HomeMy WebLinkAboutApplication - 444 SALEM STREET 8/17/2000 Town of North Andover, Massachusetts Form No.2
of NooTM� BOARD OF HEALTH
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DESIGN APPROVAL FOR
: """5`t� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Test No.
Site Location 7
Reference Plans and Sp s. 4C>
ENGINEER SIGN DATE
Permission is granted for an individual soil absorption sewage disposa stem to be installed
in accordance with regulations of Board of Health. ..
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HAIRMAN,BOARD OF HEALTH
Fee j Site System Permit No._ o�
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SEPTIC SUBMITTAL FORM
LOCATION;
NEW PLANS: $125.00/Plan
REVISED PLANS: 'YES $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: NO
DATE: 7-
DESIGN ENGINEER: wQ/'/t04 � L1�4� //� , � 1 t�12�� ✓cam'
DATE TO CONSULTANT:
.
*If you want your plans expedited, please submit four plans and included a stamped
envelope with the correct amount of postage to mail plans to Port Engineering.
When the submission is all in place, route to the]health Secretary.
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FACE 1 (1r 5
Commonwealth of Massachusetts
Application for Uc�l in Abe rove
Title 5, 310 CMR 15.000
DEP Approved form required by 31 (1)
Tube submitted to Local t�� ing Autha /board of Health: For the upgrade of a failed or
nonconforming 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 ubmitted to I31�P For the upgrade of a failed or nonconforming system with a design flow
of 10,000 up to 15,000 gpd and/or for upgrade of a 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 desiga flow above the
existing approved capacity of a system construe in accordance with either the 1978 Code or 3,10
15.000.
1) Facility/system owner
Nance t2 l qtr
Address �� L� ✓?�" d ,
Phone #
Address of facility
2) Applicant'(if different from above)
Nurse JN
Address
Phone #
3) Type of facili
idential commercial school
institutional--
itutio 1
(specify)
DEPAMOMWOM-UMM
PAGE 2 OF S
4) Type of existing system
_privy cesspools) conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, Pits-etc.)
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5) Design flow based on 310 CMR 15.203
a) Design flow of existing system I gpd
Approved? _____yes approval date ca IjGlk)
no why?
b) Design flow of proposed upgraded system Z40 gpd
c) Design flow of facility gpd
6) Proposed upg de of existing system is
a) Voluntary
Required by order, letter, etc. (attach copy)
Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date)
b) .Describe the proposed upgrade to the system
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C) Which of the following are applicable to the proposed upgrade?
yp Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
�� Percolation rate of 30-60 minutes per.inch (state actual pert rate)
DI?AMOVW DORM-IVOM
y
PAGE 3 OF 5
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 ndwater
(sp eci fy proposed reduction & e rc rate)
I
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 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)(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
DEP APPROVED FORM•11147195
PAGE 4 OF 5
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 mail 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.
List of affected Abutters:
Abutter Name Date 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:
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7W-5, I(VaO /)urylolIV 6 .
AIA b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
DFP APPROVED FORM-MOM$
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PAGE 5 OF 5
4R c) a shared system is not feasible:
NA 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 no
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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."
� `� �A
a�towner's signature Date
Print Name
Name of preparer Date t
J�A�K-�✓ ��'YLt'� �1 V e . iS G� l f✓ `7 `�`� x`75�'�'� '
Telephone # & address of preparer
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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.
W"MOVW FORM-I V17MS