91 Application for Local Upgrade 2000 FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2OF5
4) Type of existing system
privy cesspool(s) conventional system
Other (describe) S'C-t'kiK:- p&p L4- P( [
Type of soil absorption system (trenches, chambers, pits,etc.)
ifirr
5) Design flow based on 310 CMR 15.203
a) Design flow of existing system gpd
Approved? _yes approval date
no why?
b) Design flow of proposed upgraded system 333 gpd /ZE VL) (Act)
c) Design flow of facility gpd D�(CiOL'`
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)
Describe the proposed upgrade to the system
NZLi I C,64-L.6•0 SAP TIC fOTW
(-76 P -FF402 - 3N1
b)
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
Percolation rate of 30-60 minutes per.inch (state actual perc rate)
DPP APPROVED FORM-12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 1 OF
Commonwealth of Massachusetts
, 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 w Local Approving Authority/Board 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
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 facility, 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 the 1978 Code or 310
CMR 15.000.
1)
Facility/system owner
Name
Address
Phone ft
Address of f
Ilfty /14.71,,
2) Applicant (if different from above)
Name
Address
Phone #
3) Type of faty
residential commercial school
institutional
(Specify)
OFP APPROVED FORM-12107193
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 compiete 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
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 not feasible (each
section must be completed):
a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
DEP ArFROVU)FORM.12/07/9S
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)
Reduction of required separation between bottom of SA' & hieh gro ndwater
(specify proposed reduction & pert rate) 1petc_ Nneti ,-f-,y ,,
Rcbuce. p, L4-lt X17 To 3( t• eF--anti REP- `i
Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the
Code)
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)(i)(1). The evaluator must be a member or agent of the local approving authority:
Dista ce from soil absorption system to high groundwater
feet
As determined by:
Evaluator's name
Evaluator's signature
Date of evaluation
DU APPROVED FORM.17/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
c) a shared system is not feasible:
a) connection to a sewer is not feasible:
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? yes no
11) 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 knowing violations."
Facili :,_per's s'
Veb
Print Name
EZIEN C i tit e %2 t> / CA/C)
Name of preparer Date
Ce 07 )rt 1:6et Z-%J -d,c Zd
Telephone q & address of prepare!
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.
DED APPROVED FORM 12/07/95
FORM 9B - LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
, Massachusetts
DCAL UPGRADE APPROVAL ISSUED PURSUANT TO 310 CMR 15.404 & 15.405
:Any/system owner: Name: Address:
Address of facility
pe of facility: residential institutional _ commercial school _
design flow per 310 CMR 15.203 gpd
nem designer: Name Address Phone No.
cal Upgrade Approval granted for:
reduction in setback(s) (specify)
perc 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 reduction & perc rate)
relocation of a well (explain)
t local variances granted (no DEP approval required per 310 CMR 15.412(4)
t variances granted requiring DEP approval
ard of Health Approval of proposed upgrade
Name & Title
Signature
City/town Date
E SYSTEM OWNER OR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL
I THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION
VISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY
BEFORE COMMENCEMENT OF CONSTRUCTION.
a
DPP APPROVED FORM-12101195