HomeMy WebLinkAboutMiscellaneous - 105 WINTERGREEN DRIVE 10/12/1999 May-27-99 12 . 45P North Andover~ Cam. Dev . 508 688 9542 P . 01
SEPTIC PLAN SUBMITTAL FORM
LOCATION:--J'
VE\V PLANS: 1 1- �
�,,. $12 ,00/P1an_.._..
REVISED PLANS: YES S 60.00/Plan
SITE EVALUATION FORMS INCLUDED: .YES) NO
DATE:_ ---- —
DESIGN ENGINEER;�
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans to fort
Engineering.
When the submission is all in place, mute to the Health Secretary.
Page 1 of 5
9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
Commonwealth of Massachusetts
jV'c,2"tt► ��,� �` � �-gym... , Massachusetts
Application for Local Upgrade Approval
Title 5, 310 CMR 15.000
DES' approved form required by 310 CMR 15.403(f)
To be submitted to Local Apnrovin Authority/Board of Health: For the upgrade of
failed or non-conforming system with a design flow of<10,000 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 of federal facility,
where full compliance, as defined in 310 CMF 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: VV j
, t �� . `Address: V�v i
Phone #:
Address of facilit : l.-0 <"
2) Applicant (if different from above)
Name:' b VIA L'
Address:
Phone 11:
3) Type of Facility:
Rcsidential Commercial School Institutional
(specify) Al
Page 2of5
4) Type of Existing System:
!----,Privy., cesspool(s) ____conventional;system
other(describe)
Type of soil absorption system (trenches, chambers, pits, etc.)
5) Design Flow Based on 310 CMR 15.203:
a) Design flow of existing systemw Q gpd
Approved: ,,,f Yes Approval date: Cy/ 3
r
no Why:
b) Design [low of proposed upgraded system �)_gpd Why V 3.je_ �; , ,
c) Design flow of facility blo gpd
G) Proposed upgrade of existing system is:
a) j Voluntary
required by order, letter, etc. (attach copy)
Required following inspection required by 31 CMR 15.301
(provide date inspection form was submitted to the approving authority)
(date)
b) Describe the proposed upgrade to the system:
c) Which of the following are applicable to the proposed upgrade?
t,-'-Reduction of setback(s) (list setbacks to be reduced with proposed setback
distances) 1o' Yv 10` �/?O.in r) C'-0 'v f,gl r)Gr�
Percolation rate of 30-60 minutes per inch(state actual perc rate)
Up to 25% reduction in subsurface disposal area design requirements (state
required & proposed size)
Relocation of water supply well (identify well, describe relocation)
Reduction of required separation-between bottom of SAS & high
groundwater(specify proposed reduction & perc rate)
Page 3 of 5
+ Other requirements of 310 CMR 15.000 that cannot be met (specify sections
of the code) F
System upgrades that cannot be performed in accordance with 31 CMR 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)(1)(1). The evaluator must be a member or agent
of the local approving authority:
Distance from soil absorption system to lugh groundwater Y feet
As determined by:
Evaluator's name: i�� v
Evaluator's Signature: w.-')_ fjLI-L
Date of evaluation: %1-42
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 9or 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.
kil
Page 4 of 5
List of affected abutters:
Abutter Name bate notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter 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) An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
7-1lGL L77-Ey&72V - v r° Y--/-/ /=X/s 7��, jz>��n,- '��. ✓ f�'O"k01V6-
b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible.
�'�7.•� ;� hid`>12/��'JiU/%
c) A shared system is not feasible.
d) Connection to a sewer is not feasible.
�l Gt�t' ✓'� G"�!I�'S �,"�.`!`.__ �%°,�is'1 /�' �'//s i�P�l;f� l.`�� %`7✓c'�`1�'
10) An application for a disposal system construction permit, including all required
attachments (e.g. plans & specifications, site evaluation forms), must accompany
this application. 1s the DSCP application attached?
-� yes no
f I I r
Page 5 of 5
11) Certification ,
"I, the facility owner, certify under penalty of law tha4 this document and all attachments,
to the best of my knowledge and belief, are true, accurate, and complete. I am aware that F
there may be significant consequences for submitting false information, including, but not
limited to, penalties or fine and/or imprisonment for knowing violations."
Facil. Owner's Si re Date
�!" vii [fir of f S
Print Name
Name of Preparer Date
Telephone No. & Address of Preparer
NOTE: Title 5, 310 CMR 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.