HomeMy WebLinkAboutApplication - 1049 SALEM STREET 10/31/2013 t
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1600 WK,'001) STREET; SUTTE 2035
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Susan Y.Sawyer,REUS/RS 978M8,8476- FAX
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SEPTIC PLAN SUBMITTAL FORM
Date of Submission: 117
Site Location:
Engineer:° . r
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New Plans? Yes $22
5/Plan Check# (includes ls`���subapission e m
review only) ki (,ro,
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Revised.Plans?Yes $75/Plan Check#
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Site Evaluation Forms Included? Yes No o pa : a i,s 'a G IA T Na D:T
Local Upgrade Form Included? Yes No
Telephone
E-mail: 14 64 NA
Homeowner
, 'I .. .
Name: If � �i� l, '.l,°� II
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
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Commonwealth of Massachusetts
City/Town of North Andover
W
Form Application 1 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.
Farm 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 on the
computer,use 104_9 Salem Street Realty Trust Residence c/o Jeffco_Corp. ---._—__.—..—.—__------. .....__.—_—.._
only the tab key Name
to move your PO Box 802 --------- --------- --- ----
cursor-do not S tre et_Address
use the return MA 01$10
City/Town
State -------- -- Zip Cade
ab
2. Owner Name and Address (if different from above
1049 Salem Street Realtv Trust 1049 Salem Street_
--__— —.—_ st�eekAddress
-----------
ienn Name
North Andover MA
_. ----- —.---- -------
CityCTawn--- —-- ---------- State
01845
- --- —_ — ---.—.-- ------ — Telephone Number
Zip Code
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
1 Existin 3 bdrm house and 1 existing 1 bdrm house 2 dwellin s an one 5. Type Type of Existing System:
❑ Privy ❑ Cesspool(s) ❑ Conventional ® Other(describe below):
UNKNOWN
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
UNKNOWN
t5form9a.doc•rev.7/06 Application for Local Upgrade Approvalo Page 1 of 4
Commonwealth of Massachusetts
City/Town of North Andover
3 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:
Design flow of existing system: 9P UNKNOWN
Design flow of proposed upgraded system 440
gpd
Design flow of facility: 4 9 P d0
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:
Total Replacement (see plan)
3. Local Upgrade Approval is requested for (check all that apply):
® Reduction in setback(s)—describe reductions:
Setback from s a.s. to a slab(garage)from 10'to 5'
❑ 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
Percolation rate min./inch
Depth to groundwater ft
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 2 of 4
Commonwealth of Massachusetts
City/Town of North Andover
a
y orrYr 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
I
❑ 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:
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:
Limited space, presence of wetlands
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
Not warranted given the site conditions
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 3 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.
C. Explanation (continued)
3. A shared system is not feasible:
No area on an adjacent lot to provide a better solution, shared-or-not
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
"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 , deliberate violations."
10-31-13
Facility Owner's ignature Date
Print Name
Bill Dufresne/Merri ack Engineering Services 10-31-13
Name of Preparer Date
66 Park Street Andover
Preparer's address City/Town
MA/01810 (978)475-3555 x-20
State/ZIP Code Telephone
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4