380 Local Upgrade Approval & Soil Eval Form FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL,
PAGE 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 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
shall reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
Abutter Name
Address
Date notified
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
9) 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:
NAV gio�G/) ,Carer oiJ LC 7 & T 3 " /cc 'sc Tn4C
k�6a ogen --4,,7
b) an alternative system approved pursuant to 310 CMR 15 283-15 288 is not feasible:
/3�7?12n am/& sysf t.1 is AkircRroc3xb
DO ARROW FORM-LL/OLM
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
, Massachusetts
LOCAL UPGRADE APPROVAL ISSUED PURSUANT 'CO 310 CMR 15.404 & 15.405
Facility/system owner: Name:lb i.a. &e....wAddress: .30 Cite tirX
Address of facility S W
Type of facility: residential institutional commercial school
design flow pelt,310 CMR 15.203 rd System designer Nam lW .k4/NN•S Address 70/vrc V(taja icy. Phone No.
si Local Upgrade Approval granted for
reduction in setbxt(s) (specify)
pert raze 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 reduction&perc rate)
Z relocation of a well (explain)
) /.r7'Ca.-s'.l. ''Q
Lt
List local variances granted(no DEP approval required per 310 CMR 15.412(4))
List variances granted requiring DEP approval
erT JUt E7 -L it t¢>n° itiae
/A� ryne&rde tht/fV
sty town y4--
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 ueaovmronw.wanes
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 3OFS
Nick Up to 25% reduction in subsurface disposal area design requiremens (sale required
& proposed size)
pi/A Relocation of water supply well (identify well, describe relocation)
b` A Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & pert rate)
Other requirements of 310 CMR [5.000 that i
Code) at cannot be met (spec fy sections of the
5-CC- 'cliai11 6 (e
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)(0(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
DEP∎PPRO ID FORM-I2 0'15
FORM 9A - APPLICATION FOR LOCAL LPGRADEPAGER4 OF 15
gl Notice to Abusers
No application for upgrade approval in which the setback from 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
abutters
include a
in 310 completed
through application 5.405 and
List of affected Abutters:
Date notified
Abutter Name
Address
Date notified
Abutter Name
Address
Date notified
Abutter Name
Address
Date notified
Abutter Name
Address
9) 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 �not
SCe�ib�lec
ti,r—
<N<t.rc,y loci!} 01J L��iT M
Ekiec,) env"–
,._d pursuant to 310 CMR 15.283-15.288 is not feasibly
b) an alternative system
etTs n/PT.t'i✓
DO ARM ID FORM-SliPf 95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROYA;,�
PAGE') OF
4) Type of existing system
privy cesspool(s)/conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits,etc.)
P:cidWS p.r
5) Design flow based on 310 CMR 15-203
a) Design flow of existing system _ gpd _ ONKHtw&)
Approved? yes approval date
no why?
b) Design flow of proposed upgraded system j gpd
c) Design flow of facility .910 gpd
6) Proposed upgrade of existing system is
a) 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)
)
b) Describe the proposed upgrade to the system
ScStFvc Ra,Lut !. :LG`:UP P,r'c- niP9 GrSf()'>, (.
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)
RCGC,:G lr,, / " /c.:-> " 5,c778,44<- air As- Exis7-;,,,;c-
PRcpc56,v E0.✓64i %5' �c�� C;t_fi
N/A Percolation rate of 30-60 minutes per inch (state actual pert rate)
CO ZnOV FORM-la0 75
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAP
PAGE 7 OF a
4) Type of existing system
privy cesspool(s) V conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits,etc.)
5) Design flow based on 310 CMR 15203
a) Design flow of existing system _ gpd-UNKNowt)
Approved? yes approval date
no why?
b) Design flow of proposed upgraded system i7(45-gpd
c) Design flow of facility ?r"iO gpd
6) Proposed upgrade of existing system is
a) - Voluntary
Required by order, letter, etc. (attach copy)
V Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date)
b) Describe the proposed upgrade to the system
RGCCACC- Fn,,L)N(x =tJ&W 56k56& OOP
5y5
c) Which of the following are applicable to the proposed upgrade?
t� Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
RCOucc h1 ,,rci; /co 'SETS%,tie °F1RFe E)05751.1 416-a-
n nee,005e0 5As. RE6;.oecs7 75 ' 5<=rSt3ck
N/A Percolation rate of 30-60 minutes per inch (state actual pert rate)
okP AYnOVW FORM.1:0't5
AS Buy-T �) 't� (Sec RAA, pm i2.IEv45�
J
-� (FAArior L tmct
_311 - 112"DOUBLE WASHED STONE
/i
63LF-4" PVC PERF PIPE(S=.005)
I , 9
4"SOLID PIPE
DISTRIBUTION BOX
4"PVC SOLID PIPE-Sch 35•(S=.02
\ - I Q
I5
—SEPTIC TANK
GARAGE
FORM 9A - APPLICATION FOR LOCAL UPGRADE
GE OVAL
Commonwealth of Massachusetts
Afrit -tRmpB/J , Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
To be submitted to Local Approving AuthorinBoard of Health: For the upgrade of a failed or
nonconforming system with a design flow of <10,000 gpd, where full compliance, as defined in
310 CMR 15.404(1), is not feasible.
To be submitted to DEP: For the upgrade of a failed or nonconforming system with a design flow
of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full
compliance, as defined in 310 CMR 15.404(1), 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 the 1978 Code or 310
CMR 15.000. -
1) Facility/system owner SIC krnJSu;f
Name 8CATA/Ci _
Address 7g0 ,C i&ST RF'EL
Phone d
Address of facility
2) Applicant (if different from above)
Name
Address
Phone X
3) Type of facility
V residential commercial _ school
institutional
(Specify)
pp APPAO%FD ro0.M-ivy-Is
3-KO
ytu +_e,
PERCOLATION TESTIS)
Time:
Observation Hole
Depth cf Perc
Start Presoak
End Pre-soak
Time at
Time:
1
Lt'
Time at 9"
Time at 6•
C
Ti me(9•—6 )
Rate Min./Inch
Observation Hole
Depth of Perc
Start Pre-soak
End Pre-soak
Time at 12"
Time at 9
Time at 6"
Time(9'—6•)
Rate MinAnch
2
'minimum of 1 percolation tes
ust
donned in both the primary area AND reserve area.
Comments:
Witnessed by
a)-1fi I'i 4 iio
PERCOLATION TEST(S)
Time:
Time:
Observation Hole y1 Observation Hole #2
Depth of Perc
Start Pre-soak
End Pre-soak
5 L1
/
IC 5D
Depth of Parc
Start Pre-soak
End Pre-soak
Time at IT
Time at 9'
Time at IT
Time at 6"
Time(9'—6')
Rate Min finch
/0 C
Time at 9'
Time at 6"
Time(9'—6')
Rate Min./Inch
'mint/nun of 1 percol lion lest must be performed in both the primary are AND reserve area
Comments:
Crt,,tc..* }y
iPt
u
Location Address or Lot No
_ FORM I1 - SOIL EVALUATOR FORA
Page 3 of
Determination
Method Used:
r Seasonal Hi h Water Table
❑❑ Depth observed standing in observation hole ..
gDepth weeping from side of observation hole..
Depth to soil mottlesSa",yo "inches
❑ Ground water adjustment _
feet
Index Well Number
Adjustment factor ..
. inches
inches
Reading Date Index well level .._
Adjusted ground water level . .
De th of Naturally Occurring Pervious Material
Does at observed throughout ethe area proposed for the pervious
o lvabsorption system? in al�are?s
if not, what is the depth of naturally occurring pervious material?
Certification
—I-ceruy mat on
wasrperfo by by m�
described in 310CMR 17•
(date) I have passed the soil evaluator examination
t of Environmental Protection and that the above analysis
tent with • - eq red training, expertise and experience
17.
Signatu
DEP APPROV$n POgt,.L•t0'r95
Date 1B •. -�>
On-Site Review
atmnAddress or Lot*
Date
Engineering Firm
;entity on Sne Plan
Land Use
vegetation
Landtarrn
dlon an Landscape
Owner
Time
f Slope
_
Engineer r Of or Sanitarian ___.
Surface Stones
Address
Weather
C1JO�h�Ca-lt- '
Open Water Body
Possible Wet Area
Distances from
I feet I Drinking Water Well
2/ feet i Drainage Way
j1ci /f
in I)
feel
feel
Property Line
Other
d =- feel
Feel
rep Hole 4: 1 I
DEEP OBSERVATION HOLE LOG*
*MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Other
.udders Corssenci 9,
Deng.corn Soil Hoene
io L,<Ir`
Soil reo),p
USLiAI
r
l
C
San Color
.rno, ,:nl
/
Soil Mottling
rent Material(geologic) ^7
pth to groundwater. Standing Water in t e Hole
Estimated Seasonal H Ground Water
tL1 1 Depth m Bea
Z
1
Weeping
%c-
om N Face I /C,/ '-P
leep Hole#:
Sod Ilnr¢Oe
A
th 'Of
GY (
DEEP OBSERVATION HOLE LOG*
'MINIMUM OF TWO HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA
Suit exlurn
(USDAI_
-� y
Su I Color
Mu . "li
�1 f
Soil Mole, Other
ISlluclure.Stones Soulders Cunsistencor
parent Material groundwater Crfn T`
Cep h to groundwater Standing alerin the Hole
- 1 SSr-fated Seasonal High Ground Water
Depth to Bedrock
Weeping from Pit Face
Location Address or Lot No.
FORM 12 - PERCOLATION TEST
,2 o r5.)-ve cQ
COMMONWEALTH OF MASSACHUSETTS
PbR ryy„rpt Massachusetts
Percolation Test'
Date: . .(i, • Z- f 7 Time:. y,I3p..a.,9s
Observation Hole it
1
Depth of Perc
5 Y y
Start Presoak
to, j g
End Pre-soak
ID; 33
Time at 12"
X0: 33
Time at 9"
I el S G
Time at 6"
/ 1 : ODD
Time (9"-6")
(a (o
Rate Min./Inch
a a Plc,
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed
Performed By:
Witnessed By:
Comments: . .
Site Failed ❑
/men", e
C'r? --,2 ,L. EIZL.¢rr/
DQ APPROVED FORM-L-10It95
FORM I1 • SOIL EVALUATOR FORA.
Page 3 of
Location Address or Lot No. '35W fN€tTeez5eLD 120
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole _. inches
❑ Depth weeping from side of observation hole__ inches
Depth to sou mottlesca"94o inches
9 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 all areas
observed throughout the area proposed for the soil absorption system?Vry
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on (date) I have passed the soil evaluator examination
approved by the Depa m nt of Environmental Protection and that the above analysis
was performed by m cons tent with - eq red training, expertise and experience
described in 310 CMR i :.01 7.
Signatu
DE?APPROVZD FORM•I:/07'95
Date /4 '? 'f7
r
y3E74o^.2
(.TELL pSo nc„+S L.tECI-
O R t 'I 70 3E LDC TE1�
TPi
a
' rat
7P4.
L
5J3 54: ReiD p2R-I
Location Address or Lot eio.
FORM 11 - SOIL EVALUATOR FORD;
Page 2 of 2
-T
On-site Review
Deep Hole Number S.
bate: /o1_S7
Time: ,V.ro°
Loeaticn (identify pn site plan! _ A'y Weather S as a+a,X
Land Use I?C$..175Sc_a✓ - -.
_. .._.Tan Slope (%) _S Surface Stones ..4,2 y.c Vegetation {d� eta - . . _..
Position on landscape (sketch on the back)
Distances from:
Open Water Body LOg9feei
Possible We:Area_ t
feet
Drinking Water Well Apps/ feet
Depth from Sal Hoe an
Surface finches)
6 fp 6°
Ie Tr 57
S2 t>totr'
A
F;
C
Drainage way bar 'feet
Property LinetO', br fee;
DEEP OBSERVATION HOLE LOG'
Soil Secure Soil Calcr Soil
(USDA) IMuneeID Other
Molting Ism cause.Stones. Boulders,Cansire9q, %
Craven
loy,3j
7
J/
j
3
Parent Maceriai!geologic! Se e ac
N.r�f=G✓TiY 1�
h to Geo Id reao Standing Water in the Hole: Nsr..t
`:w,atatl Seasonal rfigh Cn A Watt:y 2 b
DEP.Vf•p•rD FORM-12/0;195
?tip
L
b+yTrl..a • La-e..,
LC a,577 s» a �w£T ln *
rtalot
i a 9p c., c
Depetpaeteeck:
Weepirq from Pit Face:`µ--_p— _--
F;fklt 1 t - SOiL EVALUATOR FORM
Page 2
On-site Review
Deep Hcie Number ,,,ikplti_. Date: /D'. 'g7
Location (identity on site plan) --i
Land Use 2ct_5!}.X...Y -`.._.._. Slope f`o: ._5
Vegetation ike.
Ho.IGnn on landocape ske!p:I „o the bocisii,
tc:Z ncee `rum: y
Open Water body (O?Q.siett
Possible Wrt Area a300 .. feet
'Drinking Water WerfQ i feet ether
Tim.e:_L6-BB.Z^ Weather S✓nrNY
Surface Stones ._..?as
r
.[ S' way
44. . reef
,y Line�.'�9 feet
Utaa
Property
�iEls DT S :RCM.TON IIZSL G
Sad Ma[:Lnq Stones.Sa.Cala I IS::uc:u e.Scones.9CU1Ce:a.
Gene from S�dacn
sad ar.=n ScI'e+:err_N Imursa"t Cp^sare:r.. %Gene
tmcoesl SuA:
SO y+. 416
p° 7o
ic
Jr
To
m
5/,
F
It yS
PO
Nb
o
96"
tT )y4%
Parent Material (ge Jlcyicl .SeE--G...Yv°T-'� .,._.
Coroundavar.a." Srboding 'Ala a: in the IiC'C.�,topQ_
_::r nand i235 Jnai
r.ign Grog ,rater: yo
bif4va e T LO?"/
FT/f
+/Y re Ft es"-:
K
cog,/r5 fe L
01it>Of re Z..
449VzL
Depth to Bedrock:
Reining Iron Pit Face:PtI
No.
FORM Il - SOIL EVALUATOR FORM
Page 1 or3
Date: ?
Commonwealth of Massachusetts
AUcaret..e.e-,t-A,, Massachusetts
Soil uitability ssessment or On-site Sewa e Dis.osal
Performed By: .?iEu.et.Cs_ 2 L4 co,,t,y r
Witnessed By: _6.'tt'. sirt F tc t n,
Date:
)2D G/f c s toCiz F c/tQ
Not x Nnc,/ y'n .✓ ov3b1g1
B/gal
eve Construction. ❑ Repair 2t
OMce Revie
Published Soil Survey Available: No ❑ Yes
Year Published ta.LQ.I.. Publication Scale /:Ls1YU Soil .Mao Urit 13 /C..,_L.
Drainage Class ;:..ttgrty Soil Limitations
a..a..rj Sc.apc_S
Surticlal Geologic Report Available: No ❑ Yes:
Year Published _•. . Publication Scale
Geologic Material (Map Unit)
Landfccr. a..9 ._..
Food Insurance Rate Map:
Above 500 year flood boundary No ❑Yes
Within 500 year Hood boundary No rE es ❑
Within 100 year flood boundary No S+Yes J
Wetland Ara:
National Wetland Inventory Map (map unit)Conservancy Program ) llQ�.... 0=. L ,•
Map (map unit) �� t � •
I
0--•""`_. ,cA%lice 17. r%tes-2,aso .�
..me..
Tti+e.t 320 Cyc Tc.efe/O .2G
• Lce '27'47 O/ds�
Curent Water Resource Conditions (Ul�SGS): Month
Rana: :Above Nom L;a1 Normal Below Normal ❑
Giher References Reviewed
DEP APPROVED FORP1-1]!01795
Location Address or Lot No
FORM 11 - SOIL EVALUATOR FORM
Page 2 or
ago CNcsTedz !& f2%
On-site Review
Deep Hole Number . Date: f7 Time: 2.to°An Weather `)Li4-na
Location (identify on site plan)
Land Use XCLJ b' C.AJ 74L Slope (%) C Surface Stones Nb.e/.c . . ,
Vegetation 4.2Jr1 .. ...
Landfcrm . 4s4 as __ _..,
Position on landscape (sketch on the back) _.
Distances 'rom•
no-
Open Water Body r feet Drainage way t o' feet
Possible Wet AreaadOt _ feet Property Une&O'a 2or feet
Drinking Water Well /00i feet Other _..
DEEP OBSERVATION HOLE _OG•
Depth from
Surface Inches:
Soil Horizon
Sol"flours
(USDA)
Sail Color
(Mune.III
Sod
Mottling
Other
(St/Ix-tuft Stones,Boulders,Consistency, %
Gravel)
D re L
♦a ZP $J
52 to WE"
A
F1 1
C
57“-
r (
Li
�
/Pye if?
ti'i
io ay
r !3
)0D
Joie BI
5,1 "
3 5“t
AS yA52
& 4'ares . L°-4-m
f7 (2 Go33lr s svr.7 S-7-6,,t
TO X04-
C raFR, hc.', a°MhE, 9r.>
t>-
7To.ar ii'l atttGteuct
MNIMUMVri fW.¢JfZ_VVrtU nI cecnr rnwwc�o..-..._-._...._. -
Parent Material(ge logic) _Ece t:°..tge1 earA,Oak 5 DeptmBedrack:
Death a Grcucdwa Sr Standing Water in he Hole:
Estimated Seasonal Ftigh Ground Water: 52 p
DEP APPROVED FOR-et-11107/9S
/06
N G n.t Weeping from Pit Face: PlO €