEP APPROVED FORM 12/0795
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 of 5
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 groundwater elevation pursuant to 310 CMR
15.404 (1)(i)(1).The evaluator must be a member or agent of the local approving authority.
Distance from soil absorption system to high groundwater: 3 feet
As determined by:
Evaluator's Name. Ernie Mathieu
Evaluator's Signature:
Date of Evaluation: 8/25/04
8) Notice to Abutters
No application for upgrade approval in which the setback from property lines or a private
water supply well is reduced shall be complete until the applicant has notified all abutter-,
whose property or well is affected by certified mail at least ten days before the Board of
Health meeting at which the upgrade approval will be on the agenda. Such notice shall
include the date, time and place where the upgrade approval will be discussed.
If the Department is the approving authority, then such notices to abutters must be
completed prior to the date of submission of the application to the Department.
The notices to abutters shall include a copy of the completed application form and shall
reference the standard, set forth in 310 CMR 15.402 through 15A05.
List of Affected Abutters:
Abutter Name:
Address:
Date Notified:
Abutter Name:
Address:
Date Notified:
Abutter Name:
Address:
Date Notified:
Abutter Name:
Address:
Date Notified:
DEP APPROVED FORM 1297/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 of 5
9. Explain why full compliance, as described in 310 CMR 15.404(1),is not feasible (each
section must be completed):
a) an upgraded system in full compliance with 310 CNIR 15.000 is not feasible:
In order to control cost and to minimize surface disurption,
request reduction to groundwater of 3'
b) an alternative system approved pursuant to 310 CMR 15283-15.288 is not feasible:
Not needed, conventional system feasible.
c) a shared system is not feasible:
Not required, lot will support system
d) connection to a sewer is not feasible:
No public sewer in area.
10) An application for a disposal system construction permit,including all required
attachments (e.g. plans and specifications,site evaluation forms),must accompany this
application. Is the DSCP application attached? X 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 Date
Steve Mongeon
Print Name
Thomas S. Leue, Homestead Inc. 9/5/04
Name of Preparer Date
1664 Cape Street, Williamsburg, MA 01096 (413) 628-4533
Telephone # &address of preparer
NOTE:Title 5,310 CMR 15.403(4),requires the system owner or operator to submit to the
Department a copy of the local upgrade approval upon issuance by the Board of Health
and prior to commencement of construction.
DEP APPROVED FORM 12107A5
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
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coN.N.014WE ..cTVOT' MAssAc7-Cusvfa s
Northampton, Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility.system owner: Name: Steve Monoeon, 235 Coles Meadow Rd. Northampton,
MA 01060
Address of Facility: 235 Coles Meadow Road
Type of facility: Residential
design flow per 310 CMR 15.203 330 qpm
System designer: Name: Thomas Leue Address Homestead Inc. , 1664 Cape St . ,
Will iamsbura, MA 01096 Phone No. 413 628-9533
Local Upgrade Approval granted for:
reduction in setback(s) (specify)
per rate of 30-60 min./inch (specify rate)
reduction in SAS of up to 25%
(sDeCIty% red Ctlon 8 a e of SASI
x reduction in separation between SAS & high groundwater
"specify reduction&nerc ratel 3' separation at 5 min per inch
relocation of a well (explain)
List local variances granted (no DEP approval reouired Der 310 CMR 15 412(4)1
List variances aranted reauirina DEP approval
Board of Health Approval onset uoarad
Signature
thrtair
afar ONO JAL eirthlz7,
Name&Title
/6/4/e-y
City/town Pate
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION DIVISION OF
WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORfTY&BEFORE
COMMENCEMENT OF CONSTRUCTION.
Mail to: DEP, Western Regional Office, 426 Dwight St., 5th Floor, Springfield, MA 01102
DEP APPROVED FORM 120755
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 of 5
cow oN-WEALa7-Coo WIssAcrCuszgts
Northampton, Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility.system owner: Name: Steve Mongeon, 235 Coles Meadow Rd. Northampton,
MA 01060
Address of Facility: 235 Coles Meadow Road
Type of facility:
System designer:
Residential
design flow per 310 CMR 15.203 330 qpm
Name: Thomas Leue Address Homestead Inc. . 1664 Cape St. ,
Williamsburg, MA 01096 Phone No. 413 628-9533
Local Upgrade Approval granted for:
reduction in setback(s1 (soecifvl
per rate of 30-60 min.finch (specify ratel
reduction in SAS of up to 25%
($0.@V% redb lion8S2 of CAST
x reduction in separation between SAS & high groundwater
(snepiN reduction S Derc ratel 3' separation at 5 min per inch
relocation of a well (exolainl _
List local variances granted(no DEP approval reauired Der 310 CMR 15 412(4)1
List variances granted reouirina DEP aooroval
board of Health Aoorova of or000st Darade
Nardi /2indite-;(
n t r Citvftown
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION DIVISION OF
WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY&BEFORE
COMMENCEMENT OF CONSTRUCTION.
Mail to: DEP, Western Regional Office, 426 Dwight St., 5th Floor, Springfield, MA 01102
DEP APPROVED FORM 1207/95