41 Local Upgrade Approval 1998 FORM 9A - APPLICATION FOR LOCAL UPGRADE .APPROVAL
Page 1 of 4
Commonwealth of Massachusetts
NORTHAMPTON Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To be submitted to Local Approvino Authorin/Board of Health: For the upgrade of a failed or
nonconforming system with a design flaw of< 10.000 gpd-where full compliance. as defined in
310 CMR 15.404(1). is not feasible.
To be submitted to DEP: For the upgrade of a failed or nonconforming system with a design flow
of 10.000 up to 15.000 gpd and/or for upgrade of a state or federal facility. where full compliance.
as defined in 310 CMR 15.404(1). is not feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade that includes the addition of
newt 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: Kurt Blaha
Address. 41 Old Ferry Road,Northampton,MA
Telephone: 413-586-4208
Facility Address: 41 Old Ferry Road, Northampton, MA
21 Applicant(if different from above)
Name.
Address:
Telephone:
3) Type of coedit.
® residential
(Specify)
❑ conuercial ❑ school LL institutional
4) Type of existing system
❑ pm; ❑ cesspool(s) ® conventional s)stmt
❑ Other(describe)
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system: 330 gpd
^
Approved: J TICS approval date: unknown
I no do
b) Design flow of proposed upgraded system: 330 gpd
c) Design flow of facility: 330 gpd
N\NINON DEP APPROVED FORM-12107/95
(C.t\GIN V AR FOP 1I9 w.N
ti
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
Page 2 of 4
6) Proposed upgrade of the system is
a) ❑ Voluntary
rl Required by order, letter.etc. (attach copy)
® Required following inspection required b)310 CMR 15.301 (provide date
inspection form Alas submitted to the approving authority) June/July 1998
b) Describe the proposed upgrade to the sy-stem Replace failed leach field with
new 550 SF raised bed leach field, 1,000 gallon pump chamber, and pressure
dosing/distribution system.
c) Which of the following are applicable to the proposed upgrade'
❑ Reduction of setback(s)(list setbacks to be reduced w/proposed setback distances
rl Percolation rate of 30-60 minutes per inch(state actual pore rate) 2 mpi
❑ Up to 25%reduction in subsurface disposal area design requirements(state
required& proposed size) Req'd=550 SF, Design=550 SF
n Relocation of w ater suppIN well(identify well.describe relocation)
® Reduction of required separation between bottom of SAS& high groundwater
(specify proposed reduction&perc rate) Separ.=4.0' ; Pere=2 mpi
❑ Other requirements of 310 CMR 15.000 that cannot be met(specify sections of
the Code)
System upgrades that cannot he 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 CMR 15.410-15.417.
7) If the proposed upgrade in'olvcs a reduction in the required separation between the bottom of
the soil absorption s)stem and the high groundwater elevation.an Approm ed Soil Evaluator must
determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(1)(1)_ The evaluator
must be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater 4.0 feet
As Determined by: P.McErlain witness for B.O.H.
Evaluators Name: D. LaCourse
Evaluators signature:
Date of evaluation_ July 6,1998
BASED ON DF.P APPROVED FORM-12/07/95
(CFSGIN VAR FORM9,A.DOC)
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
Page 3 of 4
8) Notice to Abutters
No application for upgrade approval in which the setback from property lines or a private well
is reduced shall be complete until the applicant has notified 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 upgrade approval will be discussed.
If the Department is the approving authority.then such notice to abutters must be completed
prior to the date of submission of the application to the Department.
The notices to abutters shall include a copy of the completed application form and shall
reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
Abutter Name: Date sent:
Address:
Abutter Name_ Date sent:
Address:
Abutter Name: Date sent:
Address:
Abutter Name: Date sent:
Address:
9) Explain wh) full compliance,as defined in 3]0 CMR 15.404( ). is not feasible(each section
must be completed)
a) an upgraded system in full compliance with 310 CMR 15.00 is not feasible:
feasihiliy; a taller system does not fit on this site—a taller system would also
have a greater negative impact on flood storage.
b) an alternative system approved pursuant to 310 CMR 15.283-15 28£1 is not feasible:
not appropriate
c) a shared system is not feasible:
not appropriate
d) connection to a sewer is not feasible:
not available
I In An application for a disposal system construction permit(DSCP),including all required
attachments(e.g. plans&specifications.site evaluation forms). must accompany this
application. Is the DSCP attached?
® yes Ti no
BASED ON DEP APPROVED FORM-12199/9_5
(C:ENGIN VAR FORM9ADOC)
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
Page 4 of 4
I I Certification
the facility muter.eertifc under penalfi of law that this document and all attaclunents,to
the best of m}knowledge and belief,are true, accurate, and complete. lam aware that there
may be significant consequences for submitting false information.including,but not limited to.
penalties or fine and/or imprisonment for knowing violations
Owners Signature: ,_ y,A,
Print Name:
2nd Owner's Signature:
Print Name:
Kvkt- A - 6caua
Dam:
� klItc
C' Rapt_ 64. Au-a
Date. '7 13l lily
Name of Preparer: G.J. Newman,Newman Enyir. Eng. Date: 8-Jul-98
Preparer's address'. 21 Guard Rd.,Worthington,MA 01098
Preparer's telephone: 413-238-5383
NOTE: Title 5,CMR 15.403(4),requires the system owner or operator to submit to the
Department a copy of the local upgrade approval upon issuance by the Board of Health and
prior to commencement of construction.
BASED ON DEP APPROVED FORM-12/I17195
(C:ENGIN\AR IORVI9_A.DOC)
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
HUNTINGTON Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility's.stem O))ner_
T1‘pc of Facilit.:
System Designer
Name: Kurt Blaha
Address: 41 Old Fern'Road,Northampton,MA
Faciht.Address: 41 Old Fern'Road, Northampton, MA
® residential
n institutional n commercial
school
Name: Newman Environmental Engineering- G.J. Newman
Address 21 Guard Road, Worthington, MA 01098
Phone: 413-238-5383
Local Upgrade Approval granted for:
rl reduction in setback(s)
❑ pere rate of 30-60 min/inch. 2 min/inch (actual rate)
I I reduction in SAS area of up to 25%: 0 % reduced: 550 SF SAS area
® reduction in SAS separation to high groundwater:
separation reduced to 4.0 feet perc rate: 2 min/inch
❑ relocation of well (explain):
List local variances granted (no DEP approlal required per 310 CMR 15.412(4)):
List variances requiring DEP approval:
Board of Health Approval of proposed upgrade.
Name M.Title
Sigimlure
Cthrlor,a Date
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE
APPROVAL TO THE DEP UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY&BEFORE
COMMENCEMENT OF CONSTRUCTION. Dept. Environmental Protection
Division of Water Pollution Control
436 Dwight Street
Springfield,MA 01103
R\SEI)ON DEP APPROVED FORM-12N79S LC.E:A06lAR FORM9H.DOC)