HomeMy WebLinkAboutCorrespondence - 52 OLYMPIC LANE 11/28/2012 KINGSTOWN CORPORATION
61 CAMELOT DRIVE, PLYMOUTH,MA 02360
PHONE: (508)746-1101
FAX: (508)747-2021
Email: kingstonwcorp @comeast.net
November 28, 2012
Mr. Raj ender Dudani
Sayana Assets Investments, LLC
1970 Beacon. St.
Waban, MA 02468
RE: Past due balance of$2316.85, J. Kellett Excavating, 52 Olympic Lane,N. Andover,
MA
Dear Mr. Dudani,
Kingstown Corporation delivered Title V Perk Fill to your house in September 2012 (see
attached invoice). After numerous calls and promises by Mr. Kellett to pay the full
balance $2316.85 the balance remains unpaid. Kingstown Corporation requests that any
and all monies owed by you to Mr. Kellett be held at this time.
Kingstown Corporation will be seeking attachments on any money, property or
equipment of Mr. Kellett's, because without these funds Kingstown will continue to
experience financial hardship.
I thank you for your immediate attention to this matter. If you have any questions please
feel free to contact me.
Since cc: Kellett Excavating
400 Salem. St.
--.� --- Lynnfield, MA 01940
V
J hn Moon cc: Board of Health
eneral Manager 1600 Osgood St. w f� �, f R A '<<A:U V r
JM/sld
N, Andover, MA Ol 845
Cert./reg mail 7012 1010 0003 0654 9980, 9966, 9959
-M - O'Z O'ZQ,tion INVOICE
CYL g itoaJYL
61 CAMELOT DRIVE • PI`'MOUTH,MA 02300
From Order# 22263
SOLD TO SHIPPED TO
KELLETT EXCAVATING OLYMPIC LN.
400 SALEM ST N. ANDOVER
LYNNFIELD, MA 01940
(781) 599-7934
KELL1001 NET 30 09 10 12
w
101 . 05 12 YRDS OF PERK FILL 12 . 00 1212 . 60
09/05/12
N. ANDOVER
69 . 14 02 Tons of Sand 14 . 00 967 . 96
09/06/12
FINANCE CHARGE
,,�" "��� �" '� ��{�' 2180 - 56
6f
A Service Charge of Misc. Charges
1-1/2%per month (18%per year)
will be charged on all unpaid 6 . 250Sales Tax 136 . 29
balances over thirty days.
THANK YOU � t Owr
tsar �sr � . 2316 . 85
}� Y
Phone:508-746-1101 • Fax:5n8 747-2021
•,;g�'CT ,l6vs ,
•
•
North Andover Health Department
Community Development Division
i
July 15, 2011 j
�I
Raj Dudani
52 Olympic Lane
North Andover, MA 01845
RE: Subsurface Sewage Disposal System Plan for 52 Olympic Lane Map 106B, lot 111,
North Andover,Massachusetts
Dear Property Owner,
The North Andover Board of Health has completed the review of the septic system design plans,
for the above referenced property, submitted on your behalf by Merrimack Engineering Services,
dated May 23, 2011, last revised June 27, 2011. The design has been approved for use in the
construction of a replacement onsite septic system for a three bedroom design at 440 gallons per
day. Generally this plan would be good for three (3)-years from the date of approval,however
since this repair is the result of a Title V report failure,this system must be completed within two
(2)-years.
This includes the approval of local upgrades
1) To the vertical offset from the Soil Absorption System to the Estimated high water table
from 5 feet to 4 feet
2) Only having one deep hole in the disposal area
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. In the event an imminent health problem such as sewage backup into the dwelling is
occurring,the North Andover Board of Health may reduce the time period for which this plan is
valid.
Page I of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01945 Phone: 978.688.9540 Fax: 978.688.8476
52 Olympic July 15, 2011
This approval is also subject to the following conditions:
1. With the understanding that the granting of the reduction of the distance to the high
water table restricts future expansion of the buildings flow capacity beyond 440
gallons per day (4 bedroom, maximum 9 rooms),unless the system is upgraded to a
compliant distance of five feet to the water table. 310 CMR 15.405(4)
2. 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(3 10 CMR 15.020(1)).
3. 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
Commission,Zoning Board,Planning Board,Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
shall not construe and/or imply compliance with any of the aforementioned
requirements.
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
might have.
Sincerely;?J
Swan Y. Sa4er,REH 9RS
Public Health Director
cc: Vladimir Nemchenok, Merrimack Engineering
file
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
•
•
North Andover Health Department
Community Development Division
July 5, 2011
Raj Dudani
52 Olympic Lane
North Andover,MA 01845
RE: Subsurface Sewage Disposal System Plan for 52 Olympic Lane Map 106B, lot 111,
North Andover, Massachusetts
Dear Property Owner,
The North Andover Board of Health has completed the review of the septic system design plans,
for the above referenced property, submitted on your behalf by Merrimack Engineering Services,
dated May 23, 2011, last revised June 27, 2011. The design has been approved for use in the
construction of a replacement onsite septic system for a three bedroom design at 440 gallons per
day. Generally this plan would be good for 3-years from the date of approval,however since this
repair is the result of a Title V report failure,this system must be completed within two years
This includes the approval of local upgrades
1) To the vertical offset from the Soil Absorption System to the Estimated high water table
from 5 feet to 4 feet
2) Only having one deep hole in the disposal area
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. In the event an imminent health problem such as sewage backup into the dwelling is
occurring,the North Andover Board of Health may reduce the time period for which this plan is
valid.
This approval is also subject to the following conditions:
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
52 Olympic July 5, 2011
1. With the understanding that the granting of the reduction of the distance to the high
water table restricts future expansion of the buildings flow capacity beyond 440
gallons per day (4 bedroom,maximum 9 rooms),unless the system is upgraded to a
compliant distance of five feet to the water table. 310 CMR 15.405(4)
2. 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 (3 10 CMR 15.020(1)).
3. 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
Commission,Zoning Board, Planning Board, Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
shall not construe and/or imply compliance with any of the aforementioned
requirements.
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
might have.
Sincerely,
Susan Y. Sawyer,REHS/RS
Public Health Director
cc: Vladimir Nemchenok, Merrimack Engineering
file
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
Commonwealth of Massachusetts
City[Town of Raj Dundani
a
Local Upgrade Approval
ra Form 913
GSM
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.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address
on the computer,
use only the tab Raj Dundani
key to move your Name
cursor-do not 52 Olympic Lane
use the return Street Address
key.
North Andover MA 01845
QCityf'rown State Zip Code
2. Owner Name and Address (if different from above):
,erg, 1970 Beacon Street
Name Street Address
Waban MA
City/Town State
02468 978 335-2366
Zip Code Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15.203: 440
gpd
5. Designer:System Vladimir Nemchenok ® PE E] RS
y 9 Name
66 Park Street Andover MA, 101810
Address Cityrrown State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s)—specify:
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
52 Olympic form 9b 7-5-11.doc•rev.7/06 Local Upgrade Approval* Page 1 of 2
Commonwealth of Massachusetts
City/Town of Raj Dundani
a
a Local Upgrade Approval
Form 9B
�M SV'y`W
B. Approval (continued)
® Reduction in separation between the SAS and high groundwater:
Separation reduction ft
Percolation rate <2 min/inch
min./inch
Depth to groundwater 4
ft.
❑ 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
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
Approving Authority
Print or Type Name and Title l riature Date
52 Olympic form 9b 7-5-11.doc•rev.7/06 Local Upgrade Approval• Page 2 of 2
Commonwealth of Massachusetts
City/Town of Raj Dundani
Local Upgrade u Approval
a
a" Fora
DEP has provided this farm 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.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address
on the computer, Raj DUndani
use only the tab 1
key to move your Name
cursor-do not 52 Olympic Lane
use the return Street Address
key. MA 01845
North Andover _
r�
City/Town State Zip Code
2. Owner Name and Address (if different from above):
, 1970 Beacon Street
Name Street Address
Waban MA
City/Town State
02468 978 335-2366
Zip Code Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
0
4. Design flow per 310 CMR 15.203: 44 44
Vladimir Nemchenok ® PE ❑ RS
5. System Designer: Name
66 Park Street Andover MA, 101810
Address City/Town State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s)—specify:
❑ Reduction in SAS area of up to 25%:
SAS size,sq.ft. %reduction
52 Olympic form 9b 7-5-11.doc•rev.7/06 Local Upgrade Approval* Page 1 of 2
Commonwealth of Massachusetts
City/Town of Raj Dundani
Local Upgrade Approval
t Form 9B
M
B. Approval (continued)
® Reduction in separation between the SAS and high groundwater:
1
Separation reduction ft
<2 min/inch
Percolation rate min./inch
4
Depth to groundwater ft
❑ 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
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
Approving Authority r
Print or Type Name and Title! ji nature Date
Print
52 Olympic form 9b 7-5-11.doc•rev.7/06 Local Upgrade Approval• Page 2 of 2
MER IMAC K ENGINEEF,1ING SERVICES, INC;,
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS 0 PLANNERS
66 PARK STREET-ANDOVER,MASSACHUSETTS 01610-TEL(978)475-3555,373-5721 -FAX(978)475-1448 m E-MAIL:rnerreng @ aal.cam
8 FANEUIL HALL MARKETPLACE-THIRD FLOOR - BOSTON,MASSACHUSETTS 02109-TEL(617)973-6462- FAX(617)973-6406
June 27, 2011
Susan Sawyer
Director of Public Health '°
1.600 Osgood Street ,
Building 20, Suite 2-36
North Andover, MA 01845 'r0wN OP NO' `t
MRIALTH WW
RE: 52 Olympic Lane
Dear Ms Sawyer,
We are in receipt of your review letter dated 6-14-11 for the above referenced project.
We have revised the plan with regards to item 3, 4, 6, 12, 1.3, 16, 17 & 18 of your letter.
With regard to item 1,the plan does show the current owners name.
With regard to item 2,the local upgrade approvals are clearly listed on the plan as they
have always been in the past. The section cited by the reviewer refers to VARIANCES
which are not the same as LUA'S and are treated as a matter of maximum feasible
compliance approved by the local authority.
With regard to item 5,no impervious barrier is proposed because the break out elevation
is met at 15 ft. The 96 contour is shown at 15.5 ft from the edge of the s,a.s. not 1.0 ft. as
the reviewer states.
With regard to item 7, Title 5 requires either a tee filter or a gas baffle. A tee filter is
proposed so we are unsure as to the intent of the reviewers comment.
With regard to item 8,the reviewer is incorrect as to their interpretation of Title 5. You
received D.E,P.'s opinion on this specific matter in the past and yet it has been expressed
again. We respectfully disagree.
With regard to item 9,the pump calculations specifically mention that flow back for 20
ft. of force main is negligible and it has been the opinion of your Board in the past that
flow back for any force mains less than 50 ft. is negligible. Friction loss has been
included in the TDH calculations.
With regard to item 10 and 11, neither of the sections specified by the reviewer require
that the control panel or alarm equipment specifications be listed on the plan as
Page 2 (Susan Sawyer)
6-27-11
mentioned. Furthermore,this has never been a requirement of the NA BOH in the past.
This equipment is provided by the pump manufacturer and it is noted on the plan that it
must be in compliance with Title 5. We question why this has been mentioned in this
instance,but never in the past.
With regard to item 14,the plan does specify that all components be marked with
magnetic marking tape if a comparable means is not provided.
Lastly, with regard to item 15, this is a requirement that all licensed contractors should be
aware of, it applies to all systems, and should be addressed in the field as site conditions
warrant.
Additionally, and in the interest of Public Health, we are frustrated by the inaccuracy,
senselessness and inconsistency of the review process which seems to only add time and
cost to the process in North Andover.
On behalf of the owner, we respectfully request that the plan be approved as re-submitted
so they may proceed with the upgrade of their failed septic system.
Yours truly,
............
William Dufresne
Merrimack.Engineering
MERRIMACK ENGINEERING SERVICES,INC.
66 PARK STREET•ANDOVER,MASSACHUSETTS 01810
0 '
•
North Andover Health Department
(ommunity Development Division
June 14, 2011
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover,MA 01810
Re: Subsurface Sewage Disposal System Plan for 52 Olympic Lane,Man 106B,Lot 111
Dear Mr.Nemchenok:
The proposed wastewater system design plan for the above site dated May 23, 2011 and received
on May 31, 2011 has been reviewed. Unfortunately,the plan cannot be approved until the
following items are corrected. Where applicable the specific section in Title 5: 310 CMR
15.000, or North Andover regulation that is not met by this design follows each item.
1. Name of owner appears as Paul D. Weinstein on assessor's field card. Please advise if
property has been sold since the assessor's cards were last updated as the local upgrade
approval form 9A has the owner as Raj Dudani of 1970 Beacon Street, Waban,MA.
2. The note listing the local upgrade approval requests does not include the citations from
the code (3 10 CMR 15.220(4)).
3. The distance between the tanks and the property line and the distance between the tanks,
leaching facility and the wetland area is not shown(North Andover Section 3.2).
4. The manufacturer of the distribution box is not called out(North Andover Section 3.2).
5. If no impervious barrier is to be installed the breakout elevation must be carried out 15'
from the edge of the sand bed. The plan view shows the breakout elevation of 96.17
being carried out 10' from the edge of the sand bed. (3 10 CMR 15.211)
6. It appears that the bottom of the septic tank may be below the ESHWT. Please provide
buoyancy calculations for the septic tank(3 10 CMR 15.221(8)).
7. A gas baffle is required on the outlet tee of the septic tank(3 10 CMR 15.227(4)).
8. The pump chamber's outlet invert is not specified. Please provide this so it can be
confirmed that the invert is at least 12" above the ESHWT (3 10 CMR 15.227(5)).
9. Pump calculations do not include flow back volume or friction loss within the pipe. (3 10
CMR 15.231(2)).
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
10. Pump control manufacturer and model number to be specified (3 10 CMR 15.220(4)(r)
and North Andover Section 3.2).
11. Alarm equipment manufacturer and model number to be specified (3 10 CMR 15.231(2)
and North Andover Section 3.2).
12. The most current DEP soil evaluation form 11 and percolation test log 12 should be used
(North Andover Section 2.3).
13. Vent should have filter on it to protect from precipitation/animal entry(3 10 CMR
15.241(1)(b))
14. Please specify all system components shall be marked magnetic marking tape including
the septic tank(3 10 CMR 15.221(12)).
15. Grading should slope away from dwelling where possible.
16. Will fence be removed from back yard or replaced when construction is complete? Also
grading is shown through what looks to be a shed. Will this be removed and relocated?
17. The infiltrator end section detail and the Quick 4 plus standard LP chamber detail on
sheet 2 both show the chamber but one has a height of 12" and the other has a height of
8". It is possible you meant to show the 8"chamber as detailed with the invert
elevations. Also on sheet one the note"Prop. Leach field w/48 quick 4 LP infiltrator
chambers in a 6' wide by 8' long configuration." It appears you meant"in a 6 chamber
wide by 8 chamber long configuration."
18. There is a spot elevation on the northwest corner of the dwelling of 94.0 but a 96 contour
comes out from it.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Sincerel/hY.r
Sus ay vr,REHS .�
Public Health Dire 66'r—
cc:
File
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
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SEPTIC PLAN SUBMITTAL FORM
Date of Submission: " 2 -
I (
Site Location: 5Zi 01,'''I.1 t , °a, vv«,w aa�,������:� i �:�is �' ;ir
I/i'�i i� i�:Om�'I,
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Engineer: pi cM�_,K-c - d � �� ��
New Plans? Yes $225/Plan Check# r C w (includes I" 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#:(°l2D) q-7 5'-3 Fax#; lg, ff
E-mail: W U i FT.
Homeowner
Name;
OF'F'ICE USE ONLY
When the submis ion is complete (including check):
Date stamp plans and letter
° Complete and attach Receipt
Copy File; Forward to Consultant
Enter on Log Sheet and Database
Commonwealth of Massachusetts
--—- City/Yawn of �larth Andover
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 Raj Dudani only the tab key Name
to move your 52 �-OI m is Lane
cursor-do not --- �----- - - - --- ------- - -- - --- -- --
use the return Street Address
key. North Andover MA 01845
O' City/Town State Zip Code
2. Owner Name and Address (if different from above):
Rat Dudani 1970 Beacon Street
reran p Name Street Address
Waban MA
City(rown - State - - -
02468 (978) 335-2336
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):
Field _
LUA FORM t5form9a.doc^rev,7/06 Application for Local Upgrade Approval* Page 1 of 4
Commonwealth of Massachusetts
City/Town of North Andover
Form 9A —a
Application r
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
�^M 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
9Pd
Design flow of proposed upgraded system 440
gpd
440
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:
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:
1.0
Separation reduction ft
2
Percolation rate min./inch
4.0
Depth to groundwater ft
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval, Page 2 of 4
Commonwealth of Massachusetts
City/Town of North Andover
Form 9A - Application I Upgrade Approval
wM 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 4-26-11
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
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
NA
LUA FORM t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 3 of 4
Commonwealth of Massachusetts
City/Town of North Andover
a
Form 9A ® Application
;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.
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."
4(`NV`s 5-24-11
Facility Owner's Signature Date
Raj Dudani
Print Name
Bill Dufresne/Merrimack Engineering 5-24-11
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
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