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43 Septic Form 9A/B FORM to Application for Local Upgrade Approval Commonwealth of Massachusetts /Uo R.77 rvtt To AJ ,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,when 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 of310 CMR 15.000,require a variance pursuant to 310 CMR 15.410 through 15.417. 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' 11.3 tA1 e_ SUP ft 7 City/Town: /UOR.77-B4/aA Tonl Facility/System owner: ' i'r'f�Ailut,tt Address: //S -ZiLAArh teat City/Town: A)otTXaa.A Toal State: /so/4 Zip: ai060 Telephone: ( Y13 ) C$'1 0307 Type of Facility(check all that apply): ®Residential ❑Institutional ❑Commercial ❑School Describe facility a t?LRd,hl ,Du4CtL j AIo C4EMAr 6p/Nde& Type of existing system: ❑Privy ❑ Cesspool(s) f Conventional System ❑Other(describe) Type of soil absorption system (trenches,chambers,leach field,pits,etc) TZ-17 Design Flow per 310 CMR 15.203: Design flow of existing system ON,ttaot04gpd Design flow of proposed upgraded system 3 7S gpd Design flow of facility ,a3O gpd Proposed upgrade of system is: ❑Voluntary ❑Required by order,letter,etc.(attach copy) R,Required following inspection pursuant to 310 CMR 15.301 Provide date of inspection A /i 7 / o'/ FORM 9A - Application for Local Upgrade Approval Department of Environmental Protection DEP Approved Form-320/02 Page 1 of3 Describe the proposed upgrade to the system /JEW /,Son GAtioni /g4JaACiIV4477S Sr/64 2 (onteAaTAIll)TSFATic 774A1,r/ N Mar AAA' .S© Fr f fAO, Aib. Local Upgrade Approval is requested for: ❑ Reduction in setback(s) (Describe reductions) ❑ 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 4'-3 ft Percolation rate 8 min/inch Depth to groundwater S ft ❑ Relocation of water supply well(Explain) ❑ Other requirements of 310 CMR 15.000 that cannot be met Describe and specify 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(1XiX1).The soil evaluator must be a member or agent of the local approving authority. High groundwater elevation determined by: 440(5T N1kTNtEJ e/S/ On, (Print or type evaluator's Name) (Signature of evaluator) (Evaluation Date) Explain why full compliance,as defined in 310 CMR 15.404(1),is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: 4 se'SCJ)g,PgTio& T %,F-cAnsam TCP wooCh -k(f pEf -MAT 7141.54S dE RAtSED A'bvf THC Ins yrtd6 (oPJJ,i1[ . 7A'S IA) Tv2N WovU IZl ConrfreW''TotY S7-0€461 DoE To -riff Pier 774AT 7x,3 ?Roktrie 45 en) ref /oo/ad.FE Oab 7L4rn 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: ' tae+T FEaitRtc Department of Environmental Protection Page 2 of 3 DEP Approved Form-320102 FORM 9A - Application for Local Upgrade Approval 3. A shared system is not feasible: Me OcJC. 7Et S/1AEc Ca IT/4 4. Connection to a public sewer is not feasible: Afe -Pon tic SE WC .- LA) A.€C4 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 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: `I,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 submitting false information,including,but not limited to,penalties or fine and/or imprisonment for deliberate violations. Facility owner's signature {rrfylii., Print nameTOSC0N A.& ByRA SI` ALc&r Date /Zb i o Y Name of preparer 17,A,,SNat440 ASSOC ,A,c Preparer's Address: /vt 7-4vice ST City/Town: GRAM)iY State: /AA Zip: D/oJ-3 Preparer's telephone: ( Y/3 ) 4"7- '222,9 Date S/z&i/ Oy 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. Department of Environmental Protection DEP Approved Form—3120/02 Page 3 of 3 FORM 9B - Local Upgrade Approval Co monwealth of Massachusetts 1,421hO (City ^) ,Massachusetts LOCAL UPGRADE APPROVAL Issued Pursuant to 310 CMR 15.404 and 15.405 Facility/System owner: City/Town: Facility Address. Address:71,69-i 3 ��`` State: Zip: O/O&c9 3 ,tv i aj i'- City/Town: Type of Facility: Residential ❑Institutional ❑Commercial ❑School Design flow per 310 CMR 15.203 PE ❑RS State:/ 74- Zip: CVd 73— System Designer Address: City/Town: Local Upgrade Approval is granted for: ❑ 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%reduction) SAS sq ft Reduction 1CJ Reduction in separation between the SAS and high groundwater Separation reduction ft-3 ft Percolation rate 3 min/inch Depth to groundwater 5 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: rsoMed by theme '� /�A23T. Lrtf Board/Lo of _ 4.2// (Print or type name and nd alth e_D Title) Signature) (Date) 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 Fonn—320/02 FORM 9B - Local Upgrade Approval Co monwealth/o�fMassachusetts A4/2166.f�D,4,A/ ,Massachusetts (Ci LOCAL UPGRADE APPROVAL Issued Pursuant to 310 CMR 15.404 and 15.405 Facility/System owner: Address: S3 City/rown: State: gh:9- Zip: D/062, City/Town: Type of Facility: Residential ❑Institutional ❑Commercial ❑School Design flow per 310 CMR 15.203 gpd System Designer: 4. RS Address: %40 CityiTown: _ / .�, .. State: Zip: CV d 7J Facility Address. Local Upgrade Approval is granted for: ❑ 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%reduction) SAS sq ft Reduction Reduction in separation between the SAS and hilt groundwater Separation reduction et—3 ft Percolation rate S min/inch Depth to groundwater 5 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: Approve• by th 4Et✓...407 Board o alth C���� .ZL1.ai ri 7 (Print or type name and Title) Signature) (Date) 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—3/20/02 • I • u. a p. n a 2 . C % C Distance • o- o I50• Slope I ^ i ( 2% Mini finish Grade J re Slope • { �• n Measure Slope_•__- i—I2* Min. m •�•• al His Point —v— ^ — >,-.r.. -1'_..JJ.. _'�^ : •_ .^ i Y 1.-M n. 2.1-1/2-IEt l./ n n < 4°Dla Pipe -FU ' Washed Slone x y O v` Natural Soll—�` Dap h • Effective c •^ ta c in Washed-1IFL ._a. `._._.—_ n r Washed Slone -' D Escavalloa Sidee>II- 12_IAin- I I Min.: Trice Zj a Elloclivo Width x E ll eclive Width w H K • rn z n Z ' rr LEACHING TREr!CH p — — z • No Scale n • IIIuctrutimi F1 " ' ;