567 Local Upgrade FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF
Commonwealth of Massachusetts
„A.A—e,lar.,®dris Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To he submitted to Local Approving. Authontw Board of Health: For the upgrade of a failed or
noncontorm.ng system with a design How of < 10,000 gpo where Pull co,r,p:iance. as defined in
310 CMR 15.404( 1 ). d not feasible.
To be submitted to DEP: For the upgrade of a
of 10,000 up to 15,000 epd and/or for upgrade
compliance. as defined in 310 CMR 15.404(1).
tailed or nonconforming system with a design flow
of a state or federal facility. where full
is not feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the
addition of new design flow to a cesspool or privy or the addition of new design flow above the
existing approved capacity of a system constructed in accordance with either the 1978 Code or 310
CMR 15.000.
1) Facility/system owner
Name__
Address
Phone x
Address of faclig
%iko c t-t„i CLo S`)c_i
? p l v-e_911 Ro
«'r —S -LP`, e
Applicant (if different
Name
Address
Phone
rom above_
3) Type of facility
A residential commercial school
institutional
(Specify
DEP APPROVED FORM I3,07/95
FORA( 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 OF 5
gl Type of existing system
privy cesspool(s) x conventional system
Other (describe)
Type of soli absorption system (trenches, chambers. pits.etc.)
5) Design flow based on 310 CMR 15.203
a) Design Pow of existing system N%A gpd
Approved? ves approval dateju,ec)r,
no why'
b) Design Row of proposed upgraded system
cf Design flow of facility 330gpd
34Cegpd
Proposed upgrade of existing system u
a) Voluntary
Required by order, letter. etc (attach copy)
Required following inspection required by 310 CMR 15301 (provide date
inspection form was submitted to the approving authority) (date)
b) Descnbe the proposed upgrade to the system
M-ti ISo-o )tetL-.r -t ;c fl - of c% �tio (a)
Ira Ia-( x o- 7J C f �IA �t �n • /ems
c) Which of the following are applicable to the proposed upgrade?
1/ Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
(� 3. '
1— - . J 79-a �� `�-� A ro
O( o` , Ai
tI -It
�.A S 4e C f7
Percolation rate of 30-60 minutes per inch (state actual pert rate)
OFP APPROVED FORM- Il.07r 95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF
Up to 25 reduction in subsurface disposal area design requirements isute required
& proposed size)
Relocation of water supply w ell (identity well, describe relocation)
Recucuon of requtme separation between bottom of SAS & h:gn groundwater
ispecifv proposed reduction & pert rate)
Other requ:rements of 1)10 CMR 15.000 that cannot be met i specify sections of the
Code)
System upgrades that cannot be performed in accordance with 310 CMR 15.404 &
15.405, or in full compliance with the requirements of 310 CMR 15.000, require a
variance pursuant to 310 CNIR 15.410-15.417.
If the proposed upgrade involves a reduction m the required separation between the bottom
of the soil absorption system and the high groundwater elevation, an Approved Soil
Evaluator must determine the Ugh ground water elevation pursuant to 310 CMR
15.405(I)(i)(1). The evaluator must be a member or agent of the local approving authority
Distance from soil absorption system to high groundwater
feet
As determined by
Evaluator's name
Evaluator's sienawre
Date of evaluation
DFP APPROVED FORM- 12i0719
FORM 9A - APPLICATION FOR LOCAL LPGRAD PA A GE 4 OF 3
Notice to Abutters
No application for upgrade approval in which me setback tram property lints or a
private water supply well is reduced shall be complete until the applicant pas
notified all abutters whose property or well is affected by certified mail at least ten
days before the Board of Health meeting at which the upgrade approval will be on
the agenda. Such notice shall include the date. time and place where the nom-adz
approval will be discussed.
It the Department is the approving authority, then such notice to abuners must be
completed prior to the date of submlsslon of the application to the Department.
The notices to abutters snail include a copy of the completed appheauon form ant
shalt reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters
Dale nauned
.Abutter Name
Address
Date notified
Abutter Name
Address
Date notified
Abutter Name
Address
Date notified
Abutter Name
Address
9) Explain why full compliance, as defined in 310 CMR 15.4041.1), is not feasible each
section must be completed):
al an upgraded system m full compliance with 310 CMR 15.000 is not feasible.
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible.
Kis & �� r
O@ MPROVm FOFM-12I0b95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE = OF
snared •um71'J 15 not te3SrDIe.
n e Av e�
0-1/2:l3"-
..unneC:,Jl :. >t ACE b not tedSWIC
An application for a disposal system construction permu. Including an required atu:nmenu
le g plans & speclticauons sire evaluation formsi must accompany ws application. Is the
DSCP application attached? „Xi ‘es _no
L I Certification
the
ire, r u uo mt a'..
n �wno
,in} � can of .-
enacv .a a, ,> Inc Cox o. nl., e u...:e1_c ard ee.uat. are [rue acc la
complete I am aware that there may be stemilcant consequences tcr sabm a:hg
talse Information. Including hut not limited to penalties or fine ane,Cr
imprisonment tor !,mowing violations
k
Facilav owner s seer
A
Print
Date
IA_ Min Lbw) ,c 1r i
Fhn�er �. JCS t
Name of preparer
1 ° S
Telephone # & address or prepares
o8
a-o /0/ D/of A— /V Di
NOTE: Title 5. 310 CMR 15 403(4L requires the system owner or operator to submit to the
Deparunent a copy of the local upgrade approval upon issuance by the Board of Health and pm;
to commencement of construction.
DO'AP PROVED FORM c:CO'95
FORM 913 - LOCAL UPGRADE APPROVAI.
Commonwealth of Massachusetts
/,,„ ( ,vi- , Massachusetts
OCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CAR 15.404 & 15.405
0.e."s 9-S , A le."--41, tr1or Cl'ce7 Mii
str.o:apslcm ow tier. flame.
ha � 1 + �adress., I Sj.IirCJ
4ddress DI (�1?/P- ---
t/ mstnunoaN commcrelal mbool
i p< Ul laCihll designILaI ��
design flow per 310 CMR 15 203 D 4P4
c �-^� y- l01 O1�F�'"Y w�13[�
ane uW y�€+lyL ,A nC r C SS / lc- La. _j4o h. /CMS P'.O lie Nt) .] V gl U�C
YSteIG ar)Lgnr� L
acM t pgrade Appro.al K ranted for
:eau- ion in srmacAt mean 1 -
� . S S
Cil �
l4
a
pert rale of 30 00 man .Inca :spec R rte)
oaucuon in SAS arca of up to .5
specay `l rcducnon & sr< of SASt
:eduction in separation between
SAS & high groundwater
tspeclty reauction & pert rata
relocation 01 a well lezplain)
List lout vanadces granted Ino DEP approval reautred per 310 CMR 15.412(1P
Ust ',as-sancta granted rcuulnng DEP approval
Bona of Hctn Approval or proposea upgraac Name & Tide --
Daze
Signature (ar}'llOwn
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
Sr BEFORE COMMENCEMENT OF CONSTRUCTION
DEP APPROVED FORM I2,a7T9]
FORM 9B - LOCAL UPGRADE .APPROV Al
Commonwealth of Massachusetts
„, - -k"-- , Massachusetts
°CAL UPGRADE APPROVAL PURSUANT TO MO CMR 15A04 & 15.405
� �
c:nt)' tc.ran Same
_ address:, ii1 �%/Lr r--- '0 <^ee/Ylil
;Cares, ---
/ commercial scboof
,pc al (achy, design N 310 CMR 15i _ 33O
design Ilow per 3I0 CS1R 15 203 H I? -
lolo :_ rn( .one. �NoSBS-S0�0
Name Fa.vr ba c�-;acres 1 , .4
nmm ac tenu
oral Cpgrade Appro.ai granted for.
IS ♦ _ r n, i/s
A
¢au' iom Scmacxrll 'toads
L. •-.
X0.1i .
aerc ram of 30-au trim :'inch i specie. ra:ei
erducuon or SAS area of up w 2515
specify % reduction & size of SASI
rWUctton in separation oetween
SAS & hlgh groundwater
I speak reduction & pert rater
relocauon or a well (explain;
Lt at :oca vanances granted lad DEP approval reouued per 310 CMR 15.412(411
List s ananc:s grouted reautnne DEP approval
Board of H , m .Approval of proposed upgrade
ti
gnature
Ciryno
ate
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
70 THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITS
& BEFORE COMMENCEMENT OF CONSTRUCTION
DEP APPROVED FOLLM
Peter J. McErlain, R.S., MPit
16 Coed Drive
Easthampton, MA 01027
Tel: (413) 527-8204
YfEMO
TO: Northampton Board of Health
DATE: August 4, 2008
RE: Review of Application for Local Upgrade Approval and Plans for the construction of a
new Soil Absorption System at 567 Sylvester Rd., Florence
System
Owner:
Designer:
Agnes& Stanley Moczulewski
567 Sylvester Rd., Florence, MA
Michael Lavigne, Environmental Design, Inc
System
Description: The proposed Soil Absorption System (SAS) is a conventional septic tank. " D box.
and leaching galley system which would replace the existing failed septic system at
567 Sylvester Rd.
Background: Title 5 the State Environmental Code, 310 CUR 15.000 Standard
R .uirements for On-site Se • Treatment & Dis osal Systems authorizes
Boards of Health to issue Local Upgrade Approvals(LUA) when it is deemed
necessary to repairreplace failed soil absorption systems on lots where conditions do
not allow full compliance with the code. An LUA must be voted upon/approved by
the Board of Health during a legally posted meeting and would vary the application
of the Code without the need to obtain a formal variance from DEP.
In Ma} -08 the Northampton DPW reported that raw sewage teas seeping from the
property at 567 Sylvester Rd. and running into the nearby drainage ditch. Subsequent
investigations revealed that septic system serving that property had failed. (a copy of
the Boll order to correct the failure is included in the application for LUAL.
Approval: The attached application for Local Upgrade Approval seeks a reduction: 1.1 in the
Local Upgrade
setback between the on-site well and the septic tank_(reduced from 50" to 32 1 1.
2.)the well and the soil absorption system (SAS) ( reduced from 100' to 641) and
■_j also a deduction between soil absorption systems and a reduction of the breakout
distance. These reductions arc necessary' in order to complete the replacement of the
failed septic system on the lot which size limitations do not otherwise allow the
required separations (setbacks) from the well.
Conclusion:
Because the lof s size limitations do not allow the required set backs from the well
I therefore recommend the issuance of the LUA. With the issuance of the Local
Upgrade Approval the proposed SAS design Would comply with all other aspects of
Title 5. (Note: the design %sill still provide adequate setback and improved protection
for the users of the well water.I. Once the LUA is issued I will be able to approve the
plan and issue the disposal system construction permit.
When the replacement system is installed it must be inspected by the designer and
the Board of Health representative to confirm that the construction is in compliance
with the approved design prior to burial of the system and application of the finish
grade.
Please feel free to contact me with any questions concerning this review.
Than co
Peter lain, R.S., MPH
Date
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