560 Local Upgrade Application & Approval 2012 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
Int:
umg out 1. Facility Name and Address:
1 the
;r, use Estate of Irene Rivard
tab key Name
your 5ba.26eSylvester Road
do return Street Address
a
Florence
City/Town
2. Owner Name and Address Of different from above)
Susan Godard (executrix)
Name
MA
State
01062
592 Sylvester Road
Street Address
Florence MA
Zip Code
City/Town State
01062
Zip Code
(413) 586-2575
Telephone Number
3. Type of Facility (check all that apply):
Z Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
4 bedroom house with no garbage disposal.
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
Existing septic tank and leachfield
® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
PROPOSED: High capacitylnfiltrator trench system-two trenches with 10 Infiltrators per trench.
tce-260 Sylvester Rd.local upgrade approval form-Form 9a•
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
440 gpd
gpd
440 gpd
gpd
B. Proposed Upgrade of System
1. 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:
Install a new High caopacity Infiltrator leaching trench system. Two trenches with 10 Infiltrators.
Install a new 1,500 gallon 2 compartment septic tank and a new distribution box. The bottom of the
SAS will be 5'above the Estimated seasonal high water table
December 16, 2011
date of inspection
3. Local Upgrade Approval is requested for(check all that apply):
Z Reduction in setback(s)—describe reductions:
Reduce distance from well to proposed leaching trenches. Install trenches< 100' >75 from existing
well.
❑ Reduction in SAS area of up to 25%:
N/A
SAS size,sq.ft.
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction ft.
Percolation rate minAnch
Depth to groundwater ft,
ice-260 Sylvester Rd.local up-grade approval farm-Form 9a•
'06
%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:
NIA
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
evaluator ormust be ane the
high groundwater elevation pursuant 310 CMR 15.405(1)(h)(1).
member or agent of the local approving
High groundwater evaluation determined by:
Daniel Wasiuk December 13, 2012
EvaluatoYs Name(type or print) — /
Si nature r Date of evaluation valuaprint) 9
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 site limititations it is not practical or economically feaseable to relocate the well to meet full
compliance. Also,there is a nearby wetland and stream.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
An alternative system is not being proposed. A High Capacity Infiltrator trench system is proposed.
ice-260 Sylvester Rd.local up-grade approval form-Form 9a•
/06
Application for Local Upgrade Approval Page 3 of 4
Commonwealth of Massachusetts
City/Town of Florence Upgrade Approval
Form 9A - Application for Local Upg
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:
Adlacent lots are too far away_
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
El Complete plans and specifications
® Site evaluation forms
O 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):
Disposal System Construction Permit-Local up-orde a pproval form
D. Certification
"I, the facility owner, certify under penalty of law that this document and all attachments,to the best of my
i
knowledge and belief, are true, accurate, and complete. 1 am aware that there may ay b be significant
consequences for submitting false information, including, but not limited to, p eom or fine and/or
imprisonment for deliberate violations."
Facility Owners Signature
Print Name
TimothLE.
Name of Prep
70 Monta
Preparers a
Ma. 01027
State/ZIP Code
NIT NP
mce-260 Sylvester Rd.local upgrade approval form-Form 9a•
7/06
Date
Dec. 19, 2012
Date
Westhampton
City/Town
413 527-5291
Telephone
Application for Local Upgrade Approval*Page 4 of 4
Gemmonwealth of Massachusetts
City/Town of Florence
Local Upgrade Approval
Form 9B
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
out 1. Facility Name and Address
se Estate of Irene Rivard— —
key Name
a 260 S vester Road 01062
not Street Address
un
Florence ,Slate Zip Code
City/room
2. Owner Name and Address(if different from above): 260 S ly venter Road
S}tsan Godard-Executrix -street Address
Name MA_—
Florence state
01062vn 1413) 566-2575
01062 Telephone Number
Zip Code
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑
Commercial ❑ School
330 _
4. Design flow per 310 CMR 15.203: six]
Macinnis ❑ PE ® RS
5. System Designer: Name 27 __
Westham to MA 010p n— _ MA E10
A0 Manta Road City/Town
Address
B. Approval
1. Local Upgrade Approval is granted for:
® Reduction in setback(s)–specify.
Install SAS< 100' >75' from existing well.
❑ Reduction in SAS area of up to 25%:
fence-260 Sylvester Road-Local Approval-Form 9b•rev.7/06
N/A
SAS sire,sq.ft.
%reduction
Local Upgrade Approval*Page 1 of 2
commonwealth of Massachusetts
City/Town of Florence
Local Upgrade Approval
Form 98
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction e.
Percolation rate min/inch
Depth to groundwater a.
❑ 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 pert test
List local variances granted not requiring DEP approval per 310 CMR 15412(4):
N/A
List variances granted requiring DEP approval:
N/A
NORTHAMPTON BOARD OF HEALTH
212 MAIN STREET
NORTHAMPTON MA 01060
••/ 2
/�� Date
Print or ype Name and Title SS natt
Cnttditlons:
1).System Designer most inspect and verify in writing
That the sewage disposal system was installed I
In accordance with the approved plans ens l le 5.
2).1f this is a system with the S.A.S. conarucied in
Title 5 till the System Designer must inspection of the excavated arms prior t o die placement
of the fill.
3).No changes can he made during both the n M1>mm
Installer without prior approval by
Designer and the Board of health Agent.
4).Other conditions:
260 Sylvester Road-Local Approval-Form 9b•rev.7106
Local Upgrade Approval•Page 2 of 2