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Home My WebLink AboutApplication - 545 JOHNSON STREET 8/17/2010 ti"i°m° i"t. tt rC1.II.i 't^lil. t^,ie.tl 1ANDOVER t. "1111" lilt I:;, VI l 111°,; 1:.bF1 LEPAR'"l'ME 1" � ' .36 160 1 t REE ttI I)ING 0; � l) t, N01041 4 M',J � VE' , 11th [; I'S 0184 979,688 9540—Phone Y. � t av�v va tr�cSavvyer° `��.�t7wf1�A°. ( _978,68K9,476--� N vw � alai mv°w.m for b:`.. �t�; Caa w 9t zvi (,s�,dcz avev,dvd�au�„a Kwva ahva.p��.cbs p� WL1!,HJ Y; 8,v0.ro L /Nwww t ar�kt va uC;7w<mcu,ylr r a a nvx SEPTIC PLAN SUBMITTAL FORM L Date of Submission: �” Cam' Site Location: `51 D � C r 7 Engineer:a ��' r..� ) �"�/'i�"��,� ... ,�� ..)�� ..e s � 1 New Flans? Yes $225/Plan Check# (includes I" submission and one re- review only) Revised Plans?Yes S75/Plan Check# Site Evaluation Forms Included? Yes V No. Of Local Upgrade Form Included? Yes V No Telephone#: ' m "r �" � . Fax#; E-mail: � (A r)/cu,' (9( Homeowner Name: c, . OFFICE USE ONLY When the subm}ssion is complete (including check): Date stamp plans and letter a� Complete and attach Receipt Copy File; Forward to Consultant Enter on Log Sheet and Database No. FEE COMMONWEALTH OF MASSAC14USETTS Board of Health, ibi�p °)j X 14A'VjV1_ , ' Am. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location 5LtL3 Owner's Name Map/Parcel# L3 A Ili d 0 Address � Y5 Jc^H A,/.:5,-'��j �3 j Lot# Telephone# y 7� -6,ry :3.�; - C)O fit` 1 Installer's Name ' Desi ners Name Designer's Address Address p .) /.3c'-°X t4)✓2L7 Telephone# Telephone# qT" '- 3 0;2-�040 Type of Building 1"l)t-S/ ( VJi�_l t_:l/<!6 LotSize ��&3' - sq.ft. Dwelling-No.of Bedrooms I !sf�� <' Garbage grinder (iVO Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) _ .> gpd Calculated design flow �_e Design flow provided ' �j C,f gpd Plan: Date % ? '! Number of sheets Z- Revision Date Title ..� � ' �..` °, Q, �' � �- ��,e ..,. (.r a Description of Soil(s) c' ' Soil Evaluator Form No. �C°Z I� ) Name of Soil Evaluator J 1 W) (_W_i 41QhjLl Date of Evaluation 7 zz, i o DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections Commonwealth of Massachusetts " City/Town of Forth Andover I I I �`ep.i'' �Val a DEP has provided this form for use by local Boards of Health. Other for information must be substantially the same as that provided here. Before using this farm, 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 on the computer, use _Frank Peluso only the tab key Name to move your 545 Johnson Street cursor-do not Street Address use the return key. North Andover _ _ _ MA 01845 City/Town State Zip Code 2. Owner Name and Address (if different from above): Frank Peluso 545 Johnson Street ---------- -- -------- �"° Name Street Address North Andover _ MA _ City/Town State 01845 (978)683-0048 --------- ------------------- 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 t5form9a rev.7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of North Andover a Form 9A ® Application for Local Upgrade Approval �^M 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: 330 gpd Design flow of proposed upgraded system gpd gpd 330 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: New system including septic tank, pump chamber, dbox and leach field. 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 n 10 Percolation rate min./inch 3 Depth to groundwater ft t5form9a•rev. 7/06 Application for Local Upgrade Approval• Page 2 of 4 Commonwealth of Massachusetts City/Town of North Andover a Form 9A — Application for Local Upgrade Approval �N °r 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: Isaac Rowe 7/22/10 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: The existing building sewer pipe exits dwelling at elevation which puts the septic tank inverts at the ESHGW elevation, with a minimum slope between the dwelling and proposed septic tank. The reduction to ESHGW at the leach field is to minimize the mound required by the ESHGW. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: An alternative is not desired by client, and would not have an impact on the septic tank invert elevations The owner would choose other options over installing an alternative technology. t5form9a•rev.7/06 Application for local Upgrade Approval* Page 3 of 4 Commonwealth of Massachusetts r City/Town of North Andover Form 9A - Application l GSM 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: There is no interest in a shared system. 4. Connection to a public sewer is not feasible: There is no public sewer 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 "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 .. " w. 2 Facility Owner's Signature Date Print Name Jim Scanlan __ > Name of Preparer Date PO Box 906 _ Georgetown _ Preparer's address City/Town MA 01833 978-372-3440 Stake/ZIP Code Telephone ' o t5form9a-rev. 7/06 Application for Local