Loading...
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