HomeMy WebLinkAboutApplication - 100 RALEIGH TAVERN LANE 9/23/2004 Commonwealth of Massachusetts
Cityrrown of
Local Upgrade pr vl
Form 913
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. The system owner shall provide a copy of the Local Upgrade Approval to the
appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource
Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before
commencement of construction.
A. Facility Information
ant:
When fining out 1. Facility Name and Address
forms on the
computer,use Brian Arsnow
only the tab key Name
to move your 100 Raleigh Tavern lane
cursor-do not Street Address
use the return
key. North Andover MA 01845
City/Town State Zip Code
m
2. Owner Name and Address(if different from above):
Name Street Address
City/Town State
Zip Code Telephone Number
3. Type of Facility(check all that apply):
X Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15.203: 440
gpd
5. System Designer: Ben Osgood ® PE ❑ RS
Name
60 Beechwood Drive North Andover 01845
Address Cityrrmn State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
® Reduction in setback(s)—specify:
Reduction in offset distance between the leach bed and the wetlands from 50 feet to 32 feet
❑ Reduction in SAS area of up to 25%: SAS size,
sq.ft. %reduction
100 Raleigh Tavern Lane 9b•rev.5/02 Local Upgrade Approval* Page 1 of 1
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction ft
Percolation rate min./inch
Depth to groundwater ft
❑ Relocation of water supply well (explain):
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
North Andover Health Department
Approving Authority
Susan Sawyer, Health Dir. s 9/23/04
Print or Type Name and Title nature Date
100 Raleigh Tavern Lane 9b•rev.5/02 Local Upgrade Approval* Page 2 of 2