HomeMy WebLinkAboutApplication - 1475 TURNPIKE STREET 10/27/2006 Page 1 of 5
9A-APPLICATION FOR LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts El W QED
North Andover, Massachusetts (0' 3 1 20OG
I , L„ NiW r ANDOVER
A pp lication for Lo cal Upgrade Approval „ I r�DEI A T
Title 15 000
__..� -_.....
DEP approved form required by 310 CMR 15.403(1)
To be submitted to Local Approving Authority/Board of Health: For the upgrade of a
failed or non-conforming system with a design flow of<I0,000 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 failed or non-conforming system with a
design flow of 10,000 up to 15,000 gpd and/or for upgrade of state or federal facility,
where full compliance, as defined in 310 CMR 15,404(1), 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: 1'�-i� E�-rA-rC r F `-f'rivwi � } t!� �fr� ►? , p 1 �I,4
Address, I LA I&, _ A�� _,__n1� �%'�c7'7
Phone#: (/yc��, �' �°�� - �"Z4�[,-,.
Address of facility: 14}°7 r; - g4,9 p 11, -ta' r
2) Applicant(if different from above):
Name:_ 6.4 9 1,_4 I L U I�y- d
Address. -r"3�01
Phone#:_
3) Type of Facility:
Residential Commercial School Institutional
(Specify) _'� Oer jtf;�_l k2w i OJ6
Page 2 of 5
4) Type of Existing System:
privy cesspool(s) conventional system
other(describe)
(Type of soil absorption system (trenches, chambers, pits, etc.)
oI a2
5) Design Flow Based on 310 CMR 15.203:
a) Design flow of existing system u Nj:�-NKLq& gpd
Approved: __._yes Approved date:
b) Design flow of proposed upgraded system _gpd
c) Design flow of facility gpd
6) Pro osed upgrade of existing system is:
a) Voluntary
Required by order, letter, etc. (attach copy)
Required following inspection required by 310 CMR 15301
(provide date inspection form was submitted to the approving authority)
(date)
b) Describe the proposed upgrade to the system:
i ,s IC 1
c) Which of the following are applicable to the proposed upgrade?
/Reduction of setback(s) (list) (setbacks to be reduced with proposed setback r
distances). vi;, i"Ai\JC r►2c�1 5,-4,;5. -To' p� rn1. FVZvV-I L:;0I -Fo
Percolation rate of 30-60 minutes per inch (state actual pert rate).
Up to 25% reduction in subsurface disposal area design requirements (state required
& proposed size).
Relocation of water supply well (identify well, describe relocation).
Page 3 of 5
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 CNM 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.
Distance from soil absorption system to high groundwater feet.
As determined by:
Evaluator's
Name:
Evaluator's Signature:
Date of Evaluation:
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 complete until the applicant has notified all abutters
whose property or well is affected by certified 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.
Page 4 of 5
List of affected abutters:
Abutter's Name Date notified
Address
Abutter's Name Date notified
Address
Abutter's Name Date notified
Address
9) Explain why full compliance,as defined in 310 CMR 15.404(1), is not feasible
(each section must be completed).
a) L`TI alt cW1�� W
b) An alternative system approved pursuant to 310 CMR 15.288 is not feasible.
c) A shared system is not feasible.
d) 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 G_-' no
F � j qtr X1 r,c1rQ H r r�
Page 5 of 5
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."
0
Facilfty Owliel"sSIgnature Date
6QV96i:�-
Print Name
Name of Preparer Date'
rAaV— !EE. A rJr2eLLe4Z,,, o-44-- &�,ioja
)
Telephone# &Address of Preparer
NOTE: Title 5,310 CNM 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.