291 Permits, Certificate of Compliance Important:When
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Commonwealth of Massachusetts
City/Town of LEEDS
Application for Disposal System $
Construction Permit Fee
Form 1A
afro 110
Number
18-07/6
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
Location of Facility:
Leeds
city/Town
2. Owner Information
John & Kim Lutz
Name
291 Haydenville Road
Address(If different from above)
Leeds
City/Town
3. Installer Information
Name
Address
City/Town
4 Designer Information
James A. Gracia
Name
99 Glendale Street
Address
Easthampton
City/rown
LAMES
ANDIOtN
GRACIA
CNIL
No.29701
a 90\OISTE•4,
SS/0 NA t-11
t5foria.doc•06/03
MA
State
01053
ZIP Code
MA
State
413-587-0556
Telephone Number
Name of Company
01053
Zip Code
State Zip Code
Telephone Number
James A. Gracia, PE
Name of Company
MA
State
413-527-5290
Telephone Number
01027
Zip Code
Application for Disposal System Construction Permit•Page 1 of 3
Commonwealth of Massachusetts
City/Town of LEEDS
Application for Disposal System
Construction Permit
Form 1A
Number
$
Fee
A. Facility Information (continued)
5. Type of Building:
® Dwelling
Other: Type of Building
❑ Showers Number of showers
Specify other fixtures:
6. Design Flow:
Calculated Daily Flow:
7. Plan:
❑ Garbage Grinder(check if present)
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
721 Gals/Day
Gallons per Day
660 Gals/Day
Gallons
9-14-08
Date of Original
1
Number of Sheets Revision Date
Septic System Upgrade for John & Kim Lutz, Dwg#2008-015
Title of Plan
8. Description of Soil.
Loamy Sand (See Soil Logs on Drawing)
9 Nature of Repairs or Alterations Of applicable):
Rehab baffles of existing 1500 gallon septic tank, install new 1000 gallon pump chamber, and install
new 15 x 65 leach field.
10. Date last inspected:
October 20, 2003
Date
tsformla.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of LEEDS
Application for Disposal System
Construction Permit
Form 1A
Number
$
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 Compliance has been issued by this Board of
Health.
Signature
Application Approved By.
Date
Name Date
Application Disapproved for the following reasons:
t5fonnl a.doc•05103
Application for Disposal System Construction Permit•Page 3 of 3
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use only the tab
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cursor-do not
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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 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 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
Z Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
DSCP Number
John 3, Kim Lutz
Facility Owner
291 Haydenville Road
Street Address or Lot p
Leeds
DSCP Date
City/Town
Designer Information:
s A. Gracia
t5form3.doc•06/03
MA
State
James A. Gracia, PE
Name of Company
ture Date
Installer Information:
Clifford Clark
Name
Sigma re
01053
Zip Code
Clark's Excavating
Name of Company
/6 '23 -08
Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be corJSq Jjj agua ? I4 k Ml m will function as
de;, -d. 1 MAIN STREET
LA, NORTHAMPTON, MA 01060
Date
3.c- i9- a-o-1(
Certificate of Compliance•Page 1 of 1
JAMES A. GRACIA, PE
99 Glendale Street, Easthampton, MA 01027
NEW
1000 GALLON
PUMP CHAMBER
1-1/2" PVC
FORCED MAIN
INSPECTION
PORT
65'
01
EXISTING
1500 GALLON
SEPTIC TANK
NEW
LEACH FIELD
7
-J
\ /
1
I I
1
1 1
1 I
1 1
I I
1 I
I I
1 1
1 1
HAYDENVILLE ROAD
JOHN & KIM LUTZ
291 HAYDENVILLE ROAD
LEEDS, MA
SEPTIC SYSTEM "AS BUILT"
SCALE: 1" = 30' 10/25/08
Important:When
filing out forms
on the computer,
use only the tab
key to move your
cursor-do not
use the ret rn
key.
Commonwealth of Massachusetts
City/Town of LEEDS
Local Upgrade Approval
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
1. Facility Name and Address
John & Kim Lutz
Name
291 Haydenville Road
Street Address
Leeds
City/Town
2. Owner Name and Address Of different from above)
John & Kim Lutz
Name
Leeds
City/Town
01053
Zip Code
3. Type of Facility(check all that apply):
MA
State
291 Haydenville Road
Street Address
MA
State
413-587-0556
01053
Zip Code
Telephone Number
® Residential ❑ Institutional ❑ Commercial ❑ School
721 Gals/Day
g pd
James A. Gracia, PE
Name
4. Design flow per 310 CMR 15.203:
5. System Designer:
99 Glendale Street
Address
Easthampton
City/Town
Z PE ❑ RS
MA 01027
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,sq.ft.
reduction
Lutz.LUA9B•rev.7/06 Local Upgrade Approval* Page 1 of 2
e• •
Commonwealth of Massachusetts
City/Town of LEEDS
Local Upgrade Approval
Form 9B
B. Approval (continued)
® Reduction in separation between the SAS and high groundwater:
1' Reduction from 4 to 3
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well (explain):
ft.
3 Min/Inch
min./inch
2.25'
❑ 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 perc test
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
p__ • Iv pd Pit liedi -`
faroving A,uthority ;� /Tory/
Print or Type`Name and Title S•nature ///111 Date e�y I , 8
tuftSias ped%/ _
Lutz.LUA9B•rev.7/06 Local Upgrade Approval Page 2 of 2
kTZ--
t
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.
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.
Commonwealth of Massachusetts
City/Town of LEEDS
Form 9A - Application for Local Upgrade Approval
A. Facility Information
Important:When
Poring out forms 1. Facility Name and Address:
on the computer, John & Kim Lutz
use only the tab
key to move your Name
cursor-do not 291 Haydenville Road
use the return Street Address
key
Leeds
City/Town
MA
State
01053
Zip Code
2. Owner Name and Address Of different from above):
John & Kim Lutz 291 Haydenville Road
Name Street Address
Leeds MA
City/Town State
01053 413-587-0556
Zip Code Telephone Number
3. Type of Facility (check all that apply):
A
Residential ❑ Institutional ❑ Commercial ❑ School
4 Describe Facility:
4 Bedroom Dwelling
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Leach field
Lutz.LUA9A•rev.7/06 Application for Local Upgrade Approval* Page 1 of 4
Jeep Hole Number: # /— / Date
Location(identi on site plan):
Land Use: Vegetation
landfontr Position of Landscape'
Distance from:
Time'. Weather
Slope(%L
Surface Stones:
Open Water Body Feet Drainaeeaav
Possible Wet Area Feet Property Line
Drinking Water Well Feet Other
TP - DEEP OBSERVATION
Depth from Soil Soil Texture Soil Color
Surface Horizon (USDA)
(himself)
(inches)
67
Ar..i/Lirs -t
Feet
Feet
Feet
OLE LOG
Soil
Mottheg
Ls
Other(Structure,Stones,Boulders,
Consistency,%Gravel)
Parent Material(geologic) ' w-r TC..
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water.
TP I DEEP OBSERVATION HOLE LOG_
Depth from Soil Soil Texture Soil Color Soil Other(Structure,
Surface Horizon (USDA) (Mansell) ( lure,Stones,Boulders,
Moulin g Consistency, %Gravel)
(Inches)
v
Depth to Bedrock
Weeping from Pit Face: j U'
r
r
Parent Material(geologic)
Depth to Groundwater. Standing Water in the Hole: 7 ) - Depth to Bedrock:
Estimated Seasonal High Ground Water: Weeping from Pit Fact 2
Certification: I certify that in November 1994. I passed the soil evaluator examination approved by the Department of Environmental
Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in
310 CMI2 15017. Mass.Soil EvaL Approval No.SE1543
Signature:
Peter J McErlain
Date:
NORTHAMPTON BOARD OF HEALTH
212 MAIN ST. , NORTHAMPTON, MP_ 01050
TEL; 413-587-1213
Site Suitability For On-Site Sewage Disposal
Project Number
Performed by 4( j-r� 1 .
Health Impostor p h`C 1.
Site Address
Q9 i +AA.
New Comuuskn
Date7/ ) /o
Equipment Operator: Tao 9
Client Name&Address
ii-
T.P.*r
Office Review
Published Soil Survey Available: No n Yes n
Year Published Publication Scale Soil Map Unit Drainage Class Soil Limitations
Surficial Geologic Report Available: No r. Yes r.
Year P li ° Publication Scale Cowin*Material(Map Unit) La rm
Flood Insurance Rate Map:
Above 500 year flood boundary it Within 500 year flood boundary n Within 100 year flood boundary it
Wetland Area:
National Wetland Invetory Map(Map Unit) Wetlands Conservacy Program Map(Map Unit)
Current Water Resource Conditions(DSGS): Month
Range: Above Normal x Normal s.
Other References Reviewed:
Below Normal x
Percolation Test Results
Percolation Rate 3 fr �--
Bottom ofPercolation Test Hole: ?
Percolation Rate:
Bottom of Percolation Test Hole:
Determination for Seasonal Malt Water Table
Method Used
❑ Depth observed standing on observation hole inches ❑ Depth weeping from side of observation hole inches
❑ Depth to soil mottles inches
❑ Ground water adjustment inches.
Index Well Number Reading Date Index well level
Adjustment factor Adjusted ground water level
nth of Naturally Occuring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
If yes, what is the depth of naturally occurring pervious material? TP#
If not,what is the depth of naturally oaming pervious material? TP#
On-Site Review
T.P. #
Time
Measurement
Time
Measurement
Begin Saturation
5 ,/i;-
Benin Saturation
End Saturation
(i1 3 3
End Saturation
9"depth
Measurement
/`
-I ,3 7
9"depth
Measurement
6"depth
Measurement
C)
6"depth
Measurement
Elapsed Time
9"to6"
k73
Elapsed Time
9"to6'
Percolation Rate 3 fr �--
Bottom ofPercolation Test Hole: ?
Percolation Rate:
Bottom of Percolation Test Hole:
Determination for Seasonal Malt Water Table
Method Used
❑ Depth observed standing on observation hole inches ❑ Depth weeping from side of observation hole inches
❑ Depth to soil mottles inches
❑ Ground water adjustment inches.
Index Well Number Reading Date Index well level
Adjustment factor Adjusted ground water level
nth of Naturally Occuring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
If yes, what is the depth of naturally occurring pervious material? TP#
If not,what is the depth of naturally oaming pervious material? TP#
On-Site Review
T.P. #