28 Title 5 Upgrade Application 2013 Important:
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Commonwealth of Massachusetts
City/Town of Florence
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
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:
Richard& Camilla Humphreys
Name
28 Morningside Drive
Street Address
Florence MA
City/Town State
2. Owner Name and Address Of different from above)
Richard &Camilla Humphreys
Name
Florence
City/Town
01062
Zip Code
01062
Zip Code
Street Address
MA
State
(413) 584-3549
Telephone Number
3. Type of Facility(check all that apply):
Z Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
Single family home-4 bedrooms- garbage disposal to be removed
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ® Conventional
❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Infiltrator Quick4 Low Profile trench system -3 trenches with 10 Infiltrators per trench
Florence-28 Morningside Drive-Richard Humphreys-Local up-grade
approval form-Form 9a-Sept.24 2013•rev.7/06
Application for Local Upgrade Approval*Page 1 of 4
Commonwealth of Massachusetts
City/Town of Florence
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:
440
gpd
440
gpd
440
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
• 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 a failing subsurface sewage disposal soil absorbtion system. Install a new distribution box
and an Infiltrator Quick-4 low profile trench system-3 trenches with 10 Infiltrators/trench
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
❑ Reduction in separation between the SAS and high groundwater:
3'
Separation reduction
Percolation rate
Depth to groundwater
Florence-28 Momingside Drive-Richard Humphreys-Local up-grade
approval form-Form 9a-Sept.24 2013•rev.7/06
ft.
20 mpi
min./inch
3'
ft.
Application for Local Upgrade Approvals Page 2 of 4
Commonwealth of Massachusetts
City/Town of Florence
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):
N/A
❑ 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
❑ 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:
Daniel Wasiuk September 12, 2013
Evaluator's Name(type or print) 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:
This is a small residential lot with a stream and BVW Westerly of the lot and a drainage easement to
the north.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
An Infiltrator Quick-4 Low Profile trench system is proposed
Florence-28 Morningside Drive-Richard Humphreys-Local up-grade
approval form-Form 9a-Sept.24 2013•rev.7/06
Application for Local Upgrade Approval• Page 3 of 4
Commonwealth of Massachusetts
City/Town of Florence
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:
Neighboring lots are too small.
4. Connection to a public sewer is not feasible:
No public sewer 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."
Facie Owners Signature Date
Print Name
Timothy E M ginnis R.S., LSE
Name of Preparer
70 Montague Road
Preparers address
Massachusette-01027
State/ZIP Code
Florence-28 Morningside Drive-Richard Humphreys-Local up-grade
approval form-Form 9a-Sept.24 2013•rev.7/06
Sept. 24, 2013
Date
Westhampton
City/Town
(413)527-5291
Telephone
Application for Local Upgrade Approval*Page 4 of 4