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Home My WebLink AboutApplication - 17 LACY STREET 6/11/2007 'TOWN 01" NORTH H ANDOVER . 'IF l)*@ �� '� Office f OM14tJ I1Y DlVEX_A PME 1 N . � I� CJ ro+ 16Q111 OR[�11 ANDOVER 1 1+1�"�.A.(:11 Js rrs 01845 �(i ; 7 s + w 9 7tl.f?s.8�9 7 0—Phone Susan Y.Sawyer, R1aMS/11S )7f,68f.817E ..-1'AX L tibllc Health Director E-MAIL:Iii;altl)(lcl2t(i�towriolltio tliij)d o\,,er.r;om 1,[,-'BS1."I.f lzttl7_!lzx�FLT k�7 �7c�fiicat°t1a�zlcic vE� cc t7a SEPTIC PLAN SUBMITTAL FORM E"I'V E Date of Submission: n: ) w, w Site Location: ,9 Engineer: 1WP11 lam) �,�k� �,n�°•�•i;�t ��al.k� m , New Plans'? Yes L-,025/Plan Check# (includes I"submission and one re- review only) Revised Plans?Ycs $75/Plan Check# Site Evaluation.Forms Included? Yes °"� No Local Upgrade Form Included? Yes No Tele 17one#• Fax#: E-mail; hosw, Yl e_eA )Yze(,1/n /0( >(TOA( Homeowner p Name: OFFICE USE ONLY When the submission iss ion is complete (including check): " Date stamp plans and letter Complete and attach Receipt Copy File; Forward to Consultant " Ar Enter on Log Sheet and Database Commonwealth of Massachusetts City/Town of No. Andover Form 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. 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 Scott Rundle only the tab key Name to move your 17 Lacy Street cursor-do not Street Address use the return key. No Andover MA 01845 City/Town State Zip Code rab 2. Owner Name and Address (if different from above): Same as Above rerom Name Street Address City/Town State 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 Form 9A Application for Local Upgrade Approval revised•rev.7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of No. Andover R r Application r l r 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. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: 440 gpd Design flow of proposed upgraded system 440 gpd Design flow of facility: 440 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: Unknown date of inspection 2. Describe the proposed upgrade to the system: Replace leach field and system components 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 1 ft. Percolation rate 15 min per inch min./inch Depth to groundwater 3 ft. Form 9A Application for Local Upgrade Approval revised•rev.7/06 Application for Local Upgrade Approval• Page 2 of 4 Commonwealth of Massachusetts City/Town of No. Andover Form 9 A - 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 ❑ 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: Randy Burley 5/21/07 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: No other location on the lot 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: The design uses an alternative system Form 9A Application for Local Upgrade Approval revised•rev. 7/06 Application for Local Upgrade Approval* Page 3 of 4 Commonwealth of Massachusetts City/Town of No. Andover Form ppli ti 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: No other adjacent is available 4. Connection to a public sewer is not feasible: Public sewer is not available 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 "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 deliberate violations." (�-- -_71?- 317 Faa ity Owner's Si ature 4V Date Benjamin C. Osgood Jr. P.E. (Agent for Owner) Print Name New England Engineering Services, Inc. Date 1600 Osgood Streeet No. Andover, MA Preparer's address City/Town 01845 (978)686-1768 State/ZIP Code Telephone Form 9A Application for Local Upgrade Approval revised•rev.7/06 Application for Local Upgrade Approval, Page 4 of 4