43 Application for Local Upgrade/Soil Eval Form 2011 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 fors 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
ortant:
filling out 1. Facility Name and Address
is on the the key WILLIAM CICHANOWICZ
use
'outer,u
the tab key Name
love your 43 OLD WILSON ROAD
:or-do not Street Address
the return
NORTHAMPTON MA
City/Town State
2. Owner Name and Address(if different from above):
Name Street Address
City/Town State
01060
Zip Code
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
Single Family Res.
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
L.F IELD
5form9a-2•rev.7/06 Application for Local Upgrade Approval* Page 1 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
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:
2
gpd
330 (min under T-5)
gpd
343
9Pd
B. Proposed Upgrade of System
Proposed upgrade is (check one):
❑ Voluntary ❑ Required by order, letter, etc. (attach copy)
Z Required following inspection pursuant to 310 CMR 15.301:
2. Describe the proposed upgrade to the system:
New L. field &S.Tank.
June 2011
date of inspection
3 Local Upgrade Approval is requested for(check all that apply):
Z Reduction in setback(s)—describe reductions:
from 20 to 14.5 of foundation (310 cmr 405(1))
❑ Reduction in SAS area of up to 25%: SAS size sq ft
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate
Depth to groundwater
R.
min/inch
ft
%reduction
5form9a-2•rev.7/06 Application for Local Upgrade Approval*Page 2 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 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:
see above.
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:
Evaluators Name(type or print)
07.07.2011
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:
Due to grading from house and existi gtopo, groundwater elevation to minimize PL offsets.
2. An alternative system approved pursuant to 310 CMR 15283 to 15.288 is not feasible:
Would not change request.
iformga-2•rev.7/06 Application for Local Upgrade Approval,Page 3 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
C. Explanation (continued)
3. A shared system is not feasible:
No applicable
4. Connection to a public sewer is not feasible:
Not 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
® 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
1, 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."
5form9a-2•rev.7/06
aciliy OameYs Signature Date
William Cichanowicz
Print Name
Alan Weiss, RS 08.05 2011
Name of Preparer .
350 Old Enfield Rad , Belchertown
Preparers address Qty/Town
MA 01007 413.323.5957
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.
C. Explanation (continued)
3. A shared system is not feasible:
No applicable
4. Connection to a public sewer is not feasible:
Not 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
• list of abutters
proof that affected[abutters have a been notified pursuant tto supply wells or
5(2). lines.setbacks to private
• 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."
Facility Owner's Signature
William Cichanowicz
7-- Print Name
I1 t t Alan Weiss, RS 08.052011
Name of Preparer Date
350 Old Enfield Road, _ Belchertown
Preparers address City/Town
MA 01007 413.323.5957
State/ZIP Code Telephone
Date
ifomi9a-2•rev.7/06
Application for Local Upgrade Approval*Page 4 of 4
COLD SPRING ENVIRONMENTAL
CONSULTANTS, INC.
ALAN E.WEISS,M.S.,R.S.,L.S.P.
Licensed She Proreshonal
Registered Sanitarian
-Wetland Con.ml:r
Hpdroeeo!oeis! -Soil and Water Tessin
President •21E Site Invesig ions
s
nfield Rd_ -Percolation Tests and
wn.MA 01004 -Septic Design.
5957 6,323-4916(FAX) -Title S Inspections
FOR11 11 - SOIL EVALUATOR-FORM
Page 1 of 3
Date: 7/7 ( 11
aew&'ss@oha11B0net Commonwealth of Massachusetts
Ho/ -Iti , Massachusetts
Soil Suitabili 1 Assessment or On-site Sewa?e Dissosal
Perfon ed By • 16('■SS-
Witnessed By L • S;i'L , -tTh cL.,
Due � � H
m:nn Add.,,
n L III ClC��e.��Z
q cfd- tin
Jew construction 'Ed Repair ❑
and
-m=
I(3 afc( 12-A bC'
Office Review
::ub'usnee Soil Survey Available: No IT
Year Puhli 2e((
Drainage Class
Yes 'J�✓
Publication Scale — I 5
Solt Limitations 5' S
S_^.ida; Geologic Repo:: Available: No H Yes i
`SCSI Pcbliarsec
Geologic Material RAag- Unit)
I
__df�m.. � r2J`4 c. ..1 .
Flood Insurance Rate Map'
Above 500 year flood boundary No !JYes
Publication Scale
Within 500 year flood boundary No �(ees
Within 100 year flood boundary No J✓Yes
Wetland Area:
EvK
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Condd( Q�s (USGS): Month
Range :Above Normal PYNomal ❑Eel.^, Normal
Other References Reviewed:
oar<
Sell ;lvEy
D FORal
PRtt4r t ( Sn,<C(
FOR; : 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. 45 d1ed
On-site Review
Deep Hole Number frit. Dare 7.12 I I( Time: i.< : Weather 5.J,cj icti
Location (identify on site plan) ....
Land Use h.t SItt''_. Slope (%) 2 Surface Stones f c ab5
Vegetation q2 55
Landform . Ier(zi.L,
Position on landscape (sketch on the back)
Distances from: _.
Open Water Body !cc ,'‘ feet Drainace way - y t feet
Possibie Wet Area l Cc t. foot Property Line `(o`i
Drinking Water Well‹:--- - -e_t Other __ --
DEEP OBSERVATION HOLE LOG*
Degth fro-
.n_.-.e
0.
. ..
(L S:,..,
(M s_-, Yc..ting
.. e._.ones Vd_ s. Co . 34
L el h
CIS 21.'r
2‘ -rob e
)00 -17$
( l
6 2
-117C
LS
$.
L5
10e43)451
1 OygSj
2 01031 2.Sy /2-
2 .Cyr/4 IOEH
- itm— 'ilc?`amtI
— r ci_
recJJ I Ism°c
— f (M. Sc-t�, Lec--e, 1 H: S,
_ ge ,y<t ijblu}a— -57 (
C -I (
5 -ZZ
ZZ - 115
;
1
1
I'
j7.,-,
C (
i5C
l_,
5
icNi 4,_31-5
tOy‘iS lc
2-s-,,5)3 I
I
49 �r
z ,_. yl2
Sa-t aS I
' MINIMUM Or 2 HOLCO h6ODIRD A7 EV OFOSc6
-CIS uaFea
Irene Material (geologd r Ge Gt*Kt a \ Se- N,
tot).to Groundwater 5tandino Water in the Hole'
Deptho6edm4 (ZV +
Weeping from PP.Face. \5 470
um+ated Seasonal High Ground Water
Th (
.y
es 5 v �� awls e,,4 C7),.4 k,tt .
DEP APPROVED FOAM-12/0795
,ocation Address or Lot No. 43 cl tb reel, Zia -
Determination for Seasonal High Water Table
( ethos) Used:
Depth observed standing in observation hole...... . inches
Depth weeping from side of observation hole ... inches
Depth to soil mottles / .. inches io kx-f c tivSi .
Ground water adjustment feet •
ndex Well Number
Reading Date index well level
=adjustment factor Adjusted ground water level
Dept: of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring
observed throughout the area proposed for the
If not, what is the depth of naturally occurring
11ertificat]on
Page 3 of 3
pervious material exist in alt areas
soli absorption system? ,1
pervious material C
I certify that on 6 ii1 (date) I have passed the soil evaluator examination
approved by the Dep rtment 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.
I I
Signature Date 7 -i ( u
DEP APPROVED FORTE. I2/V/95
C
REG. 5933 < LiSS
n
anon Address or Lot No l{
COVVO
CUR 12 - PERU)LON LEST.
1<S
WEALTH OF MASSACHUSETTS
to oh„ Massachusetts
Percolation Test`
Time:.: ime:. Loc, . .
Observation kiml.e
(f!u Fs I
'fin or Pere
Li 3
Sta- Pre-soak
=cal Pre-soak
Time 271 7 9'
jib c
Time at S'
Time
3
Rase Min.ilnch L�
Ma74nnum of ' percolation test ;nos
reserve area.
e Passed i "I ar Site Failed
rformed 8y: 4(u2.is
tnessed Ey: C., 50,
)mrnents:
S
be performed in both the primary area AND
DEE/Y?ROVE)FOFJ2-12I07/95