255 Septic Upgrade Application 2002 -- 3-1997 09:30 191371391100
MASS. DEP/WESTERN REGIONAL P.02
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF 5
Commonwealth of Massachusetts
ivoizi/fi9,P73'Taiy , Massachusetts
Application for jacaijingradritai
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To be submitted to Local Aoprovine Authority/Board of Health: For the upgrade of a failed or
nonconforming system with a design flow of <10,000 gpd, where fill 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 for upgrade of a state or federal facility, where full
compliance, as defined in 310 CMR 15.404(1). is not feasible.
add NOTE: of upgrade approval shall not be granted for an upgrade proposal that includes the
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) Pacility/system owner
Name %AR Cannon Taff CC en.,..4-2
Address /G c,.,,i/o.., Gre-Q n o/t
Phone# ��4—74,3 2
Address of facility 2 c r r /ar /nv c 0/9Ir ie(
2) Applicant (if different from above)
Name
Address
Phone #
3) Type of facility
.a. residential ca nmetoial school
institutional
(Specify)
DEP APPROVED VOW:tapes
1t-06-1997 09:16 14137641100 MASS. DEP/WESTERN REQIONAL
P.03
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL,
PAGE 2 OF 5
4) Type of existing system
privy _cesspooi(s) l-----Conventional system
Other (describe)
Type of soil absorption system (trenches, chambers. pits,etc.)
(/nxr-,...ory exc, �r-�„_
5) Design flow based on 310 CMR 15.203 7
a) Design flow of existing system C gpd
Approved? yes approval date
no why?
b) Design flow of proposed upgraded system 355
c) Design flow of facility 333 gpd
6) 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 font was submitted to the approving authority) (date)
b) Describe the proposed upgrade to the system
Tnr-,bv AG,.. 1300 %r seer_ %
n0(7 5r/ )0 err r lea.
/7n x/ FRo.
gpd
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (fiat setbacks to be reduced with proposed setback distances)
Percolation rate of 30-60 minutes per inch (state actual perc rate)
- uwovaorOwt.MOMS
11-06-1997 09:19 14137841100
MASS OEP/WESTERN REOIONAL
P.04
FORM 9A • APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF 5
Up to 25% reduction in subsurface disposal area design requirements (state required
& proposed sire)
Relocation of water supply well (identify well, describe relocation)
e/ Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & pert ram) Rom S "-k. 4'
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 15.000, require a
variance pursuant to 310 CMR 15.410-15.417.
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 dete mine the high ground water elevation pursuant to 310 CMR
15.405(1)(1)(1). The evaluator trust be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
4- feet
As determined by:
Evaluator's name - • d L4 C°o r
Evaluator's sign• .;70ilyy' tO3-71
Dam of evaluation
OSPWROrmsoasr-124/AM
11-06-1997 09:19
14137641100
MASS. DEP/WESTERN REGIONAL
P.05
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 OF 5
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 abutters 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 due, time and place where the upgrade
approval walk discussed.
If the Department.is the approving authority, then notice 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 standards'set forth in-310 CMR 15.402 through 15.405.
List of affected Abutters:
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name \ Date notified
Address ! \\
Abutter Name / Date notified
Address
9) Explain why fun 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:
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
no i- rizCers0-L
IMP•Intuvtm IO WA.turn.
11-06-1997 09.20 14137041100
MASS. OEP/WESTERN REGIONAL
P.06
FORM 9A • APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
c) a shared system is not feasible:
can n�nsrery
d) connection tot sewer is not feasible:
0
10) An application for a disposal system construction permit, including all required attachments
(e.g. pleas A specifications, site evaluation forms), must accompany this application. Is the
DSCP application attached? _yes no
11) 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 thawing violations."
Facility owner's signature Date /
SNIP 4:Thj H
Print Name •
&-niap �-/76are /0r/4,/SS
Name of prepares ate
Slay- 3 e a e 72
Telephone # &address of preparer
2 :i cs ic /c) Cna.
Olo��
NOTE: Title 5, 310 CMR 15.403(4), requires the system owner or operator to submit to the
Depsrmrmt a copy of the local upgrade approval upon issuance by the Hoard of Health and prior
to eommmcememt of com:uction.
=ranaOYm ram•tvnnl
11-06-1997 09:20
14137841100 MASS. DEP/WESTERN REGIONAL
P.07
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
)1)ocTNA/rG7ot/ , Massachusetts
Type of facility:
raidmtial iodnnional oemmmcial school
dWgo flow per 310 CMR 15.303 pd
System designer: Name Th.,a,.of F4:74e/° r2Z )IAtP.f ZI) Q.!TAted(Phone No. r,9-382S
Local Upgrade Approvnt granted ton
reduction in rctbsck(s) (specify)
pea rate of 3040 aio./inch (specify roe)
reduction la SAS area of up to 25%
(specify % rcduaion&sire of SAS)
reduction la reparation between FRa n. 4-
SAS s Wgh pwadwaer
(specify reduction&pore rate)
relocation of a well(explain)
c. Z
Liar loeal+ruiaocei granted(no DEP appnwai required per 310 CMR 15.412(4))
List minces firmed requiring DEP approval
Board of �of upgrade J (/J/' �/
� s' /VQ2��� rNov BTBe /Om�/�/
City
THE SYTT It OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE APPROPRIATE REGIONAL OFFICE OP THE DEPARTMENT OP ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL.APPROVING AUTHORITY
&BEFORE COMMENCEMENT OF CONSTRUCTION.
IMPAPIIIM VOW.IwaM
On-Site Review
Deep Hole Number .1— Date 2 . 1.-1 gl Time era, nw Weather ovt2e?s7`
Location (identify on site plan)
Land Use /2 -Sr pCNT,■L Slope (%) 0 Surface stones /Denrc
Vegetation /beta J
Landform 6c-.u,. n /7..taa,A-c
Distances from:
r
Open Water Body a-ap feet Drainageway A Lb Ai t feet
Possible Wet Area /00 -feet Property Line 3G - - -feet
Drinking Water Well C. feet Other --
DEEP OBSERVATION HOLE LOG
i =eotn from Surface
('ncn0e1
-
Soil Horton
"'_' ^"
Soil Texture
(OSSA)
-- —
Soil Color
i Munselll
Soil Mottling
Other
Swq ;e.Stones.
ravel rs.
Consistency,%Gravell
o ray
U
I Ts )77
1.
IS Ts '7`i
5-4 To (3a
A
7�
uw
C')
�
St
!L
I 07z /},
to Yee. 4,.
y/
a.5—' (y
5��2 tl/,
/�'
Sr `l, a)-
a-y //
i o yc
6
4/5
boo re etegr
1`,.,T^.,a/ 62.900 0
r" ze°
� TS/ •
Ge17•,,u f/pt re,eel
UE2.t 'Fre�n ano7y
To 4i;'cErrr`....7Et7
Co 46 kr1 NLr Ari'rf
EQY Fla•+r1 to/free
-4•44.P t 6•crtvE L
irt/ ' ue,- cog.
Li R YES- %! `,
Parent Maieri�l (geologic): �� Depth to Bedrock i ]..
f)enth to Groundwater Standing Water in the Hole: I ` Weeping from Pit Face' /C/.0
Estimated Seasonal High Ground Water:2y
er
Fi
Owner's Name Address and Tel e: .�e$;79
tvJ' 7ya2
7L CO NNec/ Dart- Cam
1k Arden; t7•
'
lira-kJ is he. Ply. Ol rite
No.:
Date: April 1,1996
Commonwealth ofMassachuaetts
j(ic,-4_211-447-Bv Massachusetts
Site Suitability Assessment for On-Side Sewage Disposal
Performed By:. 77EN Nf s P- La tan YE- Certification Number:
Witnessed By: Ferinwa /;/r -E-0.1-Ca
Location Address or Lot No.:
2,55 CAdesto e4do R&
New Construction t, Repair E
Mica Review
/ n> n* 351/4,aCH)
3J
Published Soil Survey Available: No Q Yes $
Year Published g 1 Publication Scale j,'I,5$'/
Drainage Class E7 cr s e,e&/y Soil Limitation
Surfrciat'Geologic Report Available: No { . Yes
Year Published • Publication Scale
Geologic Material(Map Unit)
Landform C,cou- .,- e+r ourre.
Flood Insurance Rate Map:
Above 500 year flood boundary No 0 VIM gf
Within 500 year flood boundary No p Yes rig
Within 100 year flood boundary No '% Yes Q
Wetland Area:
National Wetland Inventory Map(map unit)
Wetlands Conservancy Program Map (map unit)
Soil Map Unit //2
5Lope,
Current Water Resource Conditions (USGS): Month -TUki f9 94
Range: Above Normal p Normal ❑ Below Normal sa
Other References Reviewed: •
s, On-Site Review
Deep Hole Number 7 • Date 4f- / 55 Time ¥'3e 4" Weather
Location (identify on site plan)
Land Use S roe «T o; L. Slope (%) 3- Surface stones .A 70.
Vegetation tries 714 4 7
Landfomt /ocJo s7 +'+ORA-4,Afr
Distances from:
Open Water Body a 00 1- feet Drainageway /VO NC feet
Possible Wet Area /o D r feet Property Line_ I 0 feet
Drinking Water Well G Yy feet Other
bur/T82
DEEP OBSERVATION HOLE LOG
Ceoth Gam Surface
(inches)
Soil hanzon
Soil Texture I
(USDA)
Soil Color I
(Munsetll
Sod Monlirg '
Other
(Structure.mto es Boulders.
Q 70 LI
7 D III
/1
A
13
Vim .
-
S/L
5
/tom
L/
!
z
BUG /I�
to a 'l
Y /lP
715717_ sS
' r
.hrAe 4-
4y
•
7Sye C4,
L/
3
r_••rE) RStt k
69S/t5
c.ee>2, %Np∎era
2U'
at, he 4r•u/9q
Sems Fs 97 alt
_
e� a / =
FnTar45/7.5ye
/o Po 4209 06L 4-
CO 4414`i
ip
Parent Material (geologic): 39 54 c it L C Depth to Bedrock //S
flenth to Groundwater: Standing Water in the Hole: Niel; Weeping from Pit Face:yoArS
-Estimated Seasonal High Ground Water:yy
4
On-Site
3
n-Sitte Review
Deep Hole Number tT Date ` '9f f Time 9 '69.4-K Weather Aelfert en*T
Location (identify on site plan)
Land Use QE r t?6..t 9 t-- Slope (%) h Surface stones ,uort
Vegetation Lis ru/J
Landform 6,iC evv P r r, e2Aw&
Distances from:
Open Water Body 2-& feet Drainagewav NO.vc feet
Possible Wet Area / 6D feet Property Line SO feet
Drinking Water Well Lr 1 t_/ feet Other
DEEP OBSERVATION HOLE LOG
Ceara from Surface
(Incnesi
Sal Hcracn
Scil Texture
(USDAI
Soil Calve
(Munseal
Soil Mattl:ra
Other
(Structure.Stones. Boulders. I
Consistency,%Grave»
o /° Z A
v
A- 5
54 1
104J6 g
? o7s /I?' F
gaol IM01■1049,
Parent Material (geologic): 53,}reL t iI
Depth to Bedrock
MAnth to Groundwater: Standing Water in the Hale: 71. 'I Weeping from Pit Face 76
rr
Estimated Seasonal High Ground WatergLfl
s
Co � cS )AZE'tpcw
Location Address or Lot No. 7. b J` cart, ri9gDeu
FORM L -PERCOLATION TEST
>-0a•
COMMONWEALTH OF MASSACHUSETTS
?Ue&�7-1-i anepTi'• Massachusetts
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed ❑ Site Failed a
Ferfcrm.ed 'cy: it t' vt 5 ei l,9e_OVettr`
' Witnessed By:
Comments: Q_Vii'Lar41.)T B-rkkD /Taw 'F:At J m.. To 7.190 /'./r. 2•'/J17
O?Alr2OVW TO RM•=Olt,S
•
Percolation Test`
Data: _
R- 17- 45 Tim., q:ae.
Observation Hole hr
Depth of Pero
94
S-_- -.e-soak
I
^ li5
Eric Fre-stak
l C."):(:) 0
T:m.e 3- 11"
lc,' to
Time a: =
j .: 5 y
Time a: 5"
3.4.6-6 A-.775. I,
Time (S"-6"1
punt- - wre, La.* 1
t •-r. No, L.,-7-,a..J
'_.e NGn.ilnch
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed ❑ Site Failed a
Ferfcrm.ed 'cy: it t' vt 5 ei l,9e_OVettr`
' Witnessed By:
Comments: Q_Vii'Lar41.)T B-rkkD /Taw 'F:At J m.. To 7.190 /'./r. 2•'/J17
O?Alr2OVW TO RM•=Olt,S
FORM 22 - PERCOLATION
Location Address or Lot No. ..2-S5 Cate-5 in-optai /2er�
COMMONWEALTH OF MASSACHUSETTS
1Up.e2r4 mp) a , Massachusetts
' Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed ❑ Site Failed Q
Per'crmed Ey: 1cnN , j • L'¢Ce
Witnessed By: rc/Cy2 ✓ t ter-. /a)
Comments-
DE?ATTtOY=TOA.N-t--'COS
Percolation Test'
Date: • . 3. TI Time:
Observation Hate as
ve.t`. of Fero
L 0 a' e r
Li D if
Star- -re"soak
x( ` 56
I fP: oS
Ent ?.e-saak
, / 3
Time a. E
PettI > .Zr17r.7i 30
y7r fP. ao i-E
IrAPien sN ,T•• “
r30 ntevr a c,/c
Time iS"-a")
J4i)I mLX-vtnitt4t- ',ah- twal OVE2f,y 5r Sod A'
=_t_ Min./inch
' Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed ❑ Site Failed Q
Per'crmed Ey: 1cnN , j • L'¢Ce
Witnessed By: rc/Cy2 ✓ t ter-. /a)
Comments-
DE?ATTtOY=TOA.N-t--'COS
FORM ii - SOIL EVALUATOR FORN/
Page or •..
Location Address or Lot No. Zj 5 cot t:y »z2.9L`sr. Iaextb
Determination for Seasonal High Water Table
Method Used:
E Depth observed standing in observation hole inches
U Depth-weeping from side of observation hole , inches
Depth to soil mottles ..._ .. inches
I! Ground water adjustment feat
Index Well Number Reading Date .._. Index weir level
Adjusrm=^ Adjusted- tacror _ ?�dlusted crounc water level ...
D _:- Va. =!Iv Cc:_.- ._ _^ric,,c fvt=_:e• a!
Goes at leas: four feet of naturally ecc_rrinc perilous material exist in ail a _
cosented throughout the area proposed for the scii absorption system? y�5
If cc:, what is :he depth of naturally occurring pervious material?
Certifica_c
•
I certify that cn Nev- 1445 (date) r have passed the soil evaluator examination
approved by the Department of Environments(Protection and that the above analysis
was performed by me consistent with the required trainir,e, expertise and experience
described in 310 CMR 1517.
Sicnatur
OSA>PROttj FORM- {-JO':95
Date q 19�j
FORM 12-PERCOLATION
Location Address or Le: No. 3SS` C I"> Ni r.9 dew � >
COMMONWEALTH OF MASSACHUSETTS
ti -oprot.l, Massachusetts
Percolation Test
Data: 9'/ - 99 rm-. R>:oe) 9-7
Observation Hole #
3
Depth of Pero
LI11 a
S.a. . -re-wak
¶ Li `c
/J ' J
Ent Fre-s:aR
VDD
mot ' 17
Tire at
9 ;
1
Time at
q( .• 2-`1-
Time (S"-5")
Sate Min./inch
C
Minimum of t percolation test must be per'crmed in both the primary area AND
reserve area.
Site Passed ® Site Failed E
Fercrmed By:
• Witnessed Sy:
Commem •
✓ENN1)
IR-TS
� - A4 coo-aye
�'7j_ cz lr.J
"AM0 eV i7!OAH-L'c:195
Gi? Niel .. :i: - 4:::,-,
{ NA
h }
Y Yom •
f S , .. f a ,}�U"t t � 3 r Y '� 4�AM1 _ >L .• 9 ,,- LL ,t$ rax
+ R '{
00 _404
. .I Y SY J= �L C
.F
� ,.tom '�� it, `t�
\\
�N �` i O \a \r < f fbRJy t i
.3& C1 v , �
„N .y d dal a td ' 04 s'e . /' ' , � . .° Slf 3J6!d!.AttyeUJ� `a
4
' k � y
0� Qy }
.? a �i>�� . '. ti -:
td Wd0Z:L0 666T at '9W7 E07LfLL[TP : 'rn 30Hd Wpm{ 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF .. ALTH
OF.�I�I..V�
Cirrfifirutr of (gum
tuurr
THIS IS 0 C ?TI I T at t Ji livid Srwige izposal Sysmm constructed ( ) or Repaired QC)
by 's .� �I ---
aL. aS'� Ie e. )
has been installed in accordance with the provisions of TITI i},jr he State Sanitary Code as describer/Lin the
application for Disposal Works Construction Permit No `ruC7 ___.... dated ii.-L '- 99;._.—..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO ED AS A GUA$[s�1TEE THAT THE
SYSTEM WI L CTION .SATISFACTORT.
DATE— ..200 . — Ir-rcco ,...
Thomas J. FtfzGerald, R.S. ,M.S.
Percolation Testing • Serie System Design
Regis:t od Santdan• License en 1028
V6iUbel UO, 2002
Mr Deter Mrrerl,in
Normampton doarn or Realm
ivul u li Jai rpiu I, MA. 0 1060
Dear Mr. McCerlain:
This is to certify that a septic system constructed at 25b Coles Meadow Road
Northampton was installed according to plans as approved by your office using a
non-intrusive inspection methodology.
Sincerely,
cmgiThhomas'! iL.Geral
72 Davis Road,Southwick,MA 01077. 41315694828