271 (Girl Scouts) DEP Approval Form 2001 Transmittal it wo19897b
Facility ID
Of known)
Massachusetts Department of Environmental Protection
Bureau of Resource Protection• Watershed Permitting• Title 5
BRP WP 59b•DEP Approval of Variance granted by Board of Health,except variance
for increased flow to existing system
Application Form
This application must be filed by persons required to obtain DEP approval under the category
specified above in accordance with 310 CMR 15.000:The State Environmental Code Title 5:
Standard Requirements for the Siting, Construction, Inspection, Upgrade and Expansion of On-
site Sewage Treatment and Disposal Systems and for the Transport and Disposal of Septage.
DEP approval is subject to fees established under Massachusetts General Laws, Chapter 2IA,
Section 18 and 310 CMR 4.00, Timely Action Schedule and Fee Provisions.
A. Applicant Information
1. Applicant:
Ebur421, 4 id-Saw rts
Name
.271 HAybiN✓I LLC R.b
Address
A)oanie Mitt)1) P114 01034
City/Town State Zip
__ CID S84 YS66
Telephone
2. Facility/Proposed System Address:
Ssp t__f}S__ALto✓E
Address
City/Town
State Zip
3. Design Engineer or Sanitarian:
Ko Ler F___j_!iEENAsJ 7 S. —
Name
1446 7ayLoP ST
Address
WPSQh Ann mmilox
L NAUASSOC, fit
DEP Aaolicatien Form-BRP WP59b Transmittal♦ w 0/9.9 9 9h
Facility ID
3. (continued) Design Engineer or Sanitarian:
6P-AA�Y /hA
010 a.?
City/Town State Zip
1- "13- Y‘7-_7;28
Telephone
4. Registration:
_/11A.ssAc ust_rrs
Massachusetts Registered P.E.
Massachusetts Registered Sanitarian
Registration Number
5. Is the proposed system part of a project requiring a filing under 301 CMR 1000, the
Massachusetts Environmental Policy Act?
❑ Yes n No
MEPAn
If yes,has final action been taken?
❑ Yes
,uA
Date
n No
If yes, is a copy of the final actin attached?
❑ Yes NA ❑ No
6. The legal entity that owns or will own this facility is:
Individual
Municipality
Private Partnership
Federal
State/County
Corporation
Other (Specify)
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DEP Application Form -BRP WP59b Transmittal# ur 019897 b
Facity ID
6. (continued) The legal entity that owns or will own this facility is:
Ebwaet __ _Scan _gusaoiTfS
(name)
027[ HayhLNLiLLL 7th NoeflI4t4T0&) 19t1
(address) (telephone#)
yra r851 Y566
7. Two complete sets of plans and specifications, (four for submittals to the Springfield Office),
including a locus map,properly stamped and signed by a Massachusetts Registered
Professional Engineer or Massachusetts Registered Sanitarian must accompany the
application.
Are plans and specifications enclosed?
® Yes No
8. ® Variance(s)from the following Title 5 provision(s)is/are being sought:
✓Aettl feeM a;o c'nQ IltJ sNn__3JO6o e Rsd0.-= xtzvez
Poe ewahuCLA)6 nee Zen- Q,SE_LM mall Solt A.4Y4'uS BY
v&,✓ces/TY oFAtti SR__CLitifirrS_ 44.73
GTYaFr nt&froro [kAcrN A(C,uF_9La4Ttp_AbsLLt_v_gsaa_oe_BkQc Sit /S o&Lawr4Crta
9. The approval letter issued by the Board of Health having jurisdiction over the system, that
granted the variance must be attached.
Is the approval letter attached?
® Yes No
10. If applying for approval of a variance that requires notification of abutters under 310 CMR
15.411, a copy of the notification sent to the abutters and proof of notice must accompany this
application.
Is a copy and proof of the notification attached?
❑ yes No IAA
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DEP Application Form -BRP WP59b Transmittal♦ ui0 19897,6
Facility ID
11. In accordance with 310 CMR 15.410, the applicant must establish that the strict enforcement
of the provision of the Code for which the variance is being sought would be manifestly unjust
and that a level of environmental protection that is at least equivalent to that provided under
the Code can be achieved without strict application of the particular provision.
Is documentation in support of meeting these requirements attached?
® Yes ❑ No
You must complete the following:
a) I have established that enforcement of the provision from which a variance is sought
would be manifestly unjust, considering allot the relevant facts and circumstance of this
case, as follows:
2P_€ll-rY__F_Nth_712XE_, eg.iffeCriu_-I/Prom wLS}JtTcs£tL ?S, ?7Y
71-5 „f✓rksim QJe_St oFoccr.Sott- wRS___✓fRX_ A.M�,t1NFf-t2tN4_turt7£�
r Morrttf RTi2 Zti ?GEC TZST epv_LQ__Lup7__24 COMbtCreb
(use and attach additional sheets, as necessary)
b) I have established that a level of environmental protection that is at least equivalent to
that provided under 310 CMR 15.000 can be achieved without strict application of the
provision(s) from which I am seeking a variance as follows:
eaV eoMLt?TA6Wnrac rroriyLc_ TCc4$r6Q/At. re, Re¢waempJrl eP
3JOCnik /S.000 • CGAQS(,7Md .Celt. 15 AGoon_F,crce_The LmoderiG
dolt LU4S .So too? 77AT A Pet- rest wee .310 emit? /S/oVe/ /05
COotb NOT Go7dbucreb.
(Use and attach additional sheets, as necessary)
12. Is the variance requested for new construction as new construction"is defined in 310 CMR
15.002?
❑ Yes No
If yes,you must complete the following:
I have established that enforcement of the provision from which a variance is sought would
deprive me of substantially all beneficial use of the subject property as follows:
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DEP Application Form-BRP WP59b Transmittal# WO 19897 b
Facility ID
12. (Continued):
(Use and attach additional sheets, as necessary)
13. Is a copy of the complete application that was submitted to the Board of Health attached?
® Yes No
B. Certification
"I 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 are significant
penalties for submitting false information, including the possibility of fine and imprisonment for
knowiing violations."
Applicant's signature Date
Abw4b AwsAroIT S
Print . e
Name of Preparer
t ioroi
Date
DEP Tide 5 Regulations and permit application packages
aLso may be obtained from DEPs web site at
hup://www.state ma uddep
This information is available in alternative format upon request to DEP's ADA Coordinator,BAS/EER,
4th Fir.One Winter Street,Boston,MA 02108
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