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Home My WebLink AboutApplication - 114 STONECLEAVE ROAD 10/7/2009 Commonwealth of Massachusetts - City/rovun of No. Andover Application Form 9A - DEP has provided this form for use by local Boards of Health Othdiforms may be used, but the information must be substantially the same as that provided here. eiiareusing 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 1973 Code or 310 CMR 15.000. A. Facility Information Important: When filling out 1. Facility Name and Address: forms on the computer,use Richard Adams only the tab key Flame to move your 114 Stonecleave Rd cursor-do not Street Address use the return key. No. Andover MA 01845 Citylrown— — - — State Zip Code ray 2. Owner Name and Address(if different from above): Same as Above — ------------- -------- --- -------- - -- ' " 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: Single Family Dwelling 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Leach Field Form 9A Application for Local Upgrade Approval •rev.7106 Application for Local Upgrade Approval* page 1 of 4 Commonwealth of Massachusetts - - CityfTown of No. Andover = p Form 9A - 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. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: gpd -- _ pd Design flow of proposed upgraded system 440 gpd Design flow of facility: gpd - pd B. Proposed Upgrade f System 1. Proposed upgrade is(check one): ❑ Voluntary ❑ Required by order, letter, etc. (attach copy) Unknown ® Required following inspection pursuant to 310 CMR 15.301: Unkn date n of inspection 2. Describe the proposed upgrade to the system: Replace leach field ands components _ 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 ft. — <2 Percolation rate min./inch Depth groundwater 4 De to - p g ft. Form 9A Application for Local Upgrade Approval •rev.7/06 Application for Local Upgrade Approvalo gage 2 of 4 Commonwealth of Massachusetts Cityrrown of No. 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. 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: Randy Burley Mill River Cons. 10/7/09 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: No other location on the lot 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: An alternative system is not cost prohibitive. Form 9A Application for Local Upgrade Approval •rev.7/06 Application for Local Upgrade Approval* Page 3 of 4 Commonwealth of Massachusetts City/Town of No. 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: No other adjacent is available 4. Connection to a public sewer is not feasible: Public sewer is not available in the area. 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." Facilit Owners Signatures Date Benjamin C. Osgod Jr. P.E. (Agent for Owner) Print Name 10/19/09 — _ _ Date P.O. Box 932 — No. Andover, MA Preparer's address City/Town 01950 - - _C978)686-1768 State/ZIP Code Telephone Form 9A Application for Local Upgrade Approval •rev.7/06 Application for Local Upgrade Approval®Page 4 of 4