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HomeMy WebLinkAboutApplication - 1353 SALEM STREET 5/14/2015 9 "I'OWN OF NORTH ANDOVEIZ Mike of 1_"t1MM(d'��'11TY 1tEIVE1,01"MEN 1" AND SERVICES HEALTH DEPARTMENT' g600 OSGOOD ST RE ; &ma1.I11E 2035 NORTH , SdDOVFIJ�.n 10 ASSMA.itlSt;T„".I'S 0�845 978.688,9540 Phone Susan V.Sawyer, REH5/RS 9'78,688.8476 FAX Public Health Director F-Mf1,R NL iC!l0 n cwr tlu twlcl( w c n �o"al "ll CI��:G.I'F ht !/ �w!�':t,c»wr�cpftDc>nt&w,tnrytcicawvarncrtyD SEPTIC PLAN MITTAL FORM Date of Submission: G . � RECEIVED Site Location: l �A l_sL-I � 1�1 Z lid'I MAY 6 ' "H" "[�OvvU 6 C)C t'401 f P 4 N,tL)01/1",R Engineer: pal ,� ��� G� � '� '3 ��.a��,�.t� New Plans? Yes $225/Plan Check# (includes 1St submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes No Telephone#: 6­1�,?c;, ,,-e; Fax#(K) 5�)j 1 3 f C? E-mail: 1 J lj,,l)k_d l-.wt i(1a11 1"�1� 1dw —I Homeowner Name: OFFICE USE ONLY r When the subrission is complete (including check): Date stamp plans and letter Complete and attach Receipt Copy File; Forward to Consultant �°'` Enter on Log Sheet and Database � u 118r lt110h, zttlEtf�" �..{�1ht '�ti"����r�`;� P,���, J. � i� t'sl� �ra° a� t� r � E�;��:f r, a Hou I lremby c ertify tha l Ir<rve lac ,,n g iv mi a copy y" of the Uilc, 5 VA Wc:l analogy app row''1 letter, al-ld die Owneys i"v'fanual J`or the above W chno1ogy and I agree to comply ivilhr all terms arid r.oiiditio rw,. I Ibi-ther certNy tlwa 1 am mv,,,Erc,taiat this c1esigmi roes riot allow use ora ga:dbage grinder in the Smelling and that, I understrrm] my r°rw'rlr.rirerrrcrnt: t:e r'elrair, r•el-rlaee or modify or Like arry other ration required by the l:)epartmerit or the &,AA if the l:;reprxdrn(eri or dic ,'LAA cic;,wnirines the ry4rtc rrr to [icx failing to Prot.ed ptrhlic, heakh and safety rrrrcl thee rrrivircrrrrrlem, P sign r.�r :: carte: _.—_r�"_ _ _ fr_.l __..........._....._...... C;er'ti�tc��3 bT (please print) P4hE'R('Iv +C`K Ftl It E:Rlhe� r I'x�ilC�;li .IP�1(..:. 66 PAPA;Si;:F. T m AMDOVER PvASSAC:rfiJHMS Olt)i;i Commonwealth of Massachusetts -- City/Town of North Andover p Form 9A Application DEP has provided this form for use by local Boards of Wealth. 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 Wealth to determine the form they use. Form 9A is to be submitted to the Local Board of Wealth 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 Important: When filling out 1. Facility Name and Address: forms on the computer, use Jeff Greene Residence --- only the tab key Name -- —to move your 1315 Salem Street cursor-do not Street Address -- ------------ use the return key. North Andover MA 01845 City/Town State Zip Code tab 2. Owner Name and Address (if different from above): uN SAME r Name Street Address ------- ----------- --------- ------ ------ City/Town State ---------------- — - F81 858-7263 – Zip Code Telephone Number 3. Type of Facility(check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: 4 BDRM House 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Trenches t5form9a.doc^rev.7/06 Application for Local Upgrade Approval Page 1 of 4 Commonwealth of Massachuseft City/Town of North Andover Commonwealth of Massachusetts C of North Andover � �����8�� ���� �� ������U^�����~���� �»�� Local Upgrade �� ������N�y�)U Form ~-~ ~ ~ ~n�8-~~~�=~�~~~~~ ^~�~ ��~~~~~�" ��R-��~ ~~��~~ ° "n�K-^ ~� ~ ~~" DEP has provided this form for use by |DC8| B0@[dS of Health. Other forms may be us8d, but the `-~ information must be substantially the same me that provided here. Before using this form, check with your local Board of Health tV determine the form they use. B. Proposed Upgrade of System /CoDtiDUBd\ | El Relocation of water supply well (exp|ain): [] Reduction of 12-inch separation between inlet and outlet tees and high groundwater El Use of only one deep hole in proposed disposal area | F-1 Use ofa sieve analysis eoa substitute for mpanctest F] Other requirements of 310 CIVIR 15.000 that cannot be met-describe and specify sections of the Coda: 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 to310CyWR15.4O5(1)(h)(1). The soil evaluator must be a member oragent of the local approving authority. High groundwater evaluation determined by: Evaluator's Name(type nrprint) Signature Date of evaluation � C. Explanation � Explain why full compliance, as defined in 310 CIVIR 15.404(l), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310CK8R15.0OOis not feasible: NA 2. An alternative system approved pursuant to 310 CK8R 15.283 to 15.288 is not feasible: NA t5fonnSadoo^rev.700 Application for Local Upgrade Approval* Page 3uf4 � � Commonwealth of Massachusetts City/Town of North Andover R Form 9A — Applicati a 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: NA 4. Connection to a public sewer is not feasible: None 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): 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." g,�� 5-8-15 ac i wner's Si nature Date Jeff Greene Print Name Bill Dufresne/Merrimack Engineering 5-8-15 Name of Preparer Date 66 Park Street Andover Preparer's address City/Town MA/01810 _(W8)_4 75-3555 _ State/ZIP Code Telephone t5form9a.doc•rev.7/06 Application for Local Upgrade Approvals Page 4 of 4 U) sj 4, �. m G ❑4s O = 'rl O J C37 Gri h W hJ c) o Q C _ 0 O c C > - @ � c o (� nz � W � cc e ro n� �� m 0- c�i � o 0 ::r w n A 0 a rn @ ro w �m@ M (D O ' - G o fD (D O � ro ' @ v) -, @ ro a CL � o b F s2 As @CL a o o m < U) Q m a a �' 07 C7 �« m v o� n� c—D o o cr `� CD u, �' C7 (D ^� c °= v ❑ ® ❑ G) (D 0- -< -< -< -< ° (D © CA o PJ1 cc) o ❑ ❑ ® ❑ a a o o cD CO 0 0 3 cCr C C ° (DD r- (D = = i m o ur rn U) ❑ cn ❑ n o c 6 01 N " (D Xv O N O cy a { �• � ro =" U) fD � � cz o. 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Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. Important: It Information When filling out A. forms on the computer,use Jeffrey Greene only the tab key Owner Name to move your 1353 Salem Street cursor-do not -- -- -------------- ----------------- use the return Street Address or Lot# key. North Andover MA 01845 City/Town State Zip Code �11 858-7263 Contact Person(if different from ------Owner) Telephone Number B. Test Results 2-5-15 Date Time Date Time Observation Hole# P-1 Depth of Perc 40"------------___._..............-....---- ----------- Start Pre-Soak 11:41 End Pre-Soak 11:56 Time at 12" 11:56 Time at 9" 12:17 -- -Time at 6„ 12:45 ---Time (9"-6") 28 min Rate (Min./Inch) 10 Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ William Dufresne Test Performed By: Isaac Rowe Witnessed By: Comments: #5form12.doc^06/03 Perc Test•Page 1 of 1