HomeMy WebLinkAboutApplication - 35 MARIAN DRIVE 8/19/2011 TOWN F NORT11 VlXWEI �peas Vaaoa ^mod
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N ON ll I , NDOVER., 1 S";A(, "lit.M�il.l"'1`.°; 01845
978.68&9540 PhCbw
Susan V, Sawyer'RE"lls/14 S 978.68'(�,84 76 FAX
Public Health INI'Mor ds',••M,IL:
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SEPTIC PLAN SUBMITTAL FORM � Nf
711" , tlp
Date of Submission: �
Site Location. 2 1 A 1 2 HtA, I UIVI hPtWENT
11 i C
Engineer: }�,��i�',i�t~(�,��.., �- '' 1-1-
New Plans? Yes ' $225/Plan Check#105, 1 includes 1St submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes,/ No
Local Upgrade Form Included? Yes'' f No
Telephone#:6-" ) � ��C , �� �c Fax#: ��P 'D ) 1°�"`" C; i el '0
E mail 14 r>LPL:
Name:owner -A(A-h, i � a✓; `
OFFICE USE ONLY
When the submission is complete (including check):
Date stamp plans and letter
Complete and attach Receipt
a..= Copy File; Forward to Consultant
f Enter on Log Sheet and Database
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Commonwealth of Massachusetts
City/Town of
Percolation Test
Form 12
GM
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. 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
the local Board of Health to determine the form they use.
Important: A. Site Information
When filling out
forms the
computer,use
only the tab key Owner Name
to move your ??
cursor-do not Street Addr ss or Lot#
key the return qok�, ( -1 Y�
y }-1 ll�f I
, --� City/Town State Zip Code
Contact Person(if different from Owner) Telephone Nuffiber
,. B. Test Results
Date Time Date Time
Observation Hole# ✓i
X11
Depth of Pere
Start Pre-Soak
End Pre-Soak
Time at 12"
Time at 9" ` a.�2
Time at 6"
Time(9"-6")
Rate(Min./Inch)
Test Passed: [ Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Test Performed By:
Witnessed By:
Comments:
t5form12.doc•06103 Pere Test•Page 1 of 1
Commonwealth of Massachusetts
City/Town of Forth Andover
a
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.
Form 9A is to be submitted to the focal 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 John & Joan Grover Residence
only the tab key Name
to move your 35 Marian Drive
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):
SAME
Fez° Name Street Address
--------------------- — -- - —
City/Town State
_(9�685-0661 - _-
Zip Code Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
4 Bedroom House
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Unknown
LUA FORM t5form9a.doc.rev.7/06 Application for Local Upgrade Approval* Page 1 of 4
Commonwealth of Massachusetts
City/Town of North Andover
a
- Application l
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: Unknown
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: 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:
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
® Reduction in separation between the SAS and high groundwater:
Separation reduction 1.0
ft.
Percolation rate 20
min./inch
Depth to groundwater 3.0
ft.
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 2 of 4
Commonwealth of Massachusetts
KoffleEffil City/Town of North Andover
R Application r Local Upgrade
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.
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 evaluatormust be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Randy Burley 8-9-11
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:
High water table, full compliance would result in an exceptionally high mounded system causing
unreasonable financial hardship and make the marketability of the property much more difficult.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
N.A.
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval, Page 3 of 4
Commonwealth of Massachusetts
F
City/Town of North Andover
a
Form 9A
Application 1
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:
N.A.
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
1, 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."
L9l 8-15-11
Fa ' ty Owner's Signature Date
John Grover
Print Name
Bill Dufresne/Merrimack Engineering 8-15-11
Name of Preparer Date
66 Park Street Andover
Preparer's address City/Town
MA/01810 (978)475-3555
State/ZIP Code Telephone
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4