903 Septic Forms 9A/B 11 & 12 2000 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL -•
PAGE 2 OF 5
4) Type of existing system
privy cesspool(s) con veutio nal system
Other (describe)
Type of soil absorption system (trenches. chambers, pits,etc-)
� elcl
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system /VA apd
Approved? yes approval date Nbq
no why
b) Design flow of proposed upgraded system 3(19'y gpd
c) Design flow of facility330 gpd
6) Proposed upgrade of existing system is
a) Voluntary
Required by order, letter; etc. (attach copy)
t/ Required following inspection required by 310 CMR 15.301 (provide date.
inspection form was submitted to the approving authority) ivjg (date)
b) Describe the proposed upgrade to the system
✓% A-CL) /rig -c .i.: .Cc . Z &I/1Z_
� Z 6 4/0 Fr2 /at[ /, g y y
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
.Le-dkced rv1.1‘ae.E 6c ii✓e e.� I"./-�..f ez •_d (76«uzda,.irt.
rAiwn &D � 4 is'''.
Percolation rate of 30-60 minutes per.inch (state actual pere rate)
orr A NPMUtBU GO WO . I2/07/Q4
FORM 9A - APPLICATION FOR LOCAL UPCRADE.APPROVAI.
I'AGE 1 OF 5
Commonwealth of Massachusetts
Flop- c 2 , Massachusetts
Application for Local UpErade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To he submitted to Local Approvin Authority/Board of Health: For the upgrade of a failed or
nonconforming system with a design How of < 10,000 gpd, where fu!I compliance, as defined in
310 CMR 15.404(1), is not feasible_
To be submitted to DEP: For the upgrade of a
of 10.000 up to 15,000 gpd and/or for upgrade
compliance, as defined in 310 CMR 15.404(1).
failed or nonconforming system with a design flow
of a state or federal facihry, where full
is not feasible.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the
addition of new design flow to a cesspool or privy or the addition of new design flow above the
existing approved capacity of a system constructed in accordance with either die 1978 Code or 310
CMR 15.000.
I) Facility/system owner
Name
i ! 1
Address •p�
Phone /I
dii z ;c c-7-1—(51
Address of facilisy S-53-9%
/o-emc e. //77A
2) Applicant (if different from above)
Name
Address
Phone I/
3) Type of fact '
residential commercial school
institutional
(Specify)
DU'nrrgo VFD FORM • 12/07/91
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL -•
PACE 4 OF 5
8) Notice to Abutters
No application for upgrade approval in which the setback from property lines or a
private water supply well is reduced shad 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 We upgrade approval will be on
the agenda. Such notice shall include We date, time and place where We upgrade
approval will be discussed.
If the Department is the approving authority, Wen such notice to abutters must be
completed prior to the date 01 submission of the application to the Department.
The notices to abutters shall include a copy of the completed application form and
shall reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
Abutter Name
Address
Abutter Name
Address
Abutter Name
Address
Abutter Name
Address
Date notified
Date notified
Date notified
Date notified
9) Explain why full compliance, as defined in 310 CMR 15.404(1), is riot feasible (each
section must be completed):
a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
COS4- c*._o( r?cxcz
h) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
no
O@ ArraovEn FORM. I3/mM9s
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)
VReduction of required separation between bottom of SAS &
(specify proposed reduction & pert rare) Zeducc
Other requirements of 310 CMR. 15.000 that canner be met
Code)
high groundwater
Za- ed aF` /0,077r
2'-t 9A?o /e_
(specify sections of the
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.
7) 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)(1)(1). The evaluator must be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
3 feet
As determined by:
Evaluator's name
Evaluator's signature
Date of evaluation
DEP API RO VE)FORM- i 1/0),%
vi ?C Y'+•r/74-6am//`
c)
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
a shared system is not
eI feasible.
km 4— °tint i
a) connection to a sewer is not feasible_
!e & ckvrJlobk_
10) An application for a disposal system construction permit, including all required attachments
(e.g. plans & specifications, site evaluation forms), must accompany this application. Is the
DSCP application attached? roves no
II) Certification
"I. the facility owner. certify under penalty Of law hat this document and all
attachments, to the hest of my knowledge and belief, are true. accurate. and
complete. I ani aware that there may be significant consequences for submitting
false information. including, but not limited to. penalties or fine and/or
imprisonment for knowing violations. "
7
Facil
y
owner's:signature
://d
Print Name
eM rte- F e�Gr'a---c'-✓,C c C O2 -Ole -
Name of preparer Date
3JT :''-744c / i(/m a. 74). /n.9 (4/47) 7.20-0
Telephone ft & address of preparer
NOTE: Title 5, 310 CMR 15.403(4), requires the system owner or operator to submit to the
Department a.copy of the local upgrade approval upon issuance by the Board of Health and prior
to commencement of construction.
OFP APPROVED EDRN-12/07/95
FORM 98 - LOCAL UPGRADE APPROVAL
COFIZn a/zWea((/I of Massachusetts
lU %—ehcc , Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
Facihrv/sysi cnt owner_' Nam
e
Address of facility Address' �Q,� c�o<-rl�
Type of facility: residential institutional
design flow per 310 CMR 15.203 commercial school
7,30 gp(I
System d es tenen Name E� r.
Local Upgrade Approval granted for:
reduction in sctbackls) (specify)
xv-
Address Q/623-7': - 0-Y7c9 Phone No, c>__-'200
pert rate 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 rcduuion & pert rate)
relocation of a well (explain)
Ze-aikced _7 c<,R r<e 04._
/O 4,77> r 2a er.5,._ ,e4
List local variances granted (no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval
Board of Health Approval of proposed upgrade
frticEr L_
THE SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
& BEFORE COMMENCEMENT OF CONSTRUCTION
DEP APPROVED FOkM. 13/07/95
No.
FORM 11 - SOIL EVALUATOR FORM
Page 1 (1E3
Date: i a-&kQ7
Commonwealth of Massachusetts
1Jor-lharipftm , Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By: rYl ici xle I. Lau..c9m_R,.
Witnessed By: _PeCaA. . Mcfi1,�ru;tU.
Date: )a/7/_OC?
9a3 F(ourncQ, Raved
Vew Construction ❑ Repair E.
Geryy hi-CI-ch.() her' K
Aatben,QM 903 F)cRCmce. .d
itk°"°"" CCn1harnp ton /1'1 Yl 0/06,0
5-Cr abhoS}
Office Review
Published Soil Survey Available: No ❑ Yes ❑
Year Published
Drainage Class
Publication Scale
_... Soil Limitations
Surficial Geologic Report Available: No ❑ Yes f-1
Year Published
Geologic Material (Map Unit)
Land form
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes ❑
Within 500 year flood boundary No ❑Yes n
Within 100 year flood boundary No ❑Yes
Wetland Area:
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Publication Scale
Soil Map Unit
Current Water Resource Conditions (USGS): Month
Range :Above Normal ❑Normal ❑Below Normal ❑
Other References Reviewed:
DEP APPROVE/)FORM- 11/07/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 07053
(413) 586-7200
FORM II - SOIL EVALUATOR FORI11
Page 2 of 3
Location Address or Lot No. 703 FfOU,17(R geed
On-site Review
Deep Hole Number ( 1 2- Date: lel�b)j,eD� Time: YYf0i/11 L47 Weather
Location (identify on site plan) SQF. 9-40/4-) J
Land Use Slope 1%10— -/ Surface Stones bteti_
Vegetation oY-rx—SS'
Land form
Position on landscape (sketch on the back) -L s rp.fc%I //is-2...
Distances from:
Open Water Body >/00 feet Drainage way feet I)�S �
Possible Wet Area >/00 feet Property Line >/O feet
Drinking Water Well >/00 feet Other
DEEP OBSERVATION HOLE LOG'
Depth from
Surface finches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
IMunselll
Soil
Mottling
Other
(Structure,Stones. Boulders, Consistency, %
Gravel)
o ff"
sy it yg„
1/ ".-! Iii°
T/
F
C
Si—
z
G.5
/OYRs/3
L
a,syr j ,
/ 0/t1L
L
i /0
7-5-112•51Y
X60„
lgJSc4I
s0,,,,dyy -1`; it
o -W 0.y
a y"/f
O —sC</+
/4,—cam-
F
CL 7-
z
(./ls-�A
P
L
S�sl-I-I F-;II , VC'-7 (O� IT ,;t
Parent Material (go oglcl_C7k.t-\t C c Y...1)
DepthloBedrock:
Depth to Groundwater: Standing ater in the Hole: ACV / -/2
g f --� .T Cn Weeping from Pit Face) J
Estimated Seasonal High Ground Water: it k_/;21( -/V.67
DEP APPROVED point-12/07/95
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
1413) 586-7200
FORM 11 SOIL EVALUATOR F0RD9
l'age 3 of 3
(mention Address or 1,0( No. - j77io )cy : nC�+�
Determination for Seasonal High Water Table
Method Used:
Li Depth observed standing in observation hole inches
Li Depth weeping from side of observation hole ...... inches
Depth to soil mottles &O inches
U Ground water adjustment feet
Index Well Number
Reading Date Index well level
Adjustment factor .......... .... Adjusted ground water level
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist In II areas
observed throughout the area proposed for the soil absorption system?
not, what is the depth of naturally occurring pervious material?
Certification
I certify that on )( ), (/ 1/ (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature f%
uir nrrnu VEu FORM L11107195
Date ..//,A1-17
Environmental Field Services, Inc.
P.O. Box 518 Leeds, MA 01053
(413) 586-7200
FORM 12 - 1'ERCOLATION TEST
Location Address or Lot No. 9'03 J /L51PiyIC'j
COMMONWEALTH OF MASSACHUSETTS
YJo fl*hc ri)p lcPU , Massachusetts
Percolation Test'
Date: /a> '7/DO Time:,rnoviJ
Observation Halo #
Depth of Perc
,
Start Pre-soak
4i1 1
G1CL
,End Pre-soak .,
e /mui /�/
Time at 12"
Time at 9"
Time at 6"
/
-c z_- 2,P c 2_t l
Time 19"-6"I
L C7)arLi-
Rate Min./Inch -
r,%t-ic f
raDt
Minimum of I percolation test must be performed in both the primary area AND
reserve area.
Site Passed Z Site Failed
Performed By:
Witnessed By:
Comments:
II
01 ) c l"kuU c4Lc9 cix_ Q
I ` r e l ilt At
15EP APPROVFL FORM 11/07a5
Environmental Field Services, inc.
P.O. Box 518 Leeds, MA 01053
1413) 586-7200