HomeMy WebLinkAboutCorrespondence - 514 WINTER STREET 7/3/2006 OoRyi4
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PUBLIC HEALTH DEPARTMENT
Community Deveiapment Division
July 3,2006, 2006
Nicholas Guerrera
514 Winter Street
North Andover,MA 01845
RE: Septic System Design, 514 Winter Street,North Andover,Map 104A,Lot 79
Dear Homeowner,
The North Andover Board of Health has completed the review of the septic system design plan for the above
referenced property,submitted on your behalf by Merrimack Engineering Services,last revision dated May 22,
2006,and received May 31,2006.
The Board of Health approved a variance to N. Andover's regulations and a local upgrade as listed on the proposed
plan on June 22,2006. With these variances and approval, the 4-bedroom(9-room maximum)design has been
approved for a replacement onsite septic system.This approval is valid for two years from the date of the approval
in accordance with current local regulations and during this time a licensed septic system installer must obtain a
permit and complete this work,and a Certificate of Compliance be endorsed by the installer,designer and the Town
of North Andover.
Local up ade approval
Distance from SAS to wetland from 50 ft to 40 ft
Local BOH variance approvals
Distance from SAS to wetland from 100 ft to 40 ft
Distance from septic tank and pump tank to wetland from 75ft to 31 ft,2711 respectively
It is also noted by a board member that the pump specified is too large for the application.It was recommended that
a'/4 hp be utilized.Please have installer verify that this pump is appropriate prior to installation by checking with the
engineer if a change is necessary.
This approval is subject to the following conditions:
The attached DEP Form 9b must be submitted by the homeowner to the appropriate Regional Office of the
Department of Environmental Protection,as described. MassDEP NERO, 205B Lowell Street, Wilmington,MA
01887
1. If site conditions are found in the field to be different from those indicated on the design plan and/or soil
evaluation,the originally issued Disposal System Construction Permit is void,installation shall stop,and the
applicant shall reapply for a new Disposal Systems Construction Permit.
2. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or
other representative to ensure that all other state and municipal requirements are met.These may include review
by the Conservation Conunission,Zoning Board,Planning Board,Building Inspector,Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe or imply
compliance with any of the aforementioned requirement
1600 Osgood Street,North Andover,Mossochusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.coin
Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health
Department may be reached at 978.688-9540 with any questions you may have.
Sinter
r ,
G` assn Y. Sawyer,REHS/RS`
Public Health Director
Encl: list of licensed septic system installers
Cc: Merrimack Engineering Services
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9510 Fax 978.688.8476 Web www.townofnorthandover.com
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
. A
r`
Form
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. The system owner shall provide a copy of the Local Upgrade Approval to the
appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource
Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before
commencement of construction.
A. Facility Information
Important:
When filling out 1. Facility Name and Address
forms on the
computer,use Nicholas Ouerrera
only the tab key Name
to move your 514 Winter Street _—
cursor-do not Street Address T
use the return
key. north Andover __ __ MA_ ---- 01845_— -
QCity/Town State Zip Code
2. Owner Name and Address (if different from above):
too Street Address
----- ---- -
— --- -- —----
City/Town -- State
Zip Code Telephone Number
3. Type of Facility (check all that apply):
X Residential ❑ Institutional ® Commercial ❑ School
4. Design flow per 310 CMR 15.203: 440 -
gpd
5. System Designer: Anthony Donato - - X PE ❑ RS
Name
66 Park Street North Andover MA
Address City/Town State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
X Reduction in setback(s)-specify:
Reduction in setback distance between SAS and wetland from 50 feet to 40 feet
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
514 Winter Street 9b 7.3.O6.doc.rev.5/02 Local Upgrade Approval* Page 1 of 1
Commonwealth of Massachusetts
City/-rown of
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate min./iinch
Depth to groundwater --_--_-_-_ -_--- -.-- - ---__- --
❑ Relocation of water supply well (explain):
List local variances granted not requiring DEP approval per 310 CIV1R 15.412(4):
Local bylaw variance to allow reduction in offset distance between the leach bed and wetlands from
100 feet to 40 feet
Distance from septic tank and pump tank to wetland from 75ft to 31 ft,27ft respectively
List variances granted requiring DEP approval:
Susan Sawyer
Approving Authority r -- - -— --- — --
Public Health Director _ / October 25, 2004
Print or Type Name and Titie Sign ture Date
O
514 Winter Street 9b 7.3.06.doc w rev.5/02 Local Upgrade Approval® Page 2 of 2
MERRIMA K ENGINEERING IN ERVI , INC.
PROFESSIONAL ENGINEERS - LAND SURVEYORS - PLANNERS
66 PARK STREET a ANDOVER,MA 01810 a (978)475-3555,373-5721 a FAX(478)475-1448 E-MAIL info @merrimackengineering.com
May 24, 2006
..
Ms. Susan Sawyer
Director of Public Health i r( f 1��
1600 Osgood StreetI
Building 20, Suite 3-64
North Andover, MA 01845
Re: 514 Winter Street
Dear Ms. Sawyer:
We are in receipt of your review letter dated 4-17-06 regarding the above referenced
proj ect.
The plans have been revised to address your comments. Also submitted is an attachment
addressing pump curves and buoyancy calculations as insufficient space exists on the
plan. Also enclosed is a revised copy of the L.U.A. Form.
With regard to the wetland issue, Epsilon Associates, Inc, performed the delineation and
involved the conservation agent so as to have agreement on the delineation.
Requiring a conservation filing for the sole purpose of the delineation would be an
unreasonable requirement of the homeowner in a process which is already financially
overwhelming, especially when a subsequent filing with the Conservation Commission is
necessary.
We hope we have adequately addressed your comments and respectfully request the plan
be approved as re-submitted.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
William Dufresne
Project Manager
ti
(�e P-T-IC 'TAOV--) BQUYANCY CALC'S B01IYANCY CAL-
C--LS-VOL, OF WATEL3 DISE,"- ED VOL. OF WATER J?ISPL!ED
I y,`1 LG x .a,a DIP s ,'i
�SrzWI x _��? DP � ��� C.F. ��.WI x LG x C.F
W QF W DISPLACED AEI T OF 1��TE.f3_Dlsl�LgCEU Les
U V.22 C.F. x 62.4 LBS / C.F. o ?f!yD LBg _ C.F. x 62.4 LBS / C.F. a - _
WGT. OF CAL TANK = / LBS WGT. OF fxjD GAL TANK = 57 LBS
WGT, OF SOIL COVE OVER_TANK WGT. OF OF �/E{�___[i �R TANK
�— LG x __!5 e. WI x s'7 DP �_ '45.� C.F. .�_ LG x , .1 WI x DIP = �C.F
C.F. x 110 LBS / C.F. _ 60-5/h LBS C.F. x 110 LBS / C.F. _ �. 1 Z LBS
I� 1NGT. OF TANK AND $9L TOTAL WGT. OF TANK AND SOIL
;� +6& ° _!.(T�?� Las ivvnzf� + 4LL l'2 : -71 Las
THEREFORE — TANK WILL NOT FLOAT THEREFORE — TANK WILL NOT FLOAT
PWF kMAM,ff CURVE L8 50 (1' N
28 1725 RP
a
24
0 6
20 It.
to I
16
.si v
4 5 12
4
0 0
40 40 fi 80 100 120 140
U.S.Gallons Per Minute
0 2.1 4.2 6.3 6.4
Liters Per Second
Commonwealth of Massachusetts
City/Town of
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 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
5.404(1), is not feasible.
310 CMR 15.403(4) requires the system owner to provide a copy of the local upgrade approval to the
appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource
Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before
commencement of construction.
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 15.417.
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 6;L. E:W M4 VLC5412a_"
only the tab key Name
to move your
cursor-do not Street Address
use the return
key. 1._(PiAw A W 0,00 IFJV� I•tii� �, �1�� y
City/Town State Zip Code
r�
2. Owner�Name and Address(if different from above):
revn 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:
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) Conventional ❑ Other(describe below):
Septic-Form 9A-Local Upgrade Application1 •rev.5/02 Application for Local Upgrade Approval, Page 1 of 1
Commonwealth of Massachusetts
City/Town of
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.
A. Facility Information (continued)
6. Type of soil absorption system.(trenches, chambers, leach field, pits, etc):
rl a'o
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: gPd 1 }�Wc��iN
Design flow of proposed upgraded system
9P
Design flow of facility:
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
Q'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:
I4 LW 1 5i29 64 L, �� TA 61
NtGGct� ������ii ►�� r•.e� � ►.SIB ( [� �� 5�,e--r a ��
3. Local Upgrade Approval is requested for(check all that apply):
Reduction in setback(s)—describe reductions:
4,A5-
❑ Reduction in SAS area of up to 25%' sas size,sq.ft. %reduction
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction ft
Percolation rate
min./inch
Depth to groundwater ft
Septic-Form 9A-Local Upgrade Application1 •rev.5/02 Application for Local Upgrade Approval* Page 2 of 2
Commonwealth of Massachusetts
City/Town of
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.
B. Proposed Upgrade of System (continued)
❑ Relocation of water supply well (explain):
❑ 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)(i)(1). The soil evaluatormust 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:
/ f✓e eL TL,�� 1�� G'� '�ry
Lt--Lj ®r L"
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
Septic-Form 9A-Local Upgrade Application1 •rev.5/02 Application for Local Upgrade Approval, Page 3 of 3
Commonwealth of Massachusetts
City/Town of
— 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.
C. Explanation (continued)
3. A shared system is not feasible: A__4.
4. Connection to a public sewer is not feasible:
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."
Facility Owner's Signature o Date
L.16:� _64
Print Name
Name of Preparer Date
Preparer's address City/Town
p7-W�- l
State/ZIP Code Telephone
Septic-Form 9A-Local Upgrade Application1 •rev.5/02 Application for Local Upgrade Approval, Page 4 of 4
TOMIN OF' NOR"11-1 ANDOVER
Office of(.,',OMMUN1'11'Y DEVELOPM EENTAND SERVICES
HEAL'T"H DEPARTMENT
400 OSG0OD STREET
NORTH ANDOVER, MAS8ACDDSE.T[S0l845 CHO
Susan Y. Sawyer, Rl"'0YRS 978�&Q*.4548—Phone
Public Health Director 978.688.9542— FAX
April )7,2O06
Anthony Donato,P.B.
Merrimack Engineering Services
66 Park Street
Andover,88AO\8l0
Re: Subsurface Sewage Disposal Plan for 514 Winter Street, Map 104A, Lot 79
Dear Mr. Donato:
The proposed wastewater system design plan for the above site dated March 10,2006 and received on March 20,
20O6 has been reviewed. Unfortunately,the plan cannot be approved until the following items are corrected. The
specific section in Title 5: 310CMK 15.000, or North Andover regulation that ia not met hy this design follows each
item. |
|. The septic tank and pump chambers are both inthe groundwater. Please provide buoyancy calculations for �
each tank.
2. Volume calculations including flow back were not included in the calculations. Please note that the Health
Department requests that this be done on all systems.As this run would be a negligible result it is not
requested for this site,however in an effort of consistency please include flow back in all calculations.
3. Please provide pump performance curves in order to verify the calculated flow against the head.
4. It is noted that the North Andover Conservation Commission has not approved the wetland boundary depicted
on the plan as the Commission has not reviewed this plan to date, If this wetland line is changed by the
Commission a plan must be submitted to this office with the changes. In addition, it would be best to submit
verification of the wetland line prior to the Board of Health meeting so that the members may be sure they are
voting oumo accurate variance.
j. Please clarify Or Correct the Application for Local Upgrade Approval which was submitted. Part of the
Application requests information about relocating a water supply well and you provided information in this
section,though �
� |
that there is no on site water well and this request should be under"other"as it relates to a town water supply, �
on the line below,rather than well. |
�
Additionally,you might wish to consider the following in your revised plan: �
w Using un effluent fikcrin the primary(oopbo)tank
m Adding a note to the Notes section regarding the required relocation of the waterline �
Please submit the written request to be on the next available Board of Health meeting agenda for the purpose of the
variances found listed uu the plan.The May meeting will 6e held oo May 25,2O06.
Please feel free to contact the office with any questions you may have. Wc look forward Lo working with you 10
obtain a wastewater treatinent and dispersal system which will be in compliance with all regulations and assure
protection wf public health and the environment o[North Andover,
Sincerely,,,,,
Susan Y. 3npyer,REH88l8 �~
-
Public Health Director -
cc: Owner
File
TOWN OF NORTH ANDOVER 'M
Office of COMMUNITY DEVELOPMENT AND SERVICES
*b�c
HEALTH DEPARTMENT
t
400 OSGOOD STREET
NORTH ANDOVER, MA.SSACHi.1SE"ITS 01845 sAC1111
978.688.9540 -Phone
Susan Y.Sawyer,R'C;HS/RS 978.688.8476--FAX
Public Health Director E-IvlA1L:1iealthdept&u lownofiiortharadover.corrm
\VE13S1TF.'.:littp://www.townofiloi-tliaiidover.com
SEPTIC PLAN SUBMITTAL FORM
i
(3
Date of Submission: ��„�~�" I �` ��� ;� isl(�-'4�� ��� gay </<�0
Site Location: 1 wre fl/" 0, 11 i,- Lam' t
..........
Engineer: µ Pal
New Plans? Yes L,, $225/Plan Check 4_1 �'- '(includes 1't submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes No
Local Upgrade Form Included? Yes No
Telephone#:LeT7 ) '-1 ° 9.- � ,. Fax#:
E-mail: -1 Cc K) e!-e/1-j
Homeowner
Name: l -1 of E7 lz,�,.;�-0-
OFFICE USE ONLY
When the submission is complete (including check):
Date stamp plans and letter
> Complete and attach Receipt
l ,°'' Copy File; Forward to Consultant
> � Enter on Log Sheet and Database
Location:
owner's Name:Location:
Map/Parcel:
Address:
rnstallem f
Tell. New pmL.Repg
r
Date: Y Zone A _Soll Symbol Ll son&me-,I: on pus
Deep Observation Hole Logs"
Elmmtfon Depth Son H� n Soil Te=re Soil Color r Soil Mottling. % Gravel,Stone;etti
A,
0
I
(j,>
If
Parent Material. Dtp1h.,oDtdmdL::�_StmtdLgWt*rjnthe
OW
A
A
ParwmmarW pth to Wnk�� stn �s Wskerim eta frm ZU Fact
Date -
--_. 'Percolation Tests
Observation Hole
Depth of Pere
Start Pre-soil:
Time at 124
These at 9
Time at 6
Time(qn-6,1—
-Rate Mn&ch--
Performed BI".
Commonwealth of Massachusetts
City/Town of
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 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
5.404(1), is not feasible.
310 CMR 15.403(4) requires the system owner to provide a copy of the local upgrade approval to the
appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource
Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before
commencement of construction.
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 15.417.
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 'A
computer,use [c a�� 5,. 6U E>[�y�gH4 If-fi jf _"
only the tab key Name
to move your
cursor-do not Street Address
use the return
key. 00 i -r A N clo Y>✓rY
City/Town State Zip Code
VC] 2. Owner� t Nam�e and Address (if different from above):
—mo P,
"7A Name Street Address
City/Town State
(1'7 ,5 &0-? 4tQ��
Zip Code Telephone Number
3. Type of Facility(check all that apply):
residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
`C
. *CV ;'" 12"FBI 1J6
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) [Conventional ❑ Other(describe below):
Septic-Form 9A-Local Upgrade Application1 •rev.5/02 Application for Local Upgrade Approval* Page 1 of 1
Commonwealth of (Massachusetts
City/Town of
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)
6. Type of soil absorption system.(trenches, chambers, leach field, pits, etc):
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: gPd �a
Design flow of proposed upgraded system —_
' f
_ J{Vr ,
Design flow of facility:
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is(check one):
Q/oluntary ❑ 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:
6w i 5ie 6A L-- J-AIblk-
►�Gjcu 1 ?�C�t �-e_T 4-�i �il'� ( l� S'Nr� �i-�,+->'at��t?�
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
ft.
Percolation rate
min./inch
Depth to groundwater ft
Septic-Form 9A-Local Upgrade Applicationl •rev.5/02 Application for Local Upgrade Approval, Page 2 of 2
Commonwealth of Massachusetts
City/Town of
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.
B. Proposed Upgrade of System (continued)
Vf Relocation of water supply well (explain):
6L-NAL NeG e, Wakr SU W_e_ line, h_bz� 0 , min � or
❑ 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)(i)(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:
LI rniTH soo •el IA)41 a nd s o;�, �e�t_ n__il Much op lot
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
Septic-Form 9A-Local Upgrade Application'! •rev.5/02 Application for Local Upgrade Approval* Page 3 of 3
Commonwealth of Massachusetts
City/Town of
Form 9A - Application for Local Upgrade Approval
,LAM
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: Nom,
4. Connection to a public sewer is not feasible:
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
Eg/complete plans and specifications
Eg/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."
X �� n �I ►�1 ��,
F'aci'lity Owner's Signature 0 Date
Print Name
A 15— C<--
Name off Preparer Date �(
IVI, f='.nip - I YL- li'� /�K; 22V4:4Pi,
Preparer's address City/Town
State/ZIP Code Telephone '
Septic-Form 9A-Local Upgrade Application) •rev.5/02 Application for Local Upgrade Approval, Page 4 of 4