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SEPTIC PLAN STJBMITTAL FORM
Date of Submission: 10-6- 1
Site Location:� Q` � I_ /"T ,
Engineer: Itw��G° ✓"j /t�4pq Hit � 1 �°
New Plans? Yes + $225/Plan Check 041 _(includes I"submission and one re-
review only)
Revised.Plans?Yes $75/Plan Check
Site Evaluation Forms Included? Yes Nor /� ! �� � F
OMONT
Local Upgrade Form Included? Yes No 1'
Telephone#: Fax#:_66"V � Z !
E-mail:
Nameowner
Joo
OFFICE USE ONLY
When the subm Sion is complete(including check):
Date stamp plans and letter
Complete and attach Receipt
Copy File; Forward to Consultant
Y Enter on Log Sheet and Database
Commonwealth of Massachusetts
-- -- City/Town of North Andover
r Application
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
Important:
When filling out 1. Facility Name and Address:
forms on the
computer, use Jon Heydenreich Residence
------ ------ ---- -- --- ------
only the tab key Name
to move your 1907 Salem Street
cursor-do not — - – -------- -- --
-------- ------
use the return Street Address
key. North Andover ------- ----- MA 01845
---- --------- - ------ ---------- ---
City/Town State Zip Code
tab
2. Owner Name and Address (if different from above):
SAME
" Name Street Address
City/Town State
---------- ------- --- ---- -------- ---- ----
Zip Code Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
5 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):
Field
t5form9a.doc o rev.7/06 Application for Local Upgrade Approval• Page 1 of 4
Commonwealth of Massachusetts
City/Town of North Andover
a
Form Application r 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.
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: Unknown
gpd
Design flow of proposed upgraded system 550
gpd
Design flow of facility: 550
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:
Complete Replacement(see plan)
3. Local Upgrade Approval is requested for(check all that apply):
❑ Reduction in setback(s)—describe reductions:
❑ Reduction in SAS area of up to 25%:
SAS size,sq.ft. %reduction
® Reduction in separation between the SAS and high groundwater:
Separation reduction 1.0
ft.
Percolation rate 18
min./inch
Depth to groundwater 3.0
ft.
t5fonn9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 2 of 4
Commonwealth of Massachusetts
City/Town of North Andover
Form Ii i n 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:
Isaac Rowe 9-30-10
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:
Full compliance would result in having to raise the system further causing grading issues, requiring a
pump, and unreasonable financial hardship
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
NA
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 3 of 4
Commonwealth of Massachusetts
City/Town of North Andover
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:
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."
'
Ae/vl( 4l AI-, 10-6-10
ability Owner Signature Date
Jon Heydenreich
Print Name
Bill Dufresne/Merrimack Engineering 10-6-10
Name of Preparer Date
66 Park Street Andover
Preparer's address City/Town
MA/01810 (978)475-3555
State/ZIP Code Telephone
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4
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Commonwealth of Massachusetts
City/Town of
Percolation Test
Form 12
GM
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. 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
the local Board of Health to determine the form they use.
Important:
When filling out A. Site Information
When
forms on the
computer,use j a� L t1 ry R P t
only the tab key Owner Name
to move your �/ -t f .
cursor-do not
use the return Street Address or Lot#
,A1
key. "
CityTrown State Zip Code
Contact Person(if different from Owner) le hon Number
B. Test Results
mil® w!®
Date H Time Date Time
Observation Hole#
Depth of Perc GV
Start Pre-Soak 16) 'ez ago
End Pre-Soak !®'
Time at 12"
Time at 9" ® �
Time at 6"
IZ-: 1®
Time (9"-6")
Rate(Min./Inch)
Test Passed: Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Test Performed y:
CI
Witnessed y
Comments:
t5form12.doc•06/03 Pere Test•Page 1 of 1