HomeMy WebLinkAboutLocal Upgrade Approvals - 62 FARNUM STREET 11/20/2017 RECEIVED
OCT I U ?011ii
Commonwealth of Massachusetts
TOWN OF NORTH ANDOVER
City/Town of
No/e rIv '4�00 Vk HEALTH,DEPARTME-Wr
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 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 Brian &Jessica Hickey
only the tab key Name
to move your
cursor-do not 62 Farnum Street
use the return Street Address
key. North Andover Ma 01845
City/Town State Zip Code
2. Owner Name and Address (if different from above):
Name Street Address
C Ity/Town State
Zip Code Telephone Number
3. Type of Facility (check all that apply):
Residential Institutional Commercial School
4. Describe Facility:
Single family house
5. Type of Existing System:
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Privy Cesspool(s) Conventional Other (describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Infiltrator chambers
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: 330
gpd
Design flow of proposed upgraded 330
system gpd
330
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: dale of Inspection
2. Describe the proposed upgrade to the system:
New leach had pipe on stone,
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
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Percolation rate minJinch W
Depth to groundwater
fl.
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E. Proposed Upgrade of System (continued)
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Relocation of water supply well (explain):
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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 pert test
Other requirements of 310 CMR 15.000 that cannot be met— describe
and specify sections of the Code:
Y
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 sail evaluator must be a member or agent of the local
approving authority.
High groundwater evaluation determined by:
Gordon Rogerson SE2074 Sept. 26,2017
Evaluator's flame(type or print) -7signi5ture Date of evaluation
C. Explanation a
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:
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2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not
feasible:
C."explanation (continued)
3. "shared system is not feasible:
4. Connectio'jo a public sewer is not feasible:
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5. The Application foi"Local Upgrade Approv�/Must be accompanied by all of the
V,
following (check the appropriate boxes):
Application for Disposal Syste, Construction Permit
Complete plans and SPe cifi ations
Site evaluation forms
A list of abutters affec d by'Jeduced setbacks to private water supply
wells or property lines. rovide proof that affected abutters have been
notified pursuant to 310 CMR 15 05(2).
Other (List):
D. Certification
1, the facility owner, cer,/fyv under penalty of law that this'document and all attachments,
to the best of my know edge and belief, are true, accurate;",Pnd complete, I am aware
that there may be sig �ificant consequences for submitting fa�lse information, including,
but not limited to,
pe7alties or fine and/or imprisonment for deliberate violations."
Facility Owner's 8i nature Date
Print Name
Gordon R gerson Sept, 28, 2017
Name o7iparer Date
Date
603 S lem Street Wakefield, Ma, 01880
Pre is address CityrTown
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2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not
feasible:
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C. Explanation (continued)
3. A shared system is not feasible: t
4. Connection to a public sewer is not feasible:
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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 th rem y be significant consequences for submitting false information, including,
but n mi d , penalties or fine and/or imprisonment for deliberate violations."
�acifoZvner's Signature Date
Print Name
Gordon Rogerson Sept. 28,2017
Name f Pry lacP��
Date
(yJDate
60 Sa em Stree "� Wakefield, Ma.01880
Preparer's address Citylrown
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State/ZIP Code Telephone
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