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SEPTIC PLAN SUBMITTAL FOP1VI
Date of Submission:
Site Location: 7 "�
Engineer: RN Lt, Ad " ,V C:11(a
New Plans? Yes $225/Plan Check# 4 (includes Isr submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes v No
Local Upgrade Form Included? Yes No
Telephone#: Fax#: 2� /� '� �;
E-mail: 1 I ( � ? rre' t ° 7 �
Homeowner ("
Name: IAJIL,
OFFICE USE ONLY
When the submission is complete (including check):
„ Date stamp plans and letter
Complete and attach Receipt
' Copy File; Forward to Consultant
Enter on Log Sheet and Database
Commonwealth lth of Massachusetts
--- City/Town of North Andover
Form Application I 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.
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 to the _Paul Proulx Residence
computer,use only the tab key Name - ---- - -
to move your 491 Salem Street
cursor-do not Street Address
use the return
key. North Andover _ MA 01845
Ciky/Town State Zip Code
Q2. Owner Name and Address (if different from above):
m
SAME
ran Name Street Address
--- ------------------
City/Town State
- — L978)__685-2240 —
Zip Code Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
4 Bedroom 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
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval° Page 1 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.
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Unknown
Design flow of existing system: gpd
Design flow of proposed upgraded system 440 gpd
440
Design flow of facility: 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:
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:
1.0
Separation reduction ft
8
Percolation rate min./inch
3.0
Depth to groundwater ft
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval• Page 2 of 4
Commonwealth of Massachusetts
City/Town of North Andover
Form li ti n for Local Upgrade Approval
^A 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 evaluatormust be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Randy Burley 10-31-11
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 a high mound on a small lot creating drainage and grading difficulties
in addition to unecessary financial burden.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
NA
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 3 of 4
Commonwealth of Massachusetts
City/Town of North Andover
Form p lica 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.
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
"l, 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."
11-10-11
zz 42
Facility Owner's Signature Date
Paul Proulx
Print Name
Bill Dufresne/Merrimack Engineering 11-10-11
Name of Preparer Date
66 Park Street Andover
Preparees address City/Town
MA/01810 (978)475-3555
State/ZIP Code Telephone
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4
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Commonwealth of Massachusetts
City/Town of North Andover
Percolation Test
Form 12
�Af 5V 0y`OW
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: A. Site Information
When filling out
forms on the Paul PrOUIX
computer,use
only the tab key Owner Name
to move your 491 Salem Street
cursor-do not Street Address or Lot#
use the return MA 01845
key. North Andover
City/Town State Zip Code
r�5
Contact Person(if different from Owner) Telephone Number
B. Test Results
Date Time Date Time
Observation Hole#
Depth of Perc
Start Pre-Soak
End Pre-Soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate (Min./Inch)
Test Passed: ❑ Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Test Performed By:
Witnessed By:
Comments:
* SEE PARTICLE SIZE ANALYSIS BY TERRA FILTER DATED 11-9-11 in LIEU of a PERC TEST
t5form12.doc•06/03 Perc Test•Page 1 of 1
RO. Box 227 10 YMoin 5t.
01Oro . Sturbildg1e,MA 01 566
Terrali,/// Tel: 508 .347 5508
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