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SEPTIC PLAN SUBMITTAL. FORM
Date of Submission:
Site Location: � � >
Engineer:
New Plans? Yes $225/Plan Check# (includes 1st submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation I,orms Included? Yes No
Local Upgrade Form Included? Yes No
Telephone#:� t C Ad Fax#: �) /� %��2 I
E-mail: i/J P PW
Homeowner
Name:
OFFICE USE ONLY
When the submission is complete (including check):
Date stamp plans and letter t`"„�'` �� �' Aj v�
Complete and attach Receipt
Copy File; Forward to Consultant
Enter on Log Sheet and Database
Commonwealth of Massachusetts
—- - City/Town of
= F
r Application
;� Jy•°p 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 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 fillip out 1. Facility Name and Address: °� �O)4
g yI m�
forms on the
computer, use Ralph Enos Residence
only the tab key Name ❑ + u I I
to move your 1 I ( 9 r � l l�i f � �f
51 Haymeadow Road,,,,,,, , . �.,,,�f
cursor-do not — - -----------
use the return Street Address
key. North Andover MA 01810
City/Town State Zip Code
rab
2. Owner Name and Address (if different from above):
SAME
--------- ----------- --------- ------
�" Name Street Address
------------------------— _... -.-.-.... ----------......
City/Town State
---- ------- (978) 682-7617
Zip Code Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
3 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):
Seepage Pits
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval, Page 1 of 4
Commonwealth of Massachusetts
City/Town of
R= Form 9A ® Application for Local Upgrade 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: 4 bdrm -600 gpd
gpd
Design flow of proposed upgraded system 440
gpd
Design flow of facility: 330
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. Rio 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
R Form 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.
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:
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:
NA
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
NA
t5form9a.doc•rev. 7/06 Application for Local Upgrade Approval* Page 3 of 4
Commonwealth of Massachusetts
City/Town of
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.
C. Explanation (continued)
3. A shared system is not feasible:
NA
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 for deliberate violations."
7 _ 8-21-14
Facility Owner's Signature Date
Ralph Enos
Print Name
Bill Dufresne 8-21-14
Name of Preparer Date
66 Park Street Andover
Preparer's address City/Town
Ma/01810 (978)475-3555
State/ZIP Code Telephone
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4
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54 Commonwealth of Massachusetts
City/Town of
Percolation Test
} Form 12
�M
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 EA t p { L-00
computer, use '�°f 1""f
only the tab key Owner Name
to move your 5
cursor-do not Street 1Address or Lot# ` yn
key.the return a�rfl 1N'J �� �s' �
City/Town S ate Zip ode,
v� ��C., �7
Contact Person(if different from Owner) Telephone Number
B. Test Results
Date Time Date Time
Observation Hole# p®
Depth of Perc
Start Pre-Soak (fit
End Pre-Soak
Time at 12" I �'
Time at 9" I ��
Time at 6" �' d
Time (9"-6")
Rate(Min./Inch)
Test Passed: Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Test Performed By:
7�6 I ''�
Witnessed By:
Comments:
t5forml2.doc•06/03 Perc Test•Page 1 of 1