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798 Title 5 Applications/Permits 1983, 2003, Soil Survey, Local Upgrade application, Deed Restriction Ik . 7<Ko f6. ; yo COPY RESTRICTION Affected Premises: 798 North King Street Northampton, MA 01060 I, FRANCES R CYSZ, of Northampton, Hampshire County, MA., owner of real estate known and designated as 798 North King Street, Northampton, Hampshire County, MA, by virtue of a deed dated January 9, 1954, from Karl Schneider, et ux, recorded with the Hampshire County Registry of Deeds, in Book 1159, Page 246, hereby impose the following permanent restriction upon said premises, into perpetuity: "Due to the design of the septic system,a garbage disposal will never be installed on the premises" This restriction is applies to the subject premises in compliance with the waiver of Garbage Disposal Sewer Capacity Requirement issued by the City of Northampton Office of the Board of Health dated August 28, 2003. WITNESS my hand and seal this S_ day of September, 2003. Hampshire, ss. FRANCES it CYSZ COMMONWEALTH OF MASSACHUSETTS September , 2003 Then personally appeared the above-named S FRANCES R. CYSZ and acknowledged the foregoing instrument to be her free act and deed before me, My commission expires: 8/15/08 Roge A. Walasze kry Public 0 Official Receipt for Recording in: Hampshire County Registry of Deeds 33 Xing St. Northampton. Massachusetts 01060 Issued To: ATTY ROGER NALASZE' Document Description RESTR CYSZ Payment Type Check Recording Fees m Recording Number Book/Page Amount 00038699 7440 340 $75.00 $75.00 Collected Amounts 1647 Total Received : Less Total Recordings: Amount $75.00 $75.00 $75.00 $75.00 Change Due $.00 Thank You MARIANNE DONOHUE - Register of Deeds By: Beth C Receipt' Date Time 0049762 09/05/2003 14 40a-r Reprinted By; Beth C Reprinted On: 09/05/2003 11:41a /Poole` Deed &h/old/tau RESTRICTION I, owner of the real estate known and designated as imp Northampton, Hampshire County, Massachusetts by virtue of a deed dated 11.11flpla from atm recorded with the Hampshire County Registry as in Book gg L- hereby impose the following permanent restriction upon said premises, into perpetuity: Due to the design of the septic system a garbage disposal will never be install on the premises. This restriction is applied to the subject premises in compliance with the Waiver of Garbage Disposal/Sewer Capacity Requirement issued by the City of Northampton Office of the Board of Health dated'/-1 tr 3 ti 54 -q 7.003 . WITNESS my hand and seal this it day of 1111111111. COMMONWEALTH OF MASSACHUSETTS HAMPSHIRE, SS. The personally appeared the above named and acknowledged the foregoing to be his free act aty before me. Notary Public My Commission Expires: SIMS Describe the proposed upgrade to the system ReO/ace_ em-{rY¢ SY fit++• See o esiyr i IS Local Upgrade Approval is requested for: ❑ Reduction in setback(s) (Describe reductions) ❑ Percolation rate for 30 to 60 mm /inch Percolation rate mm /inch ❑ Reduction in SAS area of up to 25% (SAS size and%reduction) SAS sq ft Reduction Reduction in separation between the SAS and high groundwater Separation reduction / ft Percolation rate /4- min/inch Depth to groundwater 3 ft ❑ Relocation of water supply well(Explain) ❑ 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)(i)(1). The soil evaluator must be a member or agent of the local approving authority. HigTJk groundwater elevation determined by: JG7(Cr /-I t G C r/4/Il (Print or type evaluator's Name) 7 /27/03 (Signature of evaluator) (Evaluation Date) Explain why full compliance,as defined in 310 CMR 15.404(I),is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: LimsI-ecl .Space_ civcti/46/e h- reyr.,Yt</ ?c//. 2. An alternative system approved ursuant to 310 CMR 15.283 to 15.288 is not feasible: No+ cos-- e! hcc-rive L Department of Environmental Protection DEP Approved Form-320/02 Page 2 of 3 FORM 9A - Application for Local Upgrade Approval Commonwealth of Massachusetts No nth, mpion ,Massachusetts (Cayff own) Application for LOCAL UPGRADE APPROVAL Title 5, 310 CMR 15.000 DEP Approved Form Required by 310 CMR 15.403(1) Form 9.4 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 15.417. 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 a septic system constructed in accordance with either the 1978 Code or 310 CMR 15.000. No.+1, / / Facility Address: 790 .'n9 Sfreel- City/Town: NOYT/IQ mfg 7/en Facility/System owner: Frances C ysy Address: 798_ .Sf- City/Town: oY-/-A"Mopb', State: M/l Zip: 01060 Telephone: ( 4/3 1 5-t34 - 4837 Type of Facility(check all that apply): E.ylcesidential ❑Institutional ❑ Commercial ❑School Describe facility Type of existing system: ❑Privy ❑Cesspool(s) Es.onventional System ❑ Other(describe) Type of soil absorption system(trenches,chambers,leach field pits etc) 1e4ch Tanks Design Flow per 310 CMR 15.203: Design flow of existing system i4 n known gpd Design flow of proposed upgraded system 264 gpd Design flow of facility ,�,` 220 gpd Proposed upgrade of system is: 1<Voluntary ❑Required by order, letter,etc.(attach copy) ❑Required following inspection pursuant to 310 CMR 15.301 Provide date of inspection / / LI Department of Environmental Protection FORM 9A - Application for Local Upgrade Approval Page I of 3 DEP Approved Form—3/20/02 FORM 9A - Application for Local Upgrade Approval 3. A shared system is not feasible: Non-_ needed 4. Connection to a public sewer is not feasible: /\/one of va i ice The Application for Local Upgrade Approval must be accompanied by all of the following: (Check the appropriate boxes) Application for Disposal System Construction Permit ICV Complete plans and specifications ;�✓ .`.ite evaluation fords ❑ 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) 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. Facility owner's signature „_„-,cud />? (�rlrN Date Sl /„1 E/O 3 Print name 1 ' fl4Qc e. . R. CYS Z- 1 d Name ofrrcparcr l-tjJJvrvr, En vfro.o men ha/ Lcn$uf77hy Date 8 /27/63 Preparer's Address: O. (3ox 2Z4 / City/Town: N State: M4 Zip: 0 066 Preparer's telephone: ( 413 1 247 -S46¢ NOTE: 310 CMR 15.403(4)requires the system owner to provide a copy of the local upgrade approval to the appropriate Regional Office of the Department of Environmental Protection,Bureau of Resource Protection,Division of Watershed Management,upon issuance by the local approving authority and before commencement of construction. LI Department of Environmental Protection DEP Approved Form-3/20/02 Page 3 of 3 FORM 9B - Local Upgrade Approval Commonwealth of Massachusetts Massachusetts (City/Town) LOCAL UPGRADE APPROVAL Issued Pursuant to 310 CMR 15.404 and 15.405 Facility/System owner: Address: City/Town: State: Zip: Facility Address: City/Town: Type of Facility: ❑ Residential ❑Institutional ❑Commercial ❑ School Design flow per 310 CMR 15.203 gpd System Designer: ❑ PE ❑ RS Address: City/Town: State: Zip: Local Upgrade Approval is granted for: ❑ Reduction in setback(s) (Specify) ❑ Percolation rate for 30 to 60 min/inch Percolation rate mm /inch ❑ Reduction in SAS area of up to 25% (SAS size and%reduction) SAS sq ft Reduction ❑ Reduction in separation between the SAS and high groundwater Separation reduction ft Percolation rate min/inch Depth to groundwater ft Relocation of well(Explain) List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: Approved by the Board of Health (Print or type name and Title) (Signature) (Date) The system owner shall provide a copy of this local upgrade approval to the appropriate Regional Office of the Department of Environmental Protection,Bureau of Resource Protection,Division of Watershed Management,upon issuance by the local approving authority and before commencement of construction. Department of Environmental Protection DEP Approved Form-3/20/02 „9,t s-a ,KA?11 , ✓ , LS 5-V , 5Z ifr-ff >y y; a d ,6Z -17-v „9, 61 £-S 1-'11'0 9,°2 E-d „-17,81 2-$ ...t,.o- b U ,ZZ Z'V ->.fdas ,QI i-a }'I T ,bz rd ."9 n 'Vl..p°S -S 1. / 5,.»y d_.e-4 . • • .A., ,,,f",-C fl �,°y,yeas ---- ..°u°y psi soot ' t,a-25 _ ,r '.i+"N '+-,°A 5 L,. ,\ 7t^°N B6L +' 75 _°,c' la -'1-1°M II r '11 °1-{"S sh `"atsAs -31-4 2'5 No. FORM 3A - CERTIFICATE OF COMPLIANCE Fn COMMONWEALTH OF MASSACHUSETTS Board of Health, i'Vor-FA pion , MA. CERTIFICATE OF COMPLIANCE Description of Work: El J Individual Component(s) L� Complete System The undersigned hereby cerlify that the Sewage Disposal System; Constructed O, Repaired (,✓Upgraded O, Abandoned ( ) by: Welter Thaye✓ at: 798 K.y.9 St{ Slxcavet4-:ni (l(anceS Cysz ) et+ 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. ak Approved Design Flow 2/o4-i- (gpd) dated 49, Z7 , 2003 Installer :y14.0 ' Designer:7741"/41 j Date 5 9L 17, 2003 The issuance of this permit shall not be function as designed. LeJ ces-W,,L - ov- rec,.airec( OfP APPROVm FORM, 5/% Inspector siruud as a guarantee that the system will 4 tl©T 44 ."SS`e1 g'a J �. tpate.'. , 7f'1 �D '5 PERCOLATION TEST(S) Time: I I Time: i Observation Hole #1 Observation Hole #2 Depth of Pere Depth of Perc Start Pre-soak - , S^i-- Start Pre-soak End Pre-soak c End Pre-soak iii Time at 12" )0 Time at 12" Time at 9" /0 ;t2tii Time at 9" Time at 6" K Time at 6" Time (9"-6") "f, IOM/ Time (9"-6') Rate Min /Inch Rate Min/Inch , 7i it, ((-- 'minimum of 1 per aGOn test must be performed in both the primary area AND reserve area. SITE SITE I SITE SITE PASSED FAILED PASSED _ FAILED Performed by I (kt., j.(,f-�-- I Performed by Witnessed by 7i"J � - Witnessed by Comments: N ( 1I I/t. r,d.'`'`' `c ;a ;e`„t,^ i 4-111 4 zi-Cki , „_cam' � , 4, -: NORTHAMPTON BOARD of HEALTH— Title 5— Site Review cation tls or Lot# Date gineer Land Use Vegetation on ondi :etch on 71i1, 7%/o� s Address Co-q../1 Landform Surface Sto 'Phone# < udruHSE":.. -End Time:" an WaterBddy Bible Wet Area feet ;DrInking Water feet 'Propa[y'Lirter .:. feet uDrainege W$y'#=^k feet feet feet Hole#: DEEP OBSERVATION HOLE LOG* 'MINIMUM OF TWO HOLES REQUIRED C EVERY PROPOSED DISPOSAL AREA th from e(Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure,Stones, Boulders,Consistency,%Gravel) i � Material(geologic) I 57 , ( DSt >'/y 12 d c —36 ° to groundwater:Standing'Waterin gte'Hole Material(geologic) i Depth to Bedrock I 7 Ci to groundwater. Standing Water in the Hole (or s Weeping from Pit Face 7h stimated Seasonal High Ground Water / ci Hole#: DEEP OBSERVATION HOLE LOG* )iINIffUfd OF TWO HOLES REOUIRED nT EVERY PROPOSED DISPOSAL A REA nh from e(Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure.Stones,Boulders,Consistency,%Gravel) Material(geologic) I T1egth to Bedrock to groundwater:Standing'Waterin gte'Hole Weeping iron Pit;Face shmated Seasonal High GroundWNater w No ct- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HFrALTH .Appliratiuu fur Dis}rnsal FEE... arks (ll nstructian rrmit Application is hereby made for a Permit to Construct ( ) or Repair (✓j an Individual Sewage Disposal System at•, �� :gets 7. oa r or rot No. ,, f-Address e Installer/ Address Type of Building Size Lot Sq. feet Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons Showers ( ) — Cafeteria ( ) Other fixtures Design Flow gallons per person per day. Total daily flow gallons. Septic Tank—Liquid capacity gallons Length Width Diameter - Depth Disposal Trench—No Width Total Length Total leaching area s9. f . Seepage Pit No Diameter Depth below inlet g sq. ft. Other Distribution box Percolation Test Results Test Pit No. 1 Test Pit No. 2 Total leaching area ( /4 � Date Dosing tank ( ) Performed by minutes per inch Depth of Test Pit Depth to ground water minutes per inch Depth of Test Pit Depth to ground water Description of oil --(1^ n ��'-� 3G C4Tr•^ n d � )41 `t ,l.Ytxl.:4:t4.`—'• t euiJ_. Nature of Repairs or Alterations—Answec.when applicable A Si r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed - -- Application Approved By - E ' ,t `"& Date Application Disapproved for the following reasons Permit No Issued Date C_1 I� 1r- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF rriifiratr of Troup ma THIS IS TO C$IZT_I Y� Tha t Individual Sewage Disposal System constructed ( ) or Repaired ( Q. by /y,S/p�� ... at Iry v � s - has been installed in accordance with the pr ons of TITLE r ick,of.,The State Sanitary Code s scribed in the application for Disposal Works Construction Permit No 3--C dated -$!/V.F.3 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTXHAT THE SYSTEM WILL FUNCTION /SATISFACTORY. DATE V67(3 3 No Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF, - flio.ponat. iip4rkn �ono#rnrtion Permit ..._ , ....:.........._f.!ti::",'- - Permission is hereby g ranted_ [.t to Construct A 1_or Repair €.-' an Individual Sewage'.flisposal System at No r7g . '(-'.1 ::....,,.;T^ e p stirs . 1. as shown on the application for tsposal Works Construction Per4�itfis'o f".rF I)at<d.'_y 1 1<� Board of f3falth DATE / Li � Q- v FORM 1255 A. M. SLILKIN, INC., BOSTON J FEE ' No. 3y—o3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH City OF Nor4Firvp+on APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( 1 Repair t/Upgrade ( ) Abandon ( ) - K✓Completc System ]Individual Components 77& Nor+I, K'n §freef 4'rAnce-5 CySZyLp 79 '0 Nor+4. lorry Jt, lz:44sar 1-... MA �23� �1*less T{.icphortc L tfaNNmmlc Lm a WA I+CY Tanya✓ . F- i Uht-' Fv vi rpn v�en+ COOS 0 14;p5 '$ox 22b r lcr4t;F1a"4-tId MA 014*' S4 K,ny S+ . NaT'teld"MA °)03& 247 —r4 4 247 —gib¢ Telephone Tdeph.mus Type of Building: Sin Dwelling—No.of Bedrooms Z Other—Type of Building No.of persons Other fixtures Lot Size Sq.feet Garbage Grinder (op) Showers ( ), Cafeteria ( ) Design Flow(min. required) ZZO gpd Calculated design flow 220 gpd Design flow provided Zr+ gpd Plan: Dam A>^y, ii 2003 Number of sheets 2- Revision Dale Title Se.-'r.ye A■seesc.1 5yc }eon Peon i✓ Description of Soil(s) <22 C2 EVAI, Crm 11 Soil Evaluator Form No. Name of Soil Evaluator M;Thm-.p5en Date of Evaluation 7/29/C3 P. M.E.la,r. DESCRIPTION OF REPAIRS OR ALTERATIONS Rea/eve cn4iire sys{e.rn Sec p/rtIn . The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with TIRE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the 7Signed �n2ne-e�- !? Cr) Date Inspections J provisions of of Health. RLo FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Description of Work: THE COMMONWEALTH OF MASSACHUSETTS NO(ihaMYion BOARD OF HEALTH CERTIFICATE OF COMPLIANCE ❑ Individual Components) 6mplete System FEE The undersigned hereby certify that the Sewage Disposal System:Constructed( ),Repaired( )-Upgraded( ),Abandoned ( ) at —% 7 "c/b/( !G f„) 7 has been installed in accordance with the provisions of 310 CMR 1500 (Title 5) and the approved design plans/as-built plans relating to application No. ./(./ - t-Vjdated _ y . Approved Design Flow ' / (gpd) Installer / / Designer: / r�/.+%� I/ / i -`C`� Inspector y_� � $ /!/ %cgate The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 L No ->%-Z 3 THE r� /ICOMMONWEALTH OF MASSACHUSETTS UdYl n airlpiDn BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Co3j s rue 4 Re�aa ,t ) Upgrade (/ ) Abandon ( ) an individual sewage disposal system at -7 j 1t1 /j/7-/(�/1 i Kr eva G_' ___ 7- as described in the application for Disposal System Construction Permit No � / --- ��el-72 dated /-1' ' -2-, . Provided: Construction shall be completed within three years of the date of this period. Alt local conditions- be met. /v— Gam/ Date , __ err( "/d' �, Board of Health 4/d / //j /G/X-v-r 1 FORM 2 - DSCP ' DEP APPROVED FORM 5/96 FORM 1255 L REV 5/96) W j HOBBS&WARREN'9 PUBLISHERS- BOSTON