101 Application for Local Upgrade Approval 2003 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF 5
Commonwealth of Massachusetts
o . ell Lawpioti , Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
he submitted to Local Aoorovine Authority/Board of Health: For the upgrade of a failec or
"conforming system with a design flow of < 10,000 gpd, where full compliance, as defirec io
CMR 15.404(1). is not feasible.
be submitted to I)EP: For the upgrade of a
10,000 up to 15,C00 gpd and/or for upgrade
apliance. as defined in 310 CMR 15.404(1),
failed or nonconforming system with a design flew
of a state or federal facility, where full
is not feasible.
'TE: Local upgrade approval shall not be granted for an upgrade proposal tha: includes the
ition of new design flow to a cesspool or privy or the addition of new design flow above the
iting approved capacity of a system constructed in accordance with either the 1978 Code ar 310
R 15-000.
Facility/syster. owner
Name /1?,t ck -buo(a
Address ('5 Xatii 11A. . ._c
Phone # —gt( _�,217C
Address of facility f ,c hot_, i
Applicant (if different from above)
Name
Address
Phone ;t
Type of facility
_ res.dential commercial _ school
institutional
(Specify) C,t� rc t, c{ I �4 I-lottis
DEP MIROVED FORM- 13107/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 OF
Type of existing system
privy cesspooi(s) conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits etc.)
N/1")
Design flow based. on 310 CMR 15.203
a) Design flow of existing system A/
Approved? yes approval date
no why?
b) Design flow of proposed upgraded system S-31 gpd
c) Design flow of facility _Ogpd
Proposed upgrade of existing system is
a) V Voluntary
Reauired 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)_ (dre)
•
b) Describe _he proposed upgrade to the system �-r-
%J 2t.J 1370 q print � �Ap4 J akic o d',
3.1 t x 12 t x n.i-S" 1 ? rn r.n 22j11 *_Iloy
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback d noes)
a
Percolation rate of 30-60 minutes per.inch (state actual per° rate)
DFP I.PPROVFD Fa1LM-12.07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3OF5
Up to 25% reduction in subsurface disposal area design requirements (state required
& proposed size)
Relocation of water supply well (identify well, describe relocation)
Reduction or required separation between bottom of SAS & high zrcundweter
(specify --
cify proposed reduction & pert rate) < '9 /v'ps
Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the
Code)
System upgrades that cannot be performed in accordance with 310 Cb1R 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.
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 Sol
Evaluator must determine the high 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 grotmdwate-
Lr feet
As determined by
Evaluators name /27iciae-
Evalua tor"s signature
Date of evaluation 7p.,/o
DIY APPFOVFD FORM- 11/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE AP
?ROYAL
PAGE 4 OF
Notice to Abutters
No application for upgrade approval in which the setback from property Pines or a
private water suppiy well is reduced shall be complete until the applicant nas
notified all 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 refere::ce the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
butter Name
Address
Dale notified
butter Name
Address
Date notified
butter Name
Address
Date notified
butter Name
Address
Date notified
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 not feasible:
2. 4,(.C- gvalc& up - °u £e .
b) an alternative system approved pursuant to 310 CMR 15.283-15.2E8 is not ieasibie:
Ala Li k- c e-cr A7-Y-
Dee ATRROVFD FORM-12/07/95
FORM 9.4 - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
c) a shared system is not feasible:
a) connection to lR le:
o O
An application for a disposal system construction permit, including all required attainments
(e.g. plans & specifications, site evaluation forms), must accompany this application. Is the
DSCP application attached? 4 yes no
Certification
"1, the facility owner, 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 may be significant consequences for submi.ins
false information. including, but not limited to. penalties or fine and/or
imprisonment for knowing violations."
iv\_;
Print Name
Name of prepare: Date
IO \ Cild rzr1-.€-Pul ) t&L L.4p�-o VtA ��S ��0ZO
Telephone k & address o preparer
1TE: Title 5, 310 CMR 15.403(4), requires the system owner or operator to submit to tie
parttnent a copy cif the kcal upgrade approval upon issuance by the Board of Health and prior
:ommencement of construction.
DFP in^PROSY➢FORM-1.2.'0I/95
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
Massachusetts
CAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15A04 & 15.405
My/system owner: Name Mi n( Address:
Address of facility eh 1.
:of facility:
residential _ instituticual commercial school
design flow per 310 CMR 15.203 S''L® gpd
:m designer: Name e, Address Iol Ot ),Fer..,f'pa(cyg_p phone No.SBS=Sa2o
d Upgrade Approval granted for:
reduction in sefoack(s) (specify;
pert race of 30-60 min. /inch (specify rate)
reduction in SAS area of up to 25%
(specify % reduction & size of SAS)
reduction in separation between
SAS &high groundwater
(specify rducticn & pert rate)
relocation of a well (exp/aia)
ocai variances granted (no DEP approval required ocr 310 CMR 15.412(4))
-ariances granted recuiring DEP approval
I of Health Approva of proposed upgrade
Name & Title
Signatur
Ciry/town Date
SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
HE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
SION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
FORE COMMENCEMENT OF CONSTRUCTION.
DPP AFPROVED FORM-:Lars