41 Local Upgrade Approval 2003 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF 5
Commonwealth of Massachusetts
Nci (;fir ,. , , Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
omitted to Local Approving Authority/Board of Health: For the upgrade of a failed or
rming system with a design flow of < 10,000 gpd, where full compliance, as defined in
2 15.404(1), is not feasible.
ruined to DEP: For the upgrade of a failed or nonconforming system wither design flow
up to 15,000 gpd and/or for upgrade of a state or federal facility, where full
:e, as defined in 310 CMR 15.404(1), is not feasible.
Local upgrade approval shall not be granted for an upgrade proposal that includes the
Al new design flow to a cesspool or privy or the addition of new design flow above the
pproved capacity of a system constructed in accordance with either the 1978 Code or 310
000.
.cilityisystem owner
Name J aMl'w Ft.Es AUi ti
Address 9/ sf /cctANC / RL,;ef-ucj WA 0/04z
Phone if SFG -- 5635
Address of facility y/ 59euc& (Atn/E rte t c.r Mi- //oe 7
)plicant (if different from above)
Name
Address
Phone 11
pe of facility
✓residential commercial school
institutional
(Specify)
DEP APPROVED FORM-12/07/95
• FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2OF5
f existing system
privy cesspool(s) ,...conventional system
Other (describe)
of soil absorption system (trenches, chambers, pits,etc.)
Y i E-Ll�
n flow based on 310 CMR 15.203
sign flow of existing system gpd
proved? 'eyes approval date 4/c/k?
no why?
sign flow of proposed upgraded system 5 yg gpd
sign flow of facility gpd
sed upgrade of existing system is
✓Voluntary
Required 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)
scribe the proposed upgrade to the system
VGW - L,{t ez.D
aich of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
Pc-col)tion rate of 30 SO -?notes per inch (Hate actual pore rata)
DEP APPROVED FOAM-11/07195
if,
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3 OF 5
Up to 25% reduction in subsurface disposal area design requirements (state required
& proposed size)
Relocation of water supply well (identify well, describe relocation)
Reduction of required separation between bottom of SAS & high groundwater
(specify proposed :eduction & perc rate) q F.{ _ (Z.z .,a jz,.u)
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 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.
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 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
Evaluator's signature
Date of evaluation
DrP APPROVED FORM-1.2101195
7- Pt(U1Lv /z
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 OF 5
Notice to Abutters
No application for upgrade approval in.which the setbacicfrom 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 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
than reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
r Name
Address
Date notified
r Name
Address
Date notified
r Name
Address
Date notified
r 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:
Due i a c / 77AjG 6CRDES
b) an alternative system approved pursuant to 310 CMR 15 283-15 288 is not feasible:
613.1tF n/c. [uAN'GC 6,w . cfl3rr .
D@ APPROVED FOAM-12107195
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
a shared system is not feasible:
r11&7 :a-..alc n
connection to a sewer is not feasible:
tator R(14i t'&t
application for a disposal system construction permit, including all required attachments
t. plans & specifications, site valuation forms), must accompany this application. Is the
;P application attached? yes no
ication
the facility owner, certify under penalty of law that this document and all
chmenls, to the best of my knowledge and belief, are true, accurate, and
aplete. I am aware that there may be significant consequences for submitting -
,e information, including, but not limited to, penalties or fine and/or
irisonment for knowing violations." :.
;ihty owner's signature Date
nt Name
ILli1/4.3 L . Wc15S
me of preparer
35tc: OCa EzJFIcUb ee.
3et-c ,. z onA - 6Mc
lephone # & address of preparer
/z./74,3
Date
title 5, 310 CMR 15.403(4), requires the system owner or operator to submit to the
nt a copy of the local upgrade approval upon issuance by the Board of Health and prior
.ncement of construction.
DEP APPROVED FORM-12107195
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
, Massachusetts
UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
tern owner:
tarty:
igner:
Name:
Address of facility
Address:
residential institutional _ commercial school
design flow per 310 CMR 15.203 gpd
Name
rade Approval granted for:
luction in setback(s) (specify)
Address Phone No.
rc rate of 30-60 min /inch (specify rate)
luction in SAS area of up to 25%
ledify % reduction &size of SAS)
luction in separation between
S &higb groundwater
zeify reduction &perc rate)
ocatiou of a well (explain)
'ariances granted (no DEP approval required per 310 CMR 15.412(4))
:es granted requiring DEP approval
.eaith Approval of proposed upgrade
Name &Title
Signature
City/town Date
'EM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
.PPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHOR]T:
E COMMENCEMENT OF CONSTRUCTION.
DEP APPROVED FORM-12/07/95