140 Septic Upgrade Application 2010 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF
Commonwealth of Massachusetts
, Massachusetts
Application for Local Uwe Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To he submitted to Local Anprovine AuthornwBoard of Health: For [he upgrade of a failed or
nonconforming system with a design tlow of < 10,X0 epd, where frill CL. piiance as defined IF
310 CSfR I S 40-1(Il. is nor feasible.
To be submitted to DEP. For the upgrade of a
of 10.000 up to 15.000 gpd and/or for upgrade
compliance. as defined in 310 CMR 15.404(1)
railed 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.
Facility/system owner
Name
Address
Phone #
Address of facility
H/ -.C- 6Y-o ? ?o
Applicant (if different from above)
Name
Address
Phone #
3) Type of fac
residential _ commercial school
institutional
(Specify'
DEP MPRO VED FOLK- 4;0795
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 OF
4) Type of existing system /
privy cesspool(s) V conventional system
Other (describe)
Type of soil absorption system (trenches, chambers. pits.= )
_7 -1:1
51 Design flow based on 310 CMR 15203
at Design flow of existing system NM gpd
Approved% yes approval date
_no why'
bl Design flow of proposed upgraded system '9 gpd
c( Design flow of facilitv33p gpd
Proposed upgrade of existing system is
ai Voluntary
Reouired by order, letter. etc. (attach copy)
Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date(
b) Descnbe the proposed upgrade to the system
IIo.`
Pt 'p ci �, _b, 2 c/Z' x 4"L die,-r
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
Percolation rate of 30-60 minutes per.inch (state actual pert rate)
D P APPROVED FORM-pID7195
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF
Up to 25% reduction in subsurface disposal area design requirements state required
& proposed size)
Relocation of water supply well (identify well, describe relocation)
VReduction of required separation between bottom of SAS & hign groundwater
lspecify proposed reduction & pert rate) t--cd. p.74 4f:re? /4j/�,2in
y eye r— c.
Other requirements of 310 CMR 15.000 [hat cannot be met ispecm 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 CMR 15.410-15.417.
7) If the proposed upgrade involves a reduction w the required separation between the bottom
of the soil absorption system and the high groundwater elevation, an Approved Soil
Evaluator must determine the tigh ground water elevation pursuant to 310 CMR
15.405(1)(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 tr�.�t"�i--1-cc*y�
Evaluators signature be—r1 i `\Mi a
Date of evaluation /0//02/10
DEP APPROVED FORM 12/07•95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 OF 5
N once to Abutters
No application for upgrade approval in winch the setback from property lines or a
private water supply well is reduced shall be complete until the applicant has
notified all abutters whose property or well is affected by cenified 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. nine 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 loan aria
shall reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters.
Abutter Name
Address
Abutter Name
Address
Abuner Name
Address
Abutter Name
Address
Date notified
Date notified
Date notified
Date notified
9) Explain why full compliance, as defined in 310 CMR 15 404(1), is not feasible each
section must be completed):
a) an upgraded system in full compliance with 310 CMR 15.000 is (pet feasible:
t cc.& o r✓\-D�hT0i-_ pb'p Rr— cove r— o T S.14•S
)OCL RA—11230-1—b- 1- d e r ck94✓'e+.oay
b) an alternative system approved pursuant to 310 CMR 15183-15188 is not feasible
KQ -b w C tO k-r.
De APPROVED FORM• 12307195
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF S
c) a shared system is not feasible.
a) connection to a sewer is not feasible.
o —t 1.,is1_e_
10) An application for a disposal system construction permit, including an required attachments
I e.g plans & specifications, site evaluation forms), must accompany thus application. Is the
DSCP application attached? 1./4esno
Ill Certification
'1. the tacilttr owner cenir, under penalty of law that this document and alt
attachments. to the best of my knowledge and belief, are true. accurate. and
complete. I am aware that there may be significant consequences for submutmg
false information, including, but not limited to. penalties or fine and,,cr
imprisonment for knowing violations."
an-1/-11--C ht��-�� 4-isQ 1 QS )4ti .yhC.
Name of preparer C:-_n Date
'/77 Xi*PJ`,L�oa el %<ei e-iokJ^1/} n,39,2 �//?-6"39-//7`?
Telephone # & address of prepares
NOTE: Title 5. 310 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.
RCP APPROVED FORM
FORM 913 - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
6,--4-1-oet,E4-0,,, Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facility/system owner- Name ycc Address: )40 Colee t
Address of facility Cayoc.-e_ °`U�)�''� ^�-'7TK++�7u1Q
Type of facility residential institutional commercial school
design flow per 310 CMR 15.203 gpd
System designer 13
Name ame ' 1 c4- tir Address 'ive:r ) Phone No .739-
Local Upgrade Approval granted for:
r<ducuon N setnacK s) (speoR')
V
'/79
pert :arc of 30-60 mm.:inch (spec;r; rare
reduction in SAS area of up to 25
(specify % reduction & size of SAS)
reduction in separation between
SAS & high groundwater
(spenfy reduction & pert rate)
relocation of a well (explain)
Last local variances granted no DEP approval required per 310 CMR 15.412(4))
List variant=s grazed requiring DEP approval
Board of Health Approval of proposed upgrade
Name & Title
Signature
Ciryrtown Daze
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
& BEFORE COMMENCEMENT OF CONSTRUCTION
DEP.APPROVED FORM :n01g5