228A Septic Upgrade Application 2002 FORM 9B - Local Upgrade Approval
Co we th/ofMassachusetts
Q N ,Massachusetts
( /Town)
LOCAL UPGRADE APPROVAL
Issued Pursuant to 310 CMR 15.404 and 15.405
Facility/System owner: COOL SAW-
City/Town: .p /
ty f/oPo �./a'rt
Facility Address: �-a-p /d-pdn
Type of Facility: Residential ❑Institutional
Design flow per 310 CMR 15.203
System Designer:
Address: 70
City/Town:
Address: 673 5r614 S4pa o.
State: } Zip: /o6
)-
City/Town i P1
❑Commercial ❑ School
a3�i gpd
Local Upgrade Approval is granted for:
❑ PE RS
State: Zip: O/epoe1-'
❑ Reduction in setback(s) (Specify)
❑ Percolation rate for 30 to 60 min/inch Percolation rate
❑ Reduction in SAS area of up to 25%
min/inch
(SAS size and%reduction) SAS sq ft Reduction
Reduction in separation between the SAS and high groundwater
Separation reduction 3 ft Percolation rate
Depth to groundwater 7t-
min/inch
❑ Relocation of well(Explain)
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
A p e ro ed by the
a"
/' L,A.,,tt.47.
Board of Health
talti
(Print or type name an. Title) O (Sirnat e) (Da )
The system owner shall provide a copy 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
FORM 9A - Application for Local Upgrade Approval
Commonwealth of Massachusetts
Np( } hl ,Massachusetts
(City/Town)
Application for LOCAL UPGRADE APPROVAL
Title 5, 310 CMR 15.000
DEP Approved Form Required by 310 CMR 15.403(1)
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or
nonconforming septic system with a design flow of less than 10,000 gpd,where full compliance,as
defined in 310 CMR 15.404(1),is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405,or in full
compliance with the requirements of 310 CMR 15.000,require a variance pursuant to 310 CMR
15.410 through 15.417.
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NOTE. Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a
new design flow to a cesspool or privy,or the addition of a new design flow above the existing approved
capacity of a septic system constructed in accordance with either the 1978 Code or 310 CMR 15.000.
Facility Address: ZL& Auoopoe.( Qd. City/rown: l34o gaPcnkro fJ
Facility/System owner:
Address: c) II— —fig∎ef e
City/Town. Lcy2-44..r,¢ State:MP Zip: 01 c C
Telephone: (445 1 585 0 ci 4-g2
Type of Facility(check all that apply): eResidential ❑ Inst�tional ❑Commercial ❑School
Describe facility I ta ( A% — No 6ARi '
Type of existing system: ❑ Privy ❑Cesspool(s) UConventional System
❑Other(describe) D MK400J'
Type of soil absorption system(trenches,chambers,leach field,pits,etc) Li/%4, -N CAdd a
Design Flow per 310 CMR 15.203:
Design flow of existing system gpd
Design flow of proposed upgraded system '3 13 gpd
Design flow of facility 3 3 Pd
Proposed upgrade of system is:
U
Department of Environmental Protection
Voluntary ❑Required by order, letter,etc.(attach copy)
Required following inspection pursuant to 310 CMR 15.301
Provide date of inspection / /
FORM 9A - Application for Local Upgrade Approval
Page 1 of 3
DEP Approved Form-3/30102
upvca ,p1(,1n3C�a $v651A
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Describe the proposed upgrade to the system R e r M
ISPOSI ec, Z S)Ot/A Ea)OB G•
0
Local pgrade Approval is requested for:
µ/ p Reduction in setback(s) (Describe reductions)
N1
Percolation rate for 30 to 60 min/inch Percolation rate min/inch
Reduction in SAS area of up to 25%
(SAS size and%reduction) SAS sq ft
Reduction
Reduction in separation between the SAS and high groundwater
Separation reduction .3 ft Percolation rate 0—
Depth to groundwater a I ft
min/inch
%
Relocation of water supply well(Explain)
Other requirements of 310 CMR 15.000 that cannot be met
Describe and spccify sections of the Code
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation,an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 15.405(1)(i)(1).The soil evaluator must be a member
or agent of the local approving authority.
High groundwater elevation determined by:
(Print or type evaluator's Name) (Signature of evaluator) (Evaluation Date)
Explain why full compliance,as defined in 310 CMR 15.4040),is not feasible.
(Each section must be completed)
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
NOT s).rr.'CH celv-A 41-0 €Gss-b,..,,i c/a-CIWE tr, CoNG+ -D
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
Nfr) /.i /Ls pROFOSaY)
L
Department of Environmental Protection
Page 2 of 3
DEP Approved Fonn—3/20/02
3. A shared system is not feasible:
SNfrO,F. Sys i—A
FORM 9A - Application for Local Upgrade Approval
Pt aepi („0 13 '('o O S Ns-P(4-C-
IS NciN Sc1.36 fZc,?O$
4. Connection to a public sewer is not feasible: kl6 P uBIA(, ft t/A1( (_
The Application for Local Upgrade Approval must be accompanied by all of the following:
(Check the appropriate boxes)
Application for Disposal System Construction Permit
Complete plans and specifications
Site evaluation forms
�1 ! ' A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other(List)
CERTIFICATION:
°1, the facility owner,certify under penally of law that this document and all attachments,to the best
of my knowledge and belief,are true,accurate,and complete.1 am aware that there may be
significant consequences for submitting false information,including,but not limited to,penalties or
line and/or imprisonment for deliberate violations.
Facility owner's signature
Print name �o.e.J4/
Date S 2s/ D2—
Name of preparer I s,V.O{icy t A4 Gr„tt3 AI IS Date .S /2&1 Ct
Preparer's Address: ']O M . \Wr, )E Q Gap
City/Town:lUE1 State: pnp- Zip: 0 l
Preparer's telephone: ( l3 'I J 27' - SEA I
NOTE: 310 CMR 15.403(4)requires the system owner to provide a copy of the 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.
Deparunent of Environmental Protection DEP Approved Form-3/20/02
Page 3 of 3
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