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Home My WebLink AboutApplication for Local Upgrade and Approval • Commonwealth of Massachusetts *_- City/Town of Yarmouth Wital. Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. 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 15.404(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 15.415. 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 an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. A. Facility Information LIZarfiliD Important:When filling out forms 1. Facility Name and Address: APR 2 9'2020 on the computer, use only the tab key to move your Name HEALTH DEPT, cursor-do not 23 Lake Road East r • use the return Street Address key. Yarmouth MA 02664 _V ab City/Town State Zip Code 2. Owner Name and Address (if different from above): n X Rivers Edge Properties, LLC 1040 North Shore Road, Suite B7 Name Street Address Revere MA City/Town State 02151 617-455-2303 Zip Code Telephone Number 3. Type of Facility (check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: single family dwelling 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): flow diffusors t5form9a•rev.7/06 Application for Local Upgrade Approval• Page 1 of 4 Commonwealth of Massachusetts =,km- City/Town of Yarmouth ttitytj7N Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the M information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: unknown 9Pd Design flow of proposed upgraded system 351 gpd Design flow of facility: 330 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: Installation of a new 1,500 gallon, 2-compartment septic tank,1,000 gallon pump chamber, distribution box, and a leaching bed with 4 rows of 6 Infiltrator Quick 4 HD leaching chambers and associated piping. 3. Local Upgrade Approval is requested for(check all that apply): ® Reduction in setback(s) —describe reductions: Reduction of required 20' setback form a foundation wall to a SAS to 17' (liner provided). ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction ❑ Reduction in separation between the SAS and high groundwater: Separation reduction 5' to 4'_ ft. <2 Percolation rate min./inch Depth3.40 (per adjustment) to groundwater ft. t5form9a•rev.7/06 Application for Local Upgrade Approval' Page 2 of 4 Commonwealth of Massachusetts 0 City/Town of Yarmouth - _ 'o' Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test ❑ 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)(h)(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: Due to topographic, groundwater, and exisitng house location. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: Alternative system would not address exisitng site restrictions. t5form9a•rev. 7/06 Application for Local Upgrade Approval* Page 3 of 4 Commonwealth of Massachusetts >'=-may— City/Town of Yarmouth ' =1 Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: Alternative system would not address exisitng site restrictions. 4. Connection to a public sewer is not feasible: No public sewer is available. 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 ® 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). ❑ Other (List): Soil Logs 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 • • er's Signa ure Date SCO /-L / I ercka4) k Print Name George R. Collins, PE Lc-z - Name of Preparer Date 225 South Main Street West Bridgewater Preparer's address City/Town MA 02379 508-580-2332 State/ZIP Code Telephone t5form9a•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4 Commonwealth of Massachusetts G,= wGD -*_ City/Town of Yarmouth r►►=V Local Upgrade Approval APR 2 9 2020 Form 9B HEALTH DEPT. DEP has provided this form for use by local Boards of Health if they choose to do so. The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. A. Facility Information Important:When filling out forms 1. Facility Name and Address on the computer, use only the tab key to move your Name cursor-do not 23 Lake Road East use the return Street Address key. Yarmouth MA 02664 _VCityrrown State Zip Code ` 2. Owner Name and Address (if different from above): IIRivers Edge Properties, LLC 1040 North Shore Road, Suite B7 Name Street Address Revere MA City/Town State 02151 617-455-2303 Zip Code Telephone Number 3. Type of Facility (check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Design flow per 310 CMR 15.203: 330 gpd 5. System Designer: George R. Collins, P.E. ® PE ❑ RS Name 225 South Main Street West Bridgewater MA 02379 Address City/Town State,ZIP B. Approval 1. Local Upgrade Approval is granted for: ® Reduction in setback(s)—specify: Reduction of required 20' setback form a foundation wall to a SAS to 17' (liner provided). ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction t5form9b•rev.7/06 Local Upgrade Approval* Page 1 of 2 Commonwealth of Massachusetts *_ City/Town of Yarmouth _-r►= fi Local Upgrade Approval _°C = Form 9B j B. Approval (continued) ® Reduction in separation between the SAS and high groundwater: Separation reduction 5' to 4' ft. <2 Percolation rate min./inch Depth3.40 (per adjustment) to groundwater ft. ❑ Relocation of water supply well (explain): ❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: Approving Authority Print or Type Name and Title Signature Date t5form9b•rev.7/06 Local Upgrade Approval• Page 2 of 2