357 Soil & Perc Tests & Local Upgrade Approval Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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:.
UNKNOWN
grid
495
gpd
495
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is(check one).
Z Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301:
2. Describe the proposed upgrade to the system:
REPLACE ENTIRE SYSTEM. NEW 1500 GALLON SEPTIC TANK AND 752 SQ. FT. LEACH FIELD
date of inspection.
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.ft. %reduction
Z Reduction in separation between the SAS and high groundwater:
Separation reduction FROM 4'TO 3.18'
Percolation rate
Depth to groundwater
t5form9a•rev.7/06
8
min./inch
18"
ft.
Application for Local Upgrade Approval•Page 2 of 4
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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
Weal 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.
A. Facility Information
Facility Name and Address:
WILLIAM AND LORRAINE RYAN
Name
357 HAYDENVILLE ROAD
Street Address
LEEDS MA 01053
Cityftown State Zip Code
2. Owner Name and Address(if different from above):
Name
Street Address
City/Town
State
Zip Code
3. Type of Facility(check all that apply):
® Residential ❑ Institutional
4. Describe Facility:
SINGLE FAMILY DWELLING
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
Telephone Number
❑ Commercial
❑ School
® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
UNKNOWN
t5fonn9a•rev.7/06
Application for Local Upgrade Approval,Page 1 of 4
4
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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:
NO NEIGHBORS
4. Connection to a public sewer is not feasible:
NONE 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
® Complete plans and specifications
® Site evaluation forms
❑ 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).
❑ Other(List):
D. 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 deliberate violations."
Yawl Owners Signature Y Date
C RSA/n/F 11I . 9/AP
t5form9a•rev.7/06
Print Name
HILLTOWN ENVIRONMENTAL
Name of Preparer
11/17/06
Date
P. O. BOX 314 CHESTERFIELD
Preparers address Cdy/rown
MA 01012 413-296-4499
State/ZIP Code Telephone
Application for Local Upgrade Approval*Page 4 of 4
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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):
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
❑ Use of only one ee hole in proposed disposal area
❑ 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 determined by:
ERNEST MATHIEU.
Evaluator's Name(type or print)
8/29/06
Signature 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:
UNABLE TO CONTAIN FILL REQUIREMENTS WITHIN PROPERTY BOUNDARIES
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
TOO COSTLY, NOT NEEDED
t5fomi9a•rev.7(06
Application for Local Upgrade Approval Page 3 of 4
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Local Upgrade Approval
Form 9B
B. proval (continued)
t5fomr9b•rev.7/06
Reduction in separation between the MS and high groundwater:3groundwater:
4 f TV 'm' J
Separation reduction
Percolation rate
Depth to groundwater
❑ Relocation of water supply well (explain):
R.
min./inch
/3"
ft.
❑ 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 pert test
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
Approving Authority
AN T /l1M"aktOki
Print or Type Name and Title
Signature
Date
Local Upgrade Approval*Page 2 of 2
Important:
When filing out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
is
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
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
WILLIAM AND LORRAINE RYAN
Name
357 HAYDENVILLE ROAD (P.O. BOX 117)
Street Address
LEEDS
City/Town
2. Owner Name and Address (if different from above)
MA
State
01053
Zip Code
Name
Street Address
City/Town
Zip Code
State
413-5841957
Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
495
4. Design flow per 310 CMR 15.203:
5. System Designer:
P.O. BOX 314
Address
gpd
HILLTOWN ENVIRONMENTAL
Name
CHESTERFIELD MA 01012
❑ PE ® RS
City/Town State,ZIP
B. Approval
t Local Upgrade Approval is granted for.
❑ Reduction in setback(s)—specify:
❑ Reduction in SAS area of up to 25%:
t5form9b•rev.7/06
SAS size,sq.ft.
%reduction
Local Upgrade Approval*Page 1 of 2
Massachusetts Department Protection of Environmental
—Wastewater Protection Permitting Program 357 Nayde„,,; i\e Rood Leeds
Bureau of Resource Site Address or Map/Lot Number .,
LL
\ Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On Site Review minimum of Iwo holes rerp,ir:0 at every pronneari disposal area,
• Deep Observation Hole: Date: 8/24o6 Time: 9 ; 00 Weather: (Jri24e GO
1. Deep Hole Number -rP-1 Location (Identify on Plan ):
•
2. Land Use: Lawn Surface Stones: None, slope (%) 4% vegetation Crass
(e.g.woodland,agricultural field,vacant lot,etc
m:
Landfor terra rz Position on landscape.
3. Distances from: Open Water Body 1,50+ ft. Drainage Way 50 ft. Possible Wet Area 75 ft.
Property Line 30 ft. Drinking Water Well I SO*ft. Other_ft.
4. Parent Material: CI uvlal Unsuitable Materials Present: Yes ❑ No Ly/
If Yes: Disturbed Soil❑ Fill Maat�te//rial❑ Impervious Layer(s)❑ Weathered/Fractured Rock ❑ Bedrock ❑
5. Groundwater Observed: Yes Lv� No ❑
If Yes: Depth Weeping from Pit 2.9 Depth Standing Water in Hole 46 Estimated Depth to High Groundwater: I e)"
Soil Redoximorphic Features Coarse Fragments
Depth Soil Matrix: (mottles) %by Volume
ept Horizon/ Soil Texture Color-Moist Depth Color Percent Gravel Cobbles Soil Structure Soil Consistence Layer (USDA) (Munsell)
A 8 Stones f (Moist) Other
0-It A S L 2 .5Y 3/1 L w
r,. iy Iodic
12-20" Bl„i SL a .SY 5/3
5% 570 ,asiive. Z ,o0,
20-90 C L5 SY4/3 it SYb//b 5 / job Eye, y�as5lve -crick la
Additional Notes
HILLTOWN ENVIRONMENTAL CONSULTING
P.O.BOX 314 DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 4
CHESTERFIELD, MA 01012 Y 9 p 9
Massachusetts Department of Environmental Protection 357 140.ycienvM'it R6cJ, Lees
Bureau of Resource Protection—Wastewater Permitting Program site Address or Map/Lot Number
t Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
A. Facility Information Lour- /�
Name. WI� 4�Iqm q frvr. /� a✓� HILLTOWN ENVIRONMENTAL CONSULTING
Owner Nam
Y P.O. BOX 314
Street Address: PD.,BoX //7 e Map/Lot: CHESTERFIELD, MA 01012
(413) 296-4499
City Leech State'. M4 by Code: O/O53
B. Site Information
1. (Check one) New Construction ❑ Upgrade❑ Repair C/. 1• I
2. Published Soil Survey available? Yes 3/ No ❑ If yes:- /981 1 %
i Massachusetts Department of Environmental Protection 357 —I„y/e„�;II e Q"4) �e�s
_
Bureau of Resource Protection—Wastewater Permitting Program Site Address or Map/Lot Number
1 Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
D, Determination of High Groundwater Elevation I Z
1. Method used ❑ Depth observed standing water in observation hole A.
B.
❑ Depth weeping from side of observation hole A. B.
El/ Depth to soil redoximorphic features (mottles) A. /8 B. /9"
❑ Groundwater adjustment(USGS methodology) A. B.
2. Index Well Number Reading Date Index Well Level
Adjustment Factor Adjusted Groundwater Level
E. Depth of Pervious Material
1. Depth of Naturally Occurring Pervious Material
a. Does at least four feet of naturally/occurring pervious material exist in all areas observed throughout the area proposed for the
El
soil absorption system? Yes Non
b. If yes, at what depth was it observed? Upper boundary: 1 2 If Lower boundary. 90"
F. Certification
I certify that I have 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 CMR 15.017.
rat/ if d_ - ii
Signs ae of Soil Evaluator Dates 29, 2..006 H/LLTOWN ENVIRONMENTAL CONSULTING
P.O.BOX 314
Mark Thompson April 29, 1997 CHESTERFIELD,MA 01012
Typed or Printed Name of Soil Evaluator 'Date of Soil Evaluator Exam (417)296-4499
Ern es-( / "!Skeca /Alor/ry4M An rr<-
Name of Board of Health Witness Board of Health
DEP Fenn 11 Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 4
n 357 Idoxydenvlle R0o.d I Leeds
{ Bureau of Resource Massachusetts Department Protection of Environme—Wastewater Permitting tal Protection Program Site Address or Map/Lot Number
(t Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (minimum of two holes required at every proposed disposal area)
Deep Observation Hole: Date: 6/2.1 Rib Time. 9 30 Weather. Ia•,zi, it GDs_
1. Deep Hole Number)-#1.?--2- Location (Identify on Plan ).
2 Land Use. L qv-' Surface Stones. Nona Slope (%). C% Vegetation Gras S
(e 9 woodland,agricultural field, vacant lot,etc
Landform: tirer9- Position on landscape.
3. Distances from Open Water Body 1504 ft. Drainage Way 75 ft. Possible Wet Area 7 5 ft.
Property Line 45 ft. Drinking Water Well 1504- ft. Other ft.
4 Parent Material. I u,via I Unsuitable Materials Present Yes❑ No[/
If Yes. Disturbed Soil(] Fill MateerriialD Impervious Layer(s)❑ Weathered/Fractured Rock ❑ Bedrock ❑
wa
5. Groundwater Observed: Yes Ly No ❑
� 9If Yes: Depth Weeping from Pit Z9 Depth Standing Water in Hole Estimated Depth to High Groundwater.
Redoximorphic Features Coarse Fragments
Depth Soil Soil Matrix: (mottles) %by Volume
Horizon) Soil Texture Color-Moist Depth th Color Percent Gravel Cobbles Soil Structure Soil Consistence
(In.) Layer USDA (Munselp (Moist) Other
(USDA) & Stones ( )
D-12: A SL 2 .5YS/f c°tiv^o 1 "dse
—
1Z 19a /w SL ZSY5/3 p L .Ass,ve a�
11 -3+9 C SL 5 Y6/I IT' crIPS��O b0% ISro SVo .. ,aSAVE
34-% C LS 5Y413 =, ittjcio. ldou-
Additional Notes Remove CI
HILL TOWN ENVIRONMENTAL CONSULTING
P.O. BOX 314 DEP Fonn 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 3 of 4
CHESTERFIELD,MA 01012
(413) 296-4499
Massachusetts Department of Environmental Protection 357 NaydenvilIt Roach , L text 5
Bureau of Resource Protection -Wastewater Permitting Program Site Address or Map/Lot Number
Form 12 Percolation Test
HILLTOWN ENVIRONMENTAL CONSULTING
A. Facility Information P.O.R I3LD3 MA Y CHESTERFIELD, MA 01012
1. Facility Information (413) 296-4499
• IV;i/ . -. Ryan
Owner Name
I .O , BOX ) I7 Map/Lot
Street A ress
Lee s MA o 1053
City Slate Zip Code
Percolation Test-
Date: 8119 lob
Observation Hole# p_ I
Depth Of Perc 37
Start Pre-soak y :Zp
End Pre-soak IDOL
Time at12" lo:oz
Timeat9" o : la
Time at 6" Io l kp
Time (9"-6") 22" r'v rI
Rate - Min/Inch a MIN r..1
'Minimum of 1 Percolation test must be performed in both the primary area AND reserve area.
Site Passed Site Failed /ID
II
Performed By: MfarIC./I l�orrpsovv
Witnessed By: L✓vt eyr ) 10.4-L1∎CU
Comments:
DEP Foml 12 Percolation Test•Page 1 of 1
N. l6— ` 9 THE COMMONWEALTH OF MASSACHUSETTS FE>�1 I 0 0
A/014igrPicss BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby grant to Construct ) Repair ( �Upgrad ( ) Abandon
disposal system at 367 A d l(e_
nv, 'a.
ite 404 94,
) an individual sewage
d
NOW 17i Zao4,
in the application for Disposal System Construction Permit No. 2414— Z q ,dated
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date . Q7 2006
FORM 2 - DSCP
FORM 1255(REV 5/961
Board of Health .P'✓ri.-1'N'�_s
DEP APPROVED FORM 5/96 ERNEST J. MATP,IEIJ, IS.,
DIRECTOR OF HEALTH
HaaBS,WARE
PUBLISHERS - BOSTON
WILLIAM J. RYAN
LORRAINE M.RYAN
357 HAYDENVILLE ROAD
LEEDS MA 010539715
Pay to the
Order of
'1 S
14)
For
•
FLORENCE SAVINGS BANK
as wa.srsrrt rte.w MOM
7
D
ry / 4496
es_ Ay_ ✓ -53-7153!1118
$ 51-ad .
dr cell Dollars 8 'V
it
IC 2Li87iPaw: L 23 927800u• 4496
Septic System Permit Payment Receipt
Permit#2A?6:29Date:,Va?a7�too onst Repair
Al nowt 0a. did Cash Cheek# WS
Address:,-3 S 7 �pn,�,�8�,.,µN.(GGL -
Owner:44%,n 4zw•
WILLIAM J. RYAN
LORRAINE M. RYAN
357 HAYDENVILLE ROAD
LEEDS,MA 01053-9715
Pay to the
Order of
4496
51168/2113
Date rJtL- a'%' d6 }
$ S`•ad
f i{ ae's^ aitl( .4C �L( Dollars 8
FLORENCE SAVINGS BANK
.._..(r`__.._.
For lorrt'� Jed 11�{pir�M _ tT - _
I: 2LL87L61381: LJ_ 23 92 ?BODO. 4496
T
Pere Test Witness Payment Record
Date: Amount: $__-diD
Property Owner LA%1.ft f.C.w tQ'- 442' 1111941/4-j
Property Address 3S? 1.1
New Construction Repair
WILLIAM.J. RYAN
LORRAINE M. RYAN
351 HAYDENVILLE ROAD
LEEDS,NIA..010539715
Pay to the
Order of
4466
Da a� 4_6 53-71582118
ar�Tm $ 6O- 00
c- °`.. Dollars _8
FLORENCE SAVINGS BANK
us ANN:swat RLIBIR:Wm
For 1
L: 24.€87 €6881: 1 23 ,427800u• .4466