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Home My WebLink About2006 - DEP Application for Disposal System Construction Permit Commonwealth of Massachusett _� V7 I2 ='�-, _ City/Town of Yarmouth Number Nig _',1- Application for Disposal Syste DEC 1 1 2006 Construction Permit $ HEALTH DEPT. Fee Form 1A DEP has provided this form for use by local Boards of Health if they choose to do so. Before using the form, check with your local Board of Health to make sure that they will accept it. A. Facility Information Important: When filling out Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system forms on the ® Repair or replace an existing on-site sewage disposal system computer, use only the tab key ❑ Repair or replace an existing system component to move your cursor-do not 1. Location of Facility: use the return key. 16 Gardiner Lane 111/11 Address or Lot# Yarmouth MA City/Town State Zip Code IM/1 2. Owner Information Robert Mcdermott Name 44 Village Lane Address(if different from above) Paxton MA City/Town State Zip Code Telephone Number 3. Installer Information Name Name of Company Address City/Town State Zip Code Telephone Number 4. Designer Information Mark Santora MSPE, Inc. Name Name of Company P.O. Box 539 Address Grafton MA 01519 City/Town State Zip Code 508-839-5113 Telephone Number t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 1 of 3 Commonwealth of Massachusetts z=2---- 11 Cit /Town of Yarmouth Number Application for Disposal System Construction Permit Fee Form 1A A. Facility Information (continued) 5. Type of Building: ® Dwelling ❑ Garbage Grinder(check if present) Other: Type of Building Number of Persons Served Showers 2 Number of showers ❑ Cafeteria ❑ Other fixtures Specify other fixtures: 6. Design Flow: 660 Gallons per Day Calculated Daily Flow: 660 Gallons 7. Plan: 11/09/06 Date of Original 1 Number of Sheets Revision Date Septic Plan of 16 Gardiner Lane Title of Plan 8. Description of Soil: Class 1 9. Nature of Repairs or Alterations (if applicable): Replace system system 10. Date last inspected: Date t5forml a.doc•06/03 Application for Disposal System Construction Permit•Page 2 of 3 Commonwealth of Massachusetts -ff**. Cit /Town of Yarmouth Number City /Town ; Application for Disposal System iziii__—= Construction Permit $ Fee Form 1A B. Agreement The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signature Date Application Approved By: Name Date Application Disapproved for the following reasons: t5formla.doc•06/03 Application for Disposal System Construction Permit•Page 3 of 3 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 Important: When filling out 1. Facility Name and Address forms on the computer, use Robert Mcdermott only the tab key Name to move your 44 Village Street cursor-do not use the return Street Address key. Paxton MA City State Zip Code I�I 2. Owner Name and Address: Robert Mcdermott 44 Village Street Name Street Address Paxton MA City State (508) 791-2373 Zip Telephone Number 3. Type of Facility (check all that apply): ►./ Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: 2 Units 3 Bedrooms per unit 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ® Other(describe below): Concrete galley system 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Chambers Local Upgrade•rev.5/02 Application for Local Upgrade Approval* Page 1 of 4 ci 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: 660 gpd Design flow of proposed upgraded system 660 gpd Design flow of facility 660 gpd 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: The proposed system will be a presby enviromental designed for 6 bedrooms 3. Local Upgrade Approval is requested for: ® Reduction in setback(s)—describe reductions: Ground Water offset from 4' to 3' ❑ Percolation rate for 30 to 60 min./inch: min./inch ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction ® Reduction in separation between the SAS and high groundwater: Separation reduction 1 ft. <2 Percolation rate min./inch Depth to groundwater 2'983 ft. ❑ Relocation of water supply well (explain): Local Upgrade•rev.5/02 Application for Local Upgrade Approval* Page 2 of 4 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) ❑ 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 by: Evaluator's Name(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: The system size will be in full compliance with DEP standards 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: an alternative technology system is proposed 3. A shared system is not feasible: no systems in the area can be shared 4. Connection to a public sewer is not feasible: no sewer Local Upgrade•rev.5/02 Application for Local Upgrade Approval• Page 3 of 4 .: , . -11 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) 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ® Application for Disposal System Construction Permit V Complete plans and specifications ® 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). 11 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." Facility Owner's Signature Date Robert Mcdermott Print Name Mark Santora Name of Preparer Date P.O. Box 539 Grafton Preparer's address City/Town MA 508-839-5113 State/ZIP Telephone NOTE: 310 CMR 15.403(4) requires the system owner to provide a copy of the local upgrade approval to the appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource Protection, Division of Watershed Management, upon issuance by the local approving authority and before commencement of construction. Local Upgrade•rev.5/02 Application for Local Upgrade Approval• Page 4 of 4