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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