549 Title 5 Inspection Documents, COnservation COmmission Permit Depth of Naturally Occurine Pervious Material
Does at least four feet of naturally occurring pervious muerial exist in all areas observed throughout the area proposed for the soil
absorption system? ✓
If yes,what is the depth of naturally occurrin g pervious-ous aterial?
If not,what is the depth of naturally occurring pervious material?
On-Site Review
Deep Hole Number: Date: 1/6/3 Time:MrIJRA Wed
Location(identify on site plan):
Land UseNegerado¢ LaymitieA e� Slope(%)--
Landforrn: aye) /.
Position of Landscape: �t
Distance from:
Open Water Body
Possible Wet Area
Drinking Water Well
Fee
Feel
Feel
Drainage way
Property Line
Other
T.P.# I-I
Surface Stones: on
5,6,t€6 .N As
Feet
Feet
Feet
. __
DEEP OBSERVATION HOLE LOG
Depth from
Surface
(Inches)
I Soil
Horizon
Soil Texture
(USDA)
Soil Color
(Mansell)
Soil
Mottling
Other(Structure,Stones,Boulders,
Consistency, %Gravel)
L p1 '
8 -1g
S139
30-10("
A
23
er
CL
56-
(.5
L5
C,s
/sirl
70yrs3
0/i 571
grawe 4,
- ye5;fen , ibicks
-SzymF
Parent Material(geologic)
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water: >
Depth to Bedrock: >
Weeping from Pit Face:
BOARD OF HEALTH
MEMBERS
JAY FLEITMAN,M.D.,ACTING CHAIR
SUZANNE SMITH,M.D.
DONNA C.SAISOOM
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
DIRECTOR OF PUBLIC HEALTH OFFICE OF THE
XANTHI SCRIMGEOUR,MHEd,CHES, BOARD OF HEALTH
(413)557-1214
FM(413)557-1221
212 MAIN STREET
NORTHAMPTON,MA 01060
Site Suitability for On-Site Sewage Disposal
Project Number Date: O(.i3 !i/i
Performed by. /m /�(a9.-;+. s Equipment Operator: :/Y 6
Health Inspector. p, was.,k ill xi, g_rtfrt J
Site Address Client Name&Address
-ae4Se4/4,40- '5
/ fe,/G
New Construction 0
Office Review
Published Soil Survey Available: No 0 Yes
Year Published Publication Scale Soil Map Unit
Surficial Geologic Report Available: No 0 Yes 0
Year Published Publication Scale Geologic Material(Map Unit) Landform
Flood Insurance Rate Map:
Above 500 year flood boundary 0 Within 500 year flood boundary Cl Within 100 year flood boundary ❑
Wetland Area:
National Wetland Invetory Mapy(Map Unit) Wetlands Conservacy Program Map(Map Unit)
Current Water Resource Conditions(USGS): Month
Range: Above Normal O Normal O
Other References Reviewed:
le 4
Drainage Class Soil Limitations
Below Normal O
re. c 1rJ- 1-fie rercotanen .es. .w...,.o
Pere 1
Time
Measurement
Time
Measurement
-1
Begin Saturation
in VAM
Begin Saturation
End Saturation
/0>a44
End Saturation
9"depth
Measurement
//Vim"
9.,depth
Measurement
6"depth
Measurement
efe
6"depth
Measurement
Elapsed Time
9"to 6•
.2:
may/ /
DD
:�; 2%1
/,4,t,.y
Elapsed Time
9"to 6"
Percolation Rate <I mm.7m
Bottom of Percolation Test Tole:
r S(l/ wch
Bottom of Percolation Test Hole:
ermination fa r Se aso n allii*
Method Used
Depth observed standing on observation hole> ❑ 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
Se. F - I t; )
(4<-, 7- - o27 1- -h c(
i .
LAND OF REMAINING L"ND • ,ALTER R • • {e J Jfl"f �`
LAWRENCE E l'R3E1 *� ' 697 PAGE 209-TRACT NO2 F ('j
'1' N56•.3.y OT"W P AND BOOK 697, PAGE 2l/-LOT NO 2 4 f /�
y. �.�. �- I 513M 24934'MI h l/ µA/
'Y,s, ,,, i 1245,40 VcA Ig6A04' 59-•0745 E j 5,>J. W -r _ N+.
'"yb (60,9t '°`$ 6 N12 \ / i72DE / a
J' 0,....S.o,*„. , V 405 II OP S c
i £ yM1 ? //236095q •T/ L3 eg
�'° aW¢^ ro' / Q 8
\( 20i. 2 ash BARN 6.SS7 ACSSSt /••�p1 i
9 +".•�;� L-] (277➢p HECTARES) h, �,\
•-i-: Nm L PORTIONS OF g` 1111 • 09 PLANNING BOARD
n BOOK 697 PARE 209—TRACT NO 2 /, NORTHAMPTON, MASS
DWE NG AND BOOK697, PAGE2Il-LOT •. b
r .Z / , APPROVAL BY THE PLANNING BOARD UNDER
y..m '� 't /l SU6YYN /0N CONTROL LAWS NOT REWIRED.
1 CERTIFY THAT THIS PLAN N i L z • 11/ DATE- -.a•uc-L-2. 1 ------
HAS BEEN PREPARED IN CORER?
REGULATIONS
OF E THE REGISTERS WEALTH 6T 901 6 1111 •:b SIGNED rs `� it / ---
W U Ar•.,
lTr WITH THE 1976 RULES AND
▪ - 5•PA 666- M b // hh .4,
OF OF MASSACHUSETTS. z 3 IJ'"t45 M N hh / / 16 'b.
GATE ,_./277 w h¢ �/
5/6NE ��f8 �- W h 1111/ h
n LANDA 1111 "4
RHILlP KELLY 2 .426 • /�/A b`� —LEGEND-
.0% � / • EXISTING IRON HN /00" O' lCn 200 3QY .�
.x p§5\2� h0 . _P f 0 SET IRON HN •rt >�R _'11111_
6 {m
SEE.. PLAN:r,• '.16A' \ hP V• 'r a O NWNMgRN6 POINT
06159 _ �/ 0 62,;"3 •-1 .0— $ : - FEACE LINE
—PAGE 46 " P/ PLAN OF LAND IN M
hp try• \ O N = STONE WALL +.
a 01� ; /�ti M 0 ti NORTHAMPTON, MASS. .-.1
rr h N SURVEYED FOR
106 % /
e i . yb q ? r ., WALTER R JAGER /a
/- 4 6tY/.∎•Le nest::
Y U P li7 6 136499 y A 6,66 SCALE /00' JAW 21,/1t77
,..x / ^ vHe9.4O Zd'W ESf 3 (((\///4r.,„ FROM THE OFFICE OF �-,
• i _ ,ym
248.72 TR MOM +/ 3402.
HAWED L. EATON, REGISTERED LAND 202211M21 •
TA4.,-1Q, 44-_ SUNRISE DRIVE HADL£Y 5 924.4 "Tr
§J
-NOTE-
THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER
SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE
SURVEY AND IS NOT TO BE RECORDED. I
i''i /�S.l1-TL f-ilr[Q/ Tl3 I
G0 ]-_a2 } -06 1
Pr - Pare el L-D
3510-73
6 PAR. I 05 7 _ 0 it-GO /
{S0 $ 3510-73
, ---,JAR. -
PAR. II .
_\p /
\" 3005-263 d 3005-263 PAR. 4 _; •� -
PAR. 1
I ] G 9 1
Q LarYp� 'A 3005-263 PARCELS 2 6 3
-
440 re ri of(0CaS
TO: THE NORTHAMPTON CO-OPERATIVE BANK S
THE FIRST AMERICAN TITLE INSURANCE COMPANY
—NOTE-
1 HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING et THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
MONUMENTATION ALL EASEMENTS. ENCROACHMENTS AND BUILDINGS ARE LOOMED ON 1A i AND DOES NOT CONSTITUTE A PROPERTY SURVEY
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY YANHIN THE LOT LINES, —MORTGAGE LOAN INSPECTION PLAT—
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A ROOD PRONE ARE A.S6.SHOWN ON FEDERAL ROOD INSURANCE MAPS FOR L NORTHAMPTON, MASSACHUSETTS
6
COMMUNITY # PREPARED FOR
1 I�, LEONARD C. JEKANOWSKI b BARBARA L. WEBB
SURVEYOR:Rco- i-0- I. =v1 t�wosn o,
SCALE: 1"=300' MARCH 9, 1990
HAROLD L EATON AND 2 -E, REGISTERED PROFESSIONAL ASSOCIATES.
AND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS
Commonwealth of Massachusetts
City/Town of 53/9 F:-M J� /
Septic System Installation Checklist 'd
B. Application Checklist(cont) is/`%/• art a r/
2. Constriction Inspection
a) Building Sewer(310 CMR 15 222) Approv • N/A Problem
All waste pipes bed into building sewer Basement check ❑ ❑
Schedule 40 PVC 4'or cast iron Verify by reading pipe ❑ ❑ ❑
Minimum slope of 0.01-0.02 Visual ❑ ❑ L
Pipe laid in continuous straight line Visual .—•,_i U "
Pipe laid on Compact, firm base Visual ❑ ❑ ❑
Cleenouls precede all charges in Verify by visuaUtape ❑ ❑ ❑
arpnmenugrade
Cleanout provided every 100 fl Verify by visual/tape ❑ ❑ ❑
Beck/ill material clean Visual ❑ ❑ ❑
b) Septic Tank(310 CMR 15 223) Approved N/A Problem
Tank is set level with 6'stone under
Check with level ❑ ❑
(15 228) .�,-
Tank is required size/loading per plan Verify with plan ,RI/✓/
❑ ❑
Inlet and outlet we al proper location Verify with plan LJ ❑ ❑
(15227)
Tank is water tight(15226) Test QV ❑ ❑
Oulbt tees extend 6•above flow the Verify by visuaUtepe Li/ ❑ ❑
Approved fitter device placed at outlet DEP list L.J// ❑ ❑
Gas baffle entailed at outlet tee Visual 1[R/ ❑ ❑
Inlet and outlet tees on center line Visual L� ❑ ❑
Tank is baddiWed with acceptable material Visual [a} ❑ ❑
Notes:
Spec Sywm InfWMn Ch d00 I IMe.aoc•ale
Form Name•Per 2 of 6
-,Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B.Application Checklist (cont)
c) Distribution Box(310 CMR 15.232) Approved WA Problem
All outlet pipes at same elevation Check by adding water ❑. ❑
Number of outlets Number of laterals pa—fin/
Inlet tee min. 1'over outlet Visual and wltape �'j ❑ ❑
D box set on level base Visual L- Li u
I
Top of D box 36'max depth Visual and w/tape
D box is water-tight Add water '—. ❑
D box has a minimum of 2'thick wall and Li E ❑
IT inside dimension
d) Pump Chamber(310 CMR 15.231) Approved N/A Problem
Tank is set level Visual and w/level ❑
Proper volume is provided Check plan and tank ❑ ❑ ❑
Float elevations set per plan Measure wltape ❑ ❑ ❑
Min.2'delivery line to D box Visual ❑ ❑ ❑
Number of pumps: ___ __.._. ❑ ❑ ❑
Specified pump provided or designers ❑ ❑ ❑
approval for equal puny
Correa pump sequence ❑ ❑ ❑
Covers set to grade ❑ ❑ ❑
Electrical permit provided ❑ ❑ ❑
5 of store beneath chamber Visual ❑ ❑ ❑
Chamber is water-tight Test ❑ ❑ ❑
Min. 9'cover provided Visual ❑ ❑ ❑
Correct loading provided per plan Visual on tank ❑ ❑ ❑
Notes:
Sepik System Inflation Cfrc*Sat 11.02doc•date Form Name•Pape 3 ore
c.Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist(cont)
e) Loathing Facility(310 CMR 15.240)
No frozen material used including back fill Vsua.
No day, tailings or stones larger than 6' for
cover material
Soil at bottom/sides of excavation matches
info on deep holes
All impervious layers removed Visual
No remaining NB honzons \Rual
Groundwater conditions match plan and
deep holes
Vented N under impervious cover per plan
(15.241)
Vent is protected from precipitation
and animal entry
Cover of a minimum of 9'over leach area
VlsuaUCheck plan
Pipe slope equal to 0.005 Check wltransit
Leach area per design(15241)
Excavation is level and at required depth
Removal of 5 ft material and replacement
(if in fill)
Back fill material is acceptable
Final contours correct per pan
Surface/subsurface drainage away from
leach area
Final grade and side slopes we stable
Distribution lines are capped, vented, or
connected together
Impermeable bamer(15.255(2))
Retaining wall inspected by PE
Retaining wall is water-proofed
Retain! • im s at correct
depth/hei
sepia syeni Ingle Won ChocI dt 11-09.00c•4Ne
Visual/check plan
Visual/check plan
Visual
Check with an
Approved N/A Problem
Fam Name•Pepe 4 of B
L.
Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist (cont)
P Leaching trenches (310 CMR 15251)
Approved NiA Problem
Number of trenches.
❑ ❑ ❑
Depth of trenches. ❑ ❑ ❑
❑
w50th of trenches. ❑ L7
L.-. 0
Trench spaang per Plan
Stone is double-washed(3/4'to 115') (15.247) `''
9) Leaching fields(310 CMR 15.242) E51
❑ ❑
Length of field:
—__
Width ❑
dth N field:
Min. of 2 distribution lines
❑ ❑ ❑
Separation distance conforms to plan ❑ ❑ ❑
stone is daub/a-washed(3/4'to 1W!(15.247) ❑ ❑ ❑
h) Leaching Pits(310 CMR 15253)
Number of pits: ❑ ❑ ❑
Depth of pts: ❑ ❑ ❑
Stone is double-washed[3/4'to'PSI(15.247) ❑ ❑ ❑
Each pit has min. 1 20' access cover ❑ ❑ ❑
Piping network and configuration of ❑ ❑ ❑
pits/chambers per plan
i) Tight Tank(310CMR 15260)
Tank is set level with 6'stone under Visual and with level
Tank is proper size per plan Visual with plan
Pumping contract has been provided
Covets to grade Visual
M/alarm set at 3/5 tank repanty Check floats by raising
. AN alarm test on separate arcuit Set off alarm
spat stews Gomm ChecFH/111N.apc•__
❑ ❑ ❑
❑ ❑ ❑
❑ ❑ ❑
❑ ❑ ❑
❑ ❑ ❑
❑ ❑ ❑
Fpm Name•Pips S of
‘Commonwealth of Massachusetts
City/Town of
Septic System Installation Checklist
B. Application Checklist(cont)
j) Certrcate of Compliance(310 CMR 15.0211
As Built Plan Submrtled
Signed by Installer
Signed by Designer
Certificate of Compliance Issued
Notes.
Date
Date
Date
Date
Sap*ardent lakeMllon Cheanal 11-09 Aoc•tame
Form lane•Page 6 of 6
Important:
When filling out
forms an the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
arifn
t5form3.doe-06/03
Commonwealth of Massachusetts
City/Town of Florence
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
❑ Repair or replacement of an existing system component
Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
DSCP Date
DSCP Number
Robert and Athleen Zimmerman
Facility Owner
549 North Farms Road
Street Address or Lot#
Florence
City/Town
Designer Information:
Timothy E. Maginnis
Name ^ �fr �u Name of Company
Signature C• rr � '! '�. November 7, 2013
Date
Installer Information:
Clifford Clark
Name y if (22 Sign ure F
Clark Excavation
Name of Company
November 7, 2013
Date
Use of this system is conditioned on compliance with the provisions set forth below:
No garbage disposal allowed
The issuance of this certificate shall not be construed as a guar ntee that the system will function as
desi / le)
A
ving Authority
Signature
Certificate of Compliance•Page 1 of 1
Infiltrator leaching trench system)
3 Trenches with 9 Low Profile Infiltrators per trench
EFFLUENT FILTER NOTES
1. Effluent filter should be cleaned at least once per year.
2. Remove cover, pull out filter and wash with garden hose.
3. Replace filter and cover.
6
1
40 mil poly barrier
(3 sides)
Existing distribution box ("D')
Barn Floor drain
4' pvc solid pip
(relocated)
4' pvc solid pipe
5
0 (fluent filter
unp out non-hate ('C')
ewe
rns
AS-BUILT DIMENSIONS
500 gallon concrete
septic tank
4' pvc solid pipe
—Sewer pipe
'A' to 'C'= 17'-3'
'B' to 'C' = 22,_0'
'M' to 'B' = 72'-0'
'F' to 'D' = 103'-0'
NOVEMBER 15, 2013
N 549
Existing
3 bedroom
house
Existing well
AS BUIILT PLAN
INFILTRATOR TRENCH SYSTEM
549 North Farms Road
Florence, Massachusetts
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor-do not
use the return
key.
IA,
,Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
020/3/t7
Number
Fee
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
1. Location of Facility:
549 North Farms Road
Address or Lot#
Florence
City/Town
2. Owner Information
Robert&Athleen Zimmermann
Name
549 North Farms Road
MA.
State
01062
Zip Code
Address Of different from above)
Florence
City/Town
3. Installer Informa io
TBLT
Name
Address /
City/Town
4. Designer Information
Timothy E. Maginnis R.S., LSE
Name
70 Montague Road
Address
Westhampton
City/Town
MA
State
f413) 585-0405
Telephone Number
01062
Zip Code
Name of Company
I
ate y/y-;'k/—/ 2ir Zip Cti! /
Telephone Number ••J//
Name of Company
MA.
State
(413) 527-5291
Telephone Number
01027
Zip Code
t5form1a.doc•06/03 I Lu< ,�� ,; n �_ Application for Disposal System Construction Permit•Page 1 of 3
\\Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
/.e
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:
2
❑ Garbage Grinder(check if present)
6
Number of Persons Served
❑ Cafeteria ❑ Other fixtures
330
Gallons per Day
330
Gallons
October 1, 2013
Date of Original
Number of Sheets Revision Date
Title of Plan
B. Description of Soil:
Sandy loam -Fine sandy loam -Loamy sand with lg. stones and boulders
9. Nature of Repairs or Alterations Of applicable):
Replace a failing subsurface sewage disposal system. Install a new 1,500 gallon fiberglass septic
tank by Roth Global Plastics, a new distribution boxe and three Infiltrator Trenches with 9 Ouick4 Low
Profile Infiltrators per trench.
10. Date last inspected:
August 31, 2013
Date
t5fonntadoc•06/03 Application for Disposal System Construction Permit•Page 2 of 3
Commonwealth of Massachusetts
City/Town of Florence
Application for Disposal System
Construction Permit
Form 1A
020/3 19
Number
$ /50
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 th system in operation until a Certificate of Compliance has been issued by this Board
of Health.
Nn
Signature
Ap lication Approved By:
re
ame
434)
Application Disapproved for the following reasons:
ORTRkvirt '
212 MAliAr Sikh
Date
//3
Date /
Conditions:
1).System Designer mu t map ct and ye ify in writing
That the sewage dIsp ea!sr a m a%as ustaned
In accordance with I e apps n cc plan and an, olc
2)_If is a system with Ike. .:A.s s.n ..
Title 5 fill shc S -[asn Oedu
inspection al alike Ots pst satatt
oflhc fiIL
3).No changes can he nr,.dc
loslalicr is ol[ol n pr h..
Dcsinner and nm G
a).004 r son ci,,,„,
t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3
BOARD OF HEALTH
DONNA C.SALLOOM,CHAIR
SUZANNE SMmH.M.D.
JOANNE LEVIN,MD.
Baysnln Wood.MPH,Daeotor
Jmerla War.MPH,Health dopegpr
Patriots Abbott FW.Public Hewitt Nurse
Heather McBride,Clerk
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)587-1214
FAX(413)587-1221
212 MAIN STREET
NORTHAMPTON,MA 01060
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE: As of 1/1/11, Septic System Pemtits will not be issued by the Northampton Board of Health
until we receive this form signed by the Northampton Conservation Commission Staff Member.
The Conservation Commission can be reached by contacting:
0 Sarah LaValley,Conservation,Preservation and Land Use Planner
SLa Va ilev0 northa m pto nma.Bov
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton,MA 01060
Property Owner:A FAd/t l/Z -ole nie..4/ Address: 919 V. ,C', 6 A
Engineer. ;+'I AN5
42 ��„ %' /i arV-tie/14 C9+r1R(.Due— %?MtPll� (�q�Uite�
Co servation Corn t on Conservation, Preservation and Land Use Plar{(ler
Date: (vl l�3
Important:
When filling out
forms on the
computer,use
only the tab key
to move your
cursor-do not
use the return
key.
v
Tern
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
15.4040), 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:
Robert&Athleen Zimmermann
Name
549 North Farms Road
Street Address
Florence
City/Town
2. Owner Name and Address Of different from above)
Robert&Athleen Zimmermann 549 North Farms Road
Name Street Address
Florence MA
City/Town State
01062 585-0405
Zip Code Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
MA
State
4. Describe Facility:
Single family home-3 bedrooms-no garbage disposal
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
® Conventional
01062
Zip Code
❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
3 Infiltrator Quick-4 Low Profile trenches.
Florence-549 North Farms Road-Local up-grade approval form-Form
9a•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:
Unknown
gpd
330
gpd
330
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 system. Replace a failing 1,000
gallon concrete septic tank with a new 1,500 gallon fiberglass septic tank, SEPTECH by
ROTH GLOBAL PLASTICS. Install a new Infiltrator trench system with 3 trenches
and 9 Quick-4 Low Profile Infiltrators per trench.
August 31, 2013
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 in separation between the SAS and high groundwater:
3'
ft.
30 mpi
min./inch
3.33 (40")
Separation reduction
Percolation rate
Depth to groundwater
Florence-549 North Farms Road-Local up-grade approval form-Form
9a•rev.7/06
W.reduction
Application for Local Upgrade Approval 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 August 31, 2013
Evaluators Name(type or print) Signatu 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 system is proposed to be located on a steep slope. It would not be economically
feasible to comply fully with Title-5.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
An Infiltrator Trench system is being proposed. Three trenches with 9 Quick-4 Low Profile
Infiltrators per trench.
Florence-549 North Farms Road-Local up-grade approval form-Form
9a•rev. 7/06
Application far 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 far away and are all served by private water supplise.
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):
Z Application for Disposal System Construction Permit
Z 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."
r
Facii Owner's Signature Date
'{ ( jPP Z, Z( U4et CIG1ctt \
ri it Name
Timothy E Maginnis R.S., LSE October 1, 2013
Name of Preparer Date
70 Montague Road �H OF _r _ Westhampton
/C / ( t3
Preparers address _ . �"��. City/Town
Massachusette-01027
State/ZIP Code
Florence-M9 North Farms Road-Local up-grade approval form-Forth
9a•rev.7/06
(413)527-5291
Telephone
Application for Local Upgrade Approval*Page 4 of 4
Checklist for Septic System Plan Review
C<" ,Application page attached to plan
f PE or RS stamp, date,signature
Variances to property line setback distances must have Surveyor stamp
V VLegal boundaries noted
Easements noted
/Dwellings and buildings existing or proposed noted
Location of driveway or parking areas,other impervious areas
Location and dimensions of reserve area (new construction only)
e System design calculations
• 'u Garbage grinder, yy
✓ esnchmark not disturbed during construction within 75ft of facility
L. North arrow
=,,/�COntours
8" Deep hole location(s)and data
Perc hole location(s)and data
elevations
Names of approving authority and soil evaluator
Location of water supplies, public and private
o Within 400ft of system in case of surface water and gravel-packed public water supply
o Within 250ft of system in case of tubular public water supply
o Within SOOft of system in case of private wells(50ft from tank)
t! Well statement, if applicable
Location of any surface waters, rivers,vegetated wetlands
6, Location of water lines and other subsurface utilities
Obserrved and adjusted groundwater elevations in vicinity of system
Profile of system
Locus plan to show location of facility, including nearest street
if'�I Materials of construction and specs for system
G Gas baffle
Pipe in center line of tank
VDouble-washed stone
'11"Schedule 40 PVC for trafficked areas, house to tank
EZ Distances noted from house to tank, etc.
O If dosing is proposed, design and specs of dosing system
G When alternative technology is required,complete plan and specs including hydraulic profile
nches preferred over beds
oyancy calculations for tanks or components partly below groundwater level
1 slope outside of mound, toe ending 5ft from property line
Local upgrade requests on the plan, all variances
Local upgrade forms attached to the application
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