595 Plan to Repair Septic System Plan to Repair
SEPTIC SYSTEM
for
Helen Symons
Located at
595 Haydenville Road
in Northampton, Massachusetts
Plan Number 389
Thomas S. Leue, R.S.
Homestead Inc.
1664 Cape Street
Williamsburg, MA 01096
413 628-4533
fax: 413 628-3973
Design Date: 6/24/06
Updated:
Contents
Site Plan: 1 page
Site Suitability Form 11.1: 1 page
On-Site Review Form 11.2: 2 pages
Groundwater Form 11.3: 1 page S
Perc Test Form m 12: 1 page �fa
Specifications: 3 pages
Plan Drawing: 1 page -
Separate To be signed by Owner(s)
Application for Construction Permit: 3 pages
Local Upgrade Approval Form: 5 pages
FORM11-SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No.: 595 Haydenvi ale Road. Northampton
Number:
On-site Review
Deep Hole #: 2 Soil Evaluation Number: PT-20— 389
Date: 5/29/06 9:30 qM Tme Weather: clear
Land Use. open field Surface Stones: no
Vegetation: grass Landform: kame terrace
Slope (%). 12%
Distance in feet from:
Open Water Body: >150 Drainageway: >150
Possible Wet Area: >150 Property Line: >150
Drinking Water Well: 120 Other:
Depth from
Surface
(inches)
Soil
Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
(inches)
Other
(Structures, Stones, Boulders,
Consistency,%Gravel)
0 — 7
7 - 25
25 — 94
A
a
Cl
fine sandy
loam 10YR 3/2 no
sandy loam 10YR 5/6 no
loamy sand 10YR 5/2 40
Mottles
10% gravel, friable
25% gravel, prismatic peds
firm
10YR 4/4 >5% fine, man
• MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Comments:
Parent Material (geologic): glacial outwash
Depth to Bedrock: Depth of Excavation: 94 inches
Depth to Groundwater:
Standing Water in the Hole: NQ Depth:
Weeping from Pit Face: NO Depth:
Estimated Seasonal Hi•h Groundwater: 40 inches
DEP APPROVED FORM-11N7/95
Location Address or Lot No.
FORM 11-SOIL EVALUATOR FORM
Page 3 of 3
• - • - IV_ - s.a. \. 1 - 11. •r
Homestead Inc. No.
Determination for Seasonal High Water Table
Method Used
❑ Depth observed standing in observation hole_ inches
❑ Depth weeping from side of observation hole inches
Depth to soil mottles 27 to 40 inches
❑ Ground water adjustment inches
Index Well Number_ Reading Date _ Index well level
Adjustment Factor _ Adjusted ground water level
Depth of Naturally Occurring 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? Yes
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on June, 1995 I have passed the 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
CMR15.017.
Signature:
Date: 5/29/06
DEP APPROVED FORM - 12/07/95
FORM 12-PERCOLATION TEST
Location Address or Lot No. 595 Haydenville Road Northampton
Homestead Inc. #: 389
COMMONWEALTH OF MASSACHUSETTS
Northampton, Massachusetts
Percolation Test*
Date:
5/24/06
Time:
1:28 PM
Observation Hole#
1 2
3
4
Depth of Perc: (in.)
i
I 40
(inches)
Start Pre-soak:
1:28 PM
End Pre-soak:
1:43 PM
Time at 12":
1:57 PM
Time at 9":
2:03 PM
Time at 6":
2:14 PM
Time (9" - 6"):
0:11:00
Rate - Min./Inch:
0:03:40,
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passes/Site Fails: Passes
Performed By: Thomas S Leue. Homestead Inc.
Witnessed By: Ernie Mathieu. Northampton
Comments:
DEP APPROVED FORM - 12/07/95
CONSTRUCTION SPECIFICATIONS
595 Haydenville Road. Northampton
Title 5 Septic System Plan Number 389
I. General
a No work on this system construction shall take place until a permit for the approved system plan has
been received from the local Board of Health. A copy of the Disposal Works Construction Permit should be
on site for inspection during the time of construction. Additional specifications may be included elsewhere
in this design.
b. Loading requirements are specified for the septic tank on the system calculations page. Loading
requirements for any other component are on the drawing.Normal loading systems are designated 1-1-10. If
11-20 rating is specified on the drawing and/or on the page for system calculations,the tank or leaching
facility shall be custom built to meet the increased loading requirements using additional rebar, greater wall
thickness and/or other approved methods. Follow the manufacturer's rating system and installation
procedures.
c. Alternatives to these specifications should be discussed with the Engineer in advance at 800 285-4533.
2. Septic Tank
a The septic tank selected by the contractor shall conform with 310 CMR 15.223. The septic tank shall be
a minimum effective liquid capacity of 1,500 gallons below the outlet invert,rectangular,and with a
minimum length to width ration of 1.5:1. Liquid depth to be 48". Compartmentalized tanks are not to be
used.
b. Septic tank shall be installed on a minimum of 6"of crushed stone,leveled to grade and thoroughly
compacted. Septic tanks shall have a minimum cover of 9". No structures shall be located directly upon or
above the septic tank access locations which interfere with performance,access,inspection,pumping,or
repair.
c. All three access covers to the septic tank shall have risers at least 20"diameter, if round,tightly fitted to
the tank to resist water infiltration,and terminated with a tight fitting cover no more than 6"below ground
surface. If, with the agreement of the Owner,one or more of the risers are terminated flush with ground,
these shall be secured against unauthorized entry with stainless steel hardware.
d. Inlet and outlet tees shall be of Schedule 40 PVC and shall extend a minimum of 6"above the flow line of
the septic tank and be on the center line of the septic tank located directly under the clean-out manhole. All
fittings to be glued and secured against any movement due to horizontal or vertical impacts. Cross-sectional
flow baffles shall not be used as substitutes for inlet or outlet tees. The inlet pipe elevation shall be no less
than 2"nor more than 3"above the invert elevation of the outlet pipe. Inlet tee minimum of 10"length below
water surface. The outlet shall be provided with a tee extending below the flow line 14"to 18". There shall
be an air space of at least 3"between the tops of the tees and the inside of the tank cover. Inlet tees may be
modified or a 6" riser on inlet cover may achieve this spacing. The tops of the tees shall be left open to
provide ventilation or separate ventilation shall be provided. The effluent tee shall be fined with a
removable plastic outlet filter,as manufactured by Polylok Inc.,model PL-120,Zebco, or approved equal.
Provide manufacturer's maintenance data, as boxed with the filter,to the homeowner or the engineer.
e. Septic tank should be inspected by the Owner or his representative for solids accumulation annually.
When the sum of the sludge and scum layer approach 1/3 the net working volume of the tank(net of 16"
total thickness),as measured at the center of the tank, the tank is due for pumping. Septic tanks shall be
Homestead Inc. Page 1 6/24/06
CONSTRUCTION SPECIFICATIONS
595 Haydenville Road. Northampton
inspected and maintained in accordance with 310 CMR 15.300 and applicable local requirements.
3. Pump System
a Pump chamber to be 1000 gallon concrete pump chamber. Include one manhole access 24"diameter that
terminates at or above ground surface with a steel manhole cover that can be secured.
b. Pump to be used is specified in the pump calculation worksheet.
c. Alarm system to be installed inside of dwelling unit in an accessible location. Alarm unit to have an
audible and visible indicator of water level above the pump on level. Include a shut off or silence mode.Use
Tank-Alert or similar level alarm system with both audible and visable high water level warning systems,or
approved equal.
d. Pump circuit and control circuit to be on separate and dedicated circuit breakers installed by a licensed
electrician.
4. Distribution Box
a The distribution box selected by the contractor shall conform with 310 CMR 15.232. Material of
construction shall be concrete or plastic lined concrete. A 6"sump is required in the d-box.
b. The distribution box shall be placed on thoroughly tamped and compacted sand or peastone a minimum
of 6"thickness, and shall be leveled utilizing a water flow test. Speed levelers shall not be used on a new
installation to obtain level and equal distribution flow,but should be installed after leveling is completed in
case uneven settling occurs in the future.
c. For inlet pipe slopes of 8% or greater, or where there is a pumped flow, the distribution box shall have
an internal cast baffle or solvent welded pipe tee to reduce the velocity of the influent flow. An internal pipe
"Y"or an elbow are not acceptable.
d. The first 2 feet of pipe out of the distribution box to be set dead level. Use a fernco connector to join to
pitched pipes beyond first two feet.
5. Piping
a. Piping to the septic tank(the building sewer) shall be 4"diameter,PVC Schedule 40 or better. Slope new
pipe installations at 1/4" per foot length.
b. All piping from the septic tank to the end of the system shall be 4"diameter, SDR-35 or better,except
as noted on the drawings. Slope pipe installations 1/8"per foot length as a minimu value.
c. Pressure piping, if any,to be 1.5"diameter, 160 psi black poly pipe or 2"diameter PVC Schedule 40
pipe,as called for in the page titled Pump Calculations.
6. Leaching Facilities
a General: All leaching facilities to be of the size and location shown on the drawings. All aggregate used
in leaching facilities to be of double washed stone. Where the name brand Infiltrator is called for in this
specification, other brands of the same dimensions may be substituted for the specified units.
b. Leach fields(Infiltration chambers): Arrange infiltration chambers on levelled ground. Parallel rows
should be placed a minimum of 6"apart. Add end plates as per manufacturer's assembly directions. Fill
spaces between rows with Title 5 sand to the level of the top of the chambers. See Calculation sheet for the
size differences between these Biodiffuser Brand and Infiltrator Brand.
Homestead Inc.
Page 2
6/24/06
CONSTRUCTION SPECIFICATIONS
595 Haydenville Road. Northampton
c. Breakout bather to be minimum 40 mil thick continuous sheet. Install barrier vertically from bottom of
excavation to height of top of leaching system. Seams of membrane material to be overlapped a minimum of
12 inches and glued with sealant as recommended by manufacturer. Material to be hypolon, low density
polyethylene,buna-N rubber,EPDM, or approved equal. Backfill in lifts of no more than 6"to assure
minimal deformation of membrane. If material is wider than the vertical distance to be covered as shown on
the drawing, fold excess material over at the bottom of the trench,or trim with upper edge level at
appropriate elevation.
7. inspection
a The contractor shall notify the System Designer, Tom Leue, at 800 285-4533 for System Inspections.
Under current code,inspections are required after(1) initial excavation,but before Title 5 sand is added,and
(2)after construction of the system,but before final backfill and topsoil are put in place. No installed
system component shall be buried greater than 1"depth at the time of final inspection. Please give a
minimum of 48 hours advance notice for inspections. The system shall be essentially complete at the time of
the final inspection,including all components in place,risers and covers installed,electrical components
functional, etc. The System Designer shall verify the system was installed as designed and authorize the final
grading.
b. If the System Designer finds the system is not ready for inspection after being called,or if serious
deficiencies are discovered,the System Designer must be notified to return to the job site when it is
complete. There will be a charge to the Installer of$50 for each return trip, payable directly to the System
Designer at the time of the reinspection.
c. Inspection and project closeout forms are generated within 24 hours of final inspection by the System
Designer. Signed Certificate of Compliance forms and As-built Drawings are sent to the Installer for a
signature and date. Forms are then returned to the System Designer for final processing.
8. Final Grading
a At conclusion of work, loam and seed all disturbed areas to perennial grass mixture. Added loam may be
required for adequate grass growth. Mulch slopes with hay,burlap or netting to minimize erosion.
b. Surface over leaching facility shall be pitched so as to shed rainwater. Also pitch surface over all tanks to
shed rainwater from any exposed covers. Do not allow surface water to puddle over any tank or component.
c. Systems built late in the year,where the grass cover does not have a chance to establish itself,requires
the contractor is to return after spring thaw and resurface final grades and add grass seed cover as required to
equalize and stabilize all disturbed areas.
s
Homestead Inc.
Page 3
6/24/06
595 Haydenville Road, Northampton
DESIGN CALCULATIONS
Tvoe of Installation' Repair
Structure: Single family home
Design Flow:
Total Design Flow:
Garbage Grinder: Not Allowed
Credit for Compost Toilet: 0%
Total Design Flow:
Percolation Rate: Measured
Percolation Rate: Design Rate
Loading Rate: Class I Soil
Infiltration Area:
Variance Request for Field Reduction
Net Field Size:
3 bedrooms
110 gallons per bedroom
330 gallons per day
1.0 factor
0 gallons per day
330 gallons per day
4.0 min. per inch
5 min. per inch
0.74 gallons/sq.ft./day
446 sq. ft.
0%
446 sq. ft.
per day
Info Snurrn
Owner
JO CMR 15 ?OR
multiply above
310 CMR 15.240
310 OAR 15.784
subtract credit
from Derm test
910 CMR 15.105.
310 CMR 15.242
divide flow by loading rate
(400 so. ft. code minimum)
multiply above
Trench Configuration:
BIODIFFUSER
INFILTRATOR BRAND
Model Used: Standard Capacity
Loading: sq. ft./In. ft. 6.50
Length per Chamber: 76 in.
Width of Chamber: 34 in.
Invert height: 6.5 in.
Overall height: 11 in.
Effective Leaching Area/Chamber: 41.2 sq. ft.
# Chambers required: 10.8
# Chambers provided: 12
# of Trenches: 2
# Chambers per Trench: 6
Sand outside Chambers: 2 in.
Effective Trench Width: 3.0 feet
Space between Trenches: 6.0 feet
Total Trench Length: 38.0 feet
Effective Leaching Area: 494.0 sq. ft.
Net Calculated Capacity: 366 gals/day
Loading: H-10
Quick 4 Standard
6.96
48 in.
34 in.
8 in.
12 in.
27.8 sq. ft.
16.0
16
2
8
2 in.
3.0 feet
6.0 feet
32.0 feet
445.4 sq. ft.
330 gals/day
H-1 0
v-mac
s
System Designer
Homestead Inc.
6/24/06
DEP technology ratings
Manufacturer's rating
Manufacturer's rating
Manufacturer's rating
Manufacturers rating
length x loading area
field size divide
by leaching are
judgement
judgement
em n
chambers + sand
310 CMR 15.251 (1) 2
overall row length
# chambers X capacity
area X loading rate
judgement
ea, Ott I iaati i. Wecumadeateed
212 711aua Sheet
71oldate, 7101 01060
7d. 413-587-1214
?ax 413-587-1221
Title V Certification of Compliance
TO BE FILLED OUT BY THE SYSTEM INSTALLER
INSTALLER SIGN-OFF
Pursuant to 310.CMR 15.00 of the State Environmental Code:Title V,Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage,Section 15.021 (3),the Installer of a system is required to sign
this form as a condition for issuance of a Board of Health Certificate of Compliance for the onsite septic
system.
This is to certify that the onsite sewage disposal system that I installed as:
'Tits. 39- 7158
r /fit fti0 4t
at i� ^- on U yob
(Address)
(Date)
has been constructed in compliance with 310 CMR 15.00, and all local requirements.Any changes to the
original approved plans have been reflected on an as-built plan that has been submitted to the Board of Health.
SRI 6/I C'
(Print Installer's nam
new construction
repair(existing system)
,DWCP number D6 - S
SNP_ )C tkicv Dv✓ i44WP
(Street,City,and Zip Code)
SpoN, H . 0133 I
( 30 Ole
NOTE: This certification represents no warranty,expressed or implied as to the functioning or longevity of the on-site
subsurface disposal system.Rather,the plan and installation are in compliance with all applicable rules and regulations as are
in effect at the time of plan submittal.
No.
FORM to - APPLICATION FOR DSCP
Fee
CO? ONWT9(iT"fOTaaASSAC#USEOts
Hoard of Health_ Nertham
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to: Repair
( ) Complete System ( X ) Individual Components
Location 595 Haydenville Roa
Map/Parcel
Lot#
Installer's name
Address
Telephone #
Building Type: Dwelling
Bedrooms: .1
Other - Type of Building
No. of persons
Other Fixtures
Design Flow (min. required):
Calculated design flow:
Design flow provided:
Owner's Name Helen Symons 0.41.
Address
Telephone #
Designer's Name
Address
Telephone
Lot Size (sq. ft.)
Garbage grinder'
9 High St.
Haydenviller
268-8322
Thomas Leue,
1664 Cape St
413 628-4533
5116 .200
(no)
Y%9-_a ML7,58
MA 01039-97190
Homestead Inc.
. , Williamsburg MA
Showers ( ), Cafeteria ( )
330 gpd
330 gpd
330 gpd
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Soil Evaluation
fine loamy sand soil
389
Thomas Leue
5/24/06
DESCRIPTION OF REPAIRS OR ALTERATIONS 2 new leach trenches using Leaching
Chambers.
The undersigned agrees to install the above described Individual Sewage Disposal System In accordance with
the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance
has been issued by the Board of Health.
Signed d ✓ii <. Sfjj i
Inspections
Date /o/S/a
DEP APPROVED FORM 596
FORM 2A - DSCP
No. Fee
COM24014-'W2911TV OF WISSACIRISnr is
Board of Health, Northampton, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to: Repair an individual sewage disposal system at
595 Haydenville Road, Northampton as described in the application for Disposal System Construction
Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date Board of Health
DEP APPROVED FORM 5N6
FORM 3A - CERTIFICATE OF COMPLIANCE
No. Fee
Coaaavtoa(WZRLTil(o' ISSACa(usrr"s
Board of Health, Northampton, MA
CERTIFICATE OF COMPLIANCE
Description of Work: ( ) Complete System ( X ) Individual Components
The undersigned hereby certify that the Sewage Disposal System: Repair
by:
at: 595 Haydenville Road, Northampton
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved
design plans/as built plans relating to application No.
dated 6/24/06 . Approved Design Flow 330 (gpd).
Installer:
Designer:
Inspector:
Thomas S. Leue, Homestead Inc.
Date:
Date:
Date:
The Issuance of this permit shall not be construed as a guarantee that the system will function
as designed.
DEP APPROVED FORM 596
FORM 11-SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No.: 595 Haydenvi 1 I e Road, Northampton
Number: 3@2
On-site Review
Deep Hole #: 1 Soil Evaluation Number: PT-20— 389
Date: 5/29/06 9:30AM Time Weather clear
Land Use: open field Surface Stones: no
Vegetation: grass Landforrn: kame terrace
Slope (%): 12%
Distance in feet from:
Open Water Body >150 Drainageway: >150
Possible Wet Area: >150
Drinking Water Well: 120
Property Line: >150
Other:
Depth from
Surface
(inches)
Soil
Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil Other
Mottling (Structures, Stones, Boulders,
(inches) Consistency,%Gravel)
0 — 7 A
7 - 24 B
24 — 94 Cl
fine sandy
loam
sandy loam
loamy sand
10YR 3/2
10YR 5/6
1OYR 5/2
Mottles
no
NO
2.7
10% gravel, friable
25% gravel, prismatic peds,
firm
10YR 4/4 >5% fine, many
*MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Comments:
Parent Material (geologic): Glacial outwash
Depth to Bedrock: Depth of Excavation: 94 inches
Depth to Groundwater:
Standing Water in the Hole: L! Depth:
Weeping from Pit Face: NO Depth:
Estimated Seasonal High Groundwater: 26 inches
DEP APPROVED FORM-12/07/95
IT
ED STATES
IT OF THE INTERIOR COMMONWEALTH OF MASSACHUSETTS
DGICAL SURVEY
DEPARTMENT OF PUBLIC WORKS
686°x°^E 68] DB 42 30 Rw rep fw�uiaMSBUR�� X91 40'
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No. pT-20-389
Commonwealth of Massachusetts
Northampton, Massachusetts
FORM11 -SOIL EVALUATOR FORM
Soil Suitability Assessment for On-site Disposal
Performed By:
Witnessed By:
Thomas S. Leue Date: 5/24/06
Location Address or Lot No.
New or Repair Construction: Repair
Owner's Name. Address &Tel. #
Helen Symona
9 High St .
Haydenville. MA 01039-97190
268-8322
Office Review
Published Soil Survey Available: No ❑ Yes
Year Published: 1980 Publication Scale: 15840 Soil Map Unit: 9
Drainage Class: Well drained.
Soil Limitations: Moderate to severe effluent limitations: poor filter.
Soil Type: AoC. Agawam fine sandy loam
Superficial Geologic Report Available: No ® Yes ❑
Year Published Publication Scale:
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Within 500 year flood boundary No Yes
Within 100 year flood boundary No Yes
rl
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Condition Month
Range: Above Normal LI GS):Normal Below Normal ❑
Other References Reviewed:
a
DEP APPROVED FORM. - 12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 of 5
cog1M4o1W(wEA.LT?-CoE MAssAC7-&rU.sETts
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)
t •.
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: Helen Symons
Address: 9 High St.,
Haydenville,MA 01039-97190
Phone # 268-8322
Address of facility: 595 Haydenville 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.)
leach pit
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 unknown gpd
Approved' no
Approval Date around 1955
If not, why? too old to find files
b) Design flow of proposed upgraded system
c) Design flow of facility 330
6) Proposed upgrade of existing system is
X Voluntary
Required by order letter, etc. (attach copy)
_ 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 leaching trenches made of Infiltrator type chambers.
330 gpd
gPd
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 ft. separation at 4 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 1207/95
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)(O(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: 5/24/06
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 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 standards set forth in 310 CMR 15.402 through 15.405.
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 12/07/95
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 CMR 15.000 is not feasible:
In order to control cost and to minimize surface disurption,
request reduction to groundwater of 3 ft.
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
Not needed. conventional system feasible.
c) a shared system is not feasible:
Not required. lot wt] 1 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
"L 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."
f S
Facility Owner's sign hln e
Helen Symons
/o/slab
ate
Print Name
Thomas S. Leue Homestead Inc. 6/24/06
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 12'07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 of 5
COM4.ONwflLTi-COT 2vMssR04-(Usrn is
Northampton, Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility.system owner:
Type of facility:
System designer:
Name: Helen Symons, 9 High St . Haydenville, MA 01039-
97190
Address of Facility: 595 Havdenville Road
Residential
design flow per 310 CMR 15203 330 qpm
Name:Thomas LeueAddressHomestead Inc. . 1669 Cape st. ,
Will amsburg. MA 010 6 Phone No. 413 62R-4534
Local Upgrade Approval granted for:
reduction in setback(s) (specify'
per rate of 30-60 min.lnch (specify rate)
reduction in SAS of up to 25%
fsoeriN% reduction&size of SAS)
x reduction in separation between SAS & high groundwater
Isneriry reduction&oerc rate) 3 ft. separation at 4 min per inch
relocation of a well (explain'
I ist local variances wanted (no DEP anoroval required oer 310 CMR 15.412(411
I ist variances aranted reauirina DEP aoproval
.n- . • .--I A..r.v-I r
Name &Title
Signature
city/town Qata
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