349 Permit & Application for Local Upgrade COI
Commonwealth of Massachusetts
ARVORC-
City/Town of
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 15415.
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
tenant:
en fining out 1. Facility Name and Address: �/�+
ns on the use XM, E C'7/ 0CYL ,vas ( tilt C
r the tab key Name
love your
for-do not
the return
_397 Cocas Nfl/Douu ,c_0,/9
Street Address
.t.eeentan1oto.cJ
City/Town Sg5-ea 6 7
2. Owner Name and Address(if different from above)
M/X 6/0476
ame
CO/47eA
State Zip Code
.i1niou/
I Street Addre
410 ,-777441711,/tad
,/ta, ) State /4C5
City/Town
o/D /a6
Zip Code
3. Type of Facility (check all that apply):
, Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
.4j.VC1l5 Pf11/14 c, 4L $•c8Ivok4 .00 .o/sPTS&
A s/.aaJa Aio x.0
5 Type of Existing System:
❑ Privy ❑ Cesspool(s) Conventional ❑ Other(describe below):
Sara,
Telephone Number
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
EX/5)7%l4 LEZFf1t F/.jt6 U9r57J
/570 C/4L r w1C
form9a.doc•rev.7/06
Application for Local Upgrade Approval*Page 1 of 4
Commonwealth of Massachusetts
City/Town of
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:
«r'
gpdT '' /T q e
wad,
4/X
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
yr Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301:
date of inspection
2. Describe the proposed upgrade to the system:
Iiei2 are'/ad /0 , ithie _ <isjt (4O
Z Cite./.Ci,g_c/J
3. Local Upgrade Approval is requested for(check all that apply):
Reduction in setback(s)—describe reductions:
.s. .64 k ox/ 2en Z,s/o/1e,4 ���c O
novhiceiurcor4tss 0wcm
s y 1044 e CHte.eyc ,oascoccC
❑ Reduction in SAS area of up to 25%:
15form9a.doc•rev.7/06
SAS size,sq.ft. %reduction
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction ft
Percolation rate min finch
Depth to groundwater ft
Application for Local Upgrade Approval Page 2 of 4
Commonwealth of Massachusetts
CityrTown of
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:
v, .y 002/ ,/ ,'Qflf
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)
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:
,-00/24 Lei-Pau LOT-
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
DA/01
t5torm9a.doc•rev.7/06
Application for Local Upgrade Approval*Page 3 of4
Commonwealth of Massachusetts
City/Town of
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:
QN
4. Connection to a public sewer is not feasible:
Aug
5. The Application for Local Upgrade Approval must be accompanied by all of the following(check the
appropriate boxes):
14 pplication for Disposal System Construction Permit
Complete plans and specifications
to 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): ,fir"O9°itc j SW 4142 C cu.c..er
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."
Facility Owners Signature
tt5d /3/-i5-co CCC_
Print Name
ith /Pin LTSite-AW %%
Name of Preparer
Pr/r�st2o7
SS G,o5-5/
Siate/ZIP Code
Sform9a.doc•rev.7/06
a
71,101
j2
/aC/poi 6
Date
Date
a?u7.17-
City/Town
/6/
Telep one
Application for Local Upgrade Approval• Page 4 of 4
BOARD OF HEALTH
DONNA C.ALL 0011 CHAIR
SUZANNE SMRH,M.D.
JOANNE LEVIN,MD.
Benjamin wool,MPH,Dinar
awls Mir. M.Hat Inge r
Patti Atte,RN,Public He Mn.
*mew McaS.,Clan
CITY OF NORTHAMPTON
MASSACHUSETTS 01060
OFFICE OF THE
BOARD OF HEALTH
(413)557-1214
FAX(413)567-1221
212 MAIN STREET
NORTHAMPTON.MA 01060
Onsite Septic System Construction Permit: Conservation Commission Review
NOTE: As of 1/1/11, Septic System Permits 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
SU Vallevgancrthamptonma.sof
Office of Planning&Development
210 Main Street, Rm. 11,City Hall
Northampton,MA 01060
'roperty Owwnner:h,,, 'fth e/l rca, !{,.
ingineer:nin r// 92 4t
orjer�v7ation Com 'n Conservation, Preservation and Land Use Planner
ate: 2/5//l,