HomeMy WebLinkAboutApplication - 34 RALEIGH TAVERN LANE 5/8/2013 Commonwealth of Massachusetts
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City/Town of North Andover
Local Upgrade Approval
Form 9
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.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address
on the computer,
use only the tab -Frances Stiglln
--- ---- ---- ---- - -------
key to move your Name
cursor-do not 34 Raleigh Tavern Lane
use the return -- - ----- - _. ------
key. Street Address
North Andover MA 01845
rab City/Town State -- Zip Code -"
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):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15.203: 440 —
gpd
5. System Designer: Vladimir Nemch_enok
Name ® PE F1 RS
66 Park St Andover 01910
Address City/Town State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s)—specify:
❑ Reduction in SAS area of up to 25%' sas size,sq.ft. %reduction
34 Raleigh Tevern Lane St form9b^rev.7/06 Local Upgrade Approval® Page 1 of 2
Commonwealth of Massachusetts
City/Town of North Andover
R Local Upgrade Approval
a
Form 9B
GSM
B. Approval (continued)
® Reduction in separation between the SAS and high groundwater:
Separation reduction 1
ft.
Percolation rate alt to perc
min./inch
Depth to groundwater 3
ft.
❑ 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
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
Health Department
Approving Authority
Susan Sawyer May 8, 2013
Print or Type Name and Title $griature Date
r'
34 Raleigh Tevern Lane St form9b•rev.7/06 Local Upgrade Approval* Page 2 of 2