6 LUA 2008 FORM 9B - Local Upgrade Approval
t »� Ith of Massachusetts
�/ /�f ,Massachusetts
( ity/ own)
LOCAL UPGRADE APPROVAL
Issued Pursuant to 310 CMR 15.404 and 15.405
(R.l, Address: 6), e
State: M A- Zip: D/060
City/Town: 'J012-4- I9 4 1 1,�t
Facility/System ow'er:
City/Town:
Facility Address:
Type of Facility:
System Designer:
Address:
City/Town:
Residential ❑Ins[imtiona
Design flow per 310 CMR 15203
❑Commercial ❑School
gpd
❑PE 11E-
State:State:✓
Local Upgrade Approval is granted for:
Zip: O (
❑ Reduction in setback(s) (Specify)
❑ Percolation rate for 30 to 60 min/inch- Percolation rate
min/inch
❑ Reduction in SAS area of up to 25%
(SAS size and 13/0 reduction) SAS sq ft Reduction %
Reduction in separation between the SAS and high groundwater
Separation reduction ft Percolation rate min/inch
Depth to groundwater ft
❑ Relocation of well(Explain)
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
pp oved by the Board o
(Print or type name and Title)Zia t (P ature) (Date)
The system owner shall provide a co of this local upgrade approval to the appropriate Regional
Office of the Department of Environmental Protection,Bureau of Resource Protection,Division of
Watershed Management,upon issuance by the local approving authority and before commencement
of construction.
Department of Environmental Protection
DEP Approved Form—320/02