155 Application for Local Upgrade 2004 Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
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
5.404(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.
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.
A. Facility Information
portant:
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Facility Name and Address
Name
LOT
Street Address O 1- LOC — `SU�L
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city��
2. Owner Name and Address:
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Name
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State Zip Code
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Street Address
State
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Zip Telep one Number
3. Type of Facility(check all that apply):
k Residential
4. Describe Facility:
❑ Institutional
❑ Commercial❑ School
5. Type of Existing System:
❑ Privy ❑ Cesspool(s);(Conventional
❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Bosse, "To BE Lg#c4k cal)
M-LOCAL UP-GRADE.doc•rev.5/02
Application for Local Upgrade Approval. Page of 5
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wastewater Management Program
Form 9A — Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: wad
_es 4f,56 £PO
Design flow of proposed upgraded system gpd
Design flow of facility gpd
330
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301: date of inspection
2. Describe the proposed upgrade to the system:
(JP& - rya 5,5 T3 M -'f rut-5 ftvD ,Ns—TALL.
tsoaALw SepALc T�f'
3. Local Upgrade Approval is requested for:
❑ Reduction in setback(s)—describe reductions:
❑ Percolation rate for 30 to 60 min./inch: minn i.c
❑ Reduction in SAS area of up to 25%: SA siS te.sq.ft. i reduction
❑ Reduction in separation between the SAS and high groundwater:
4 ��65.,> '�zn
l ,6 l
Percolation rate min./inch
Separation reduction
M-LOCAL UP-GRADE doc•rev.5/02
Application for Local Upgrade Approval• Page 2 of 5
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
Depth to groundwater
❑ Relocation of water supply well (explain):
t15
❑ 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(1)(i)(1). The soil evaluator must be a member
or agent of the local approving authority.
High groundwater evaluation determined b •
T.o4051- y E. MPt -)LUIS T w ZS -0'3
Evaluator's (type or print) Signature Date of evaluation
C. Explanation
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:
S&*-Ac Lot w :kt GA. “1oJtit aale
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
A L-Ltr2.40,4Vva Syslcti.,l. uS *Jo( I&ZluEc PRci?c Eo
3. A shared system is not feasible: (.401 t.(,cn,G{1 Svc Jeri-a (dv,Ab
M-LOCAL UP-GRADE.doc•rev.5/02
Application for Local Upgrade Approval. Page 3 or
Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Management Program
Form 9A - Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
4. Connection to a public sewer is not feasible:
µ.o QuP,LLC- S�uJER AUAILASi!-
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
l/ Application for Disposal System Construction Permit
IS_Complete plans and specifications
cZ 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):
D. 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." �,/
x!�''W 421 'i-i—� /
Facility Owner's Signa Date
✓_inndt4 St«cc k,
Print Name Act",P n"i b&O/d(/yi
Name of PretE Date
Preparer's address Si \> Aka o I o .9
y/Town b Ikko Vh Q Q qp
A-LOCAL UP-GRADE doc•rev.5/02
Application for Local Upgrade Approval. Page 4 of 5