21 Certificate of Compliance 2016 Commonwealth of Massachusetts FILE COPY
prow hCit /Town of NORTHAMPTON
.L— ,' City/Town
of Compliance
.
.-i-= Form 3
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
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
Important:When
ening out forms ❑ Construction of a new system
on the computer, ® Repair or replacement of an existing system
use only the tab ❑ Repair or replacement of an existing system component
key to move your
cursor-do not
use the return Has been done in accordance with Title 5 and the Disposal yst Construction Permit(DSCP):
key. / / //
�/Ilap O DSCP Number
_ _ - DSCJ 9 Ir0
SRS LLC
Facility Owner
Alm”Xa 21 HATFIELD ROAD
Street Address or Lot#- -
NORTHAMPTON _ MA 01060
CilYrTown State Zip Code
Design- ornation:
DO. • ` M.4 •Y _ MacLEAY ENGINEERING
- .I Name of o pant
7
Dat ill-7
Si! ature p� _ -Installer Inf :tion:
W.R.THA sr" - _ W.R.THAYER&SON
Name , Name of Company
G/fi/ _ /i—/—/ 9
Signature Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
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Lhw ti e� P
e A proving A only
i/ /7
re P /!•✓=..f•✓i Date
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t5torm3.doe.06/03 Certificate of Compliance•Page 1 of I
•
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
;+ Form 9A - Application for Local Upgrade Approval
tl
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 Hearth 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
Important:When
filling out forms 1. Facility Name and Address:
on the computer, SRS LLC
use only the tab _- -
key to move your Name --- --- - - _
cursor-do not 21 HATFIELD ROAD
use the return - - --
key. Street Address
mQ' NORTHAMPTON MA 01060
City/Town State _. _ - — Zip Code
�� 2. Owner Name and Address(if different from above):
SRS LLC 9 VALLEY STREET
Name Street Address --
HATFIELDMA
City/Town
_. State __-
01038 413-2473P4e 9-/T
ZipCode
Telephone Number
-- - - - - -
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
SINGLE FAMILY RESDIENCE
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
UNKNOWN
t5form9a•rev.7/06 FILE CO P YApplication for Local Upgrade Approval• Page 1 of 4
Lik E Lt iia A
Commonwealth of Massachusetts
=el City/Town of NORTHAMPTON
-,_� __I Form 9A — Application for Local Upgrade Approval
` ef 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: N/A _ _--
gptl
Design flow of proposed upgraded system 330
gptl
Design flow of facility: 330
gptl
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
® Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301: orale of inspection -2. Describe the proposed upgrade to the system:
REPLACEMENT OF EXISTING BELOW STANDARD SYSTEM WITH A MAXIMUM FEASIBLE
COMPLIANT SYSTEM
3. Local Upgrade Approval is requested for(check all that apply):
❑ Reduction in setback(s)—describe reductions:
❑ Reduction in SAS area of up to 25%: sns size,sq.ft. _ reduction
® Reduction in separation between the SAS and high groundwater
Separation reduction 5 FEET TO 4 FEET
fl.
Percolation rate —`2
min./inch
Depth to groundwater 28
t5form9a•rev.7/06 Application for Local Upgrade Approval* Page 2 or4
Commonwealth of Massachusetts
City/Town of NORTHAMPTON
Form 9A - Application for Local Upgrade A
,�( •" pproval
i.c 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 ane 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:
LACK OF FOUR FEET OF NATURALLY OCOURING PERMEABLE SOIL. 35 INCHES AVAILABLE.
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:
DANIEL WASIUK —
Evaluator's Name(type or print) Signature — - - e 1
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:
LACK OF AREA WITH MINIMUM DEPTH OF PERMEABLE SOIL
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
ELGIN MANTIS ALTERNATIVE SYSTEM BEING USED
i5fonn9a•rev.7/06 — —
Application for Local Upgrade Approval, Page 3 of 4
Commonwealth of Massachusetts
=._-- City/Town of NORTHAMPTON
. i
_=