The URL can be used to link to this page

Home My WebLink AboutLocal Upgrade Approvals - 9 TURTLE LANE 11/22/2017 . . Commonwealth of Massachusetts Cof North Andover Form 9A — Application for Local Upgrade p ~rov ~Q DEP has provided this form for use by |oom| 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 ofHealth todetermine 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 adesign flow ofless than 1O,O0Ugpd. where full compliance, eedefined in31OCN1R 15.404(1). isnot feasible. System upgrades that cannot beperformed inaccordance with 31OCK8R15.4D4and 15.4U5. or|nfull compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CIVIR 15.410 through 15.415. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of anew design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity ofmnon-site system constructed ina000rdan weefte 1078Code or31OCMR 15.00O. VED Important:When 1 Facility TOWN OpNORTH ANDOVER nNUN ~ -- � mnevmforms HEALTH DEPARTMENT '��NQF�ORTHANDOVBR �m:�m�m computer, ~�- DEPAFTMGNT mmm�V�� key to move your Name cursor-do not 9Turtle Lane use the return Street Address key. North Andover MA0184� Cityrrwwn State Zip Code 2. Owner Name and Address (if different from above): VViUi8nn Durfee 0Turtle Lane ��------ Name Street Address North AndoverMA City/Town State O1845 Zip Code Telephone Number 3. Type ofFacility (check all that app|y): E Residential Fl Institutional Fl Commercial School 4. Describe Facility: Existing 4bedroom h m 5. Type ofExisting System: El Privy 0 Cesspool(s) Conventional Other(describe ba|uxv : 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): leach field tmo,m8a`rev,n0n Application for Local Upgrade Approval* Page 1o[4 Commonwealth of Massachusetts City/Town of North Andover 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) 7. Design Flow per 310 CMR 15.203: 40 Design flow of existing system: 9 4.pd 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): R Voluntary El Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: -1 d 11 a 11 te of inspectI- .io n 2. Describe the proposed upgrade to the system: Install new 1500 gallon tank, 1000 gallon pump chamber and pipe in stone leach system -------------- .......... 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 1fi.... ... Percolation rate 4 MPI min./inch Depth to groundwater 3 t5form9a-rev.7/06 Application for Local Upgrade Approval* Page 2 of 4 Commonwealth of Massachusetts City/Town of North Andover Form 9AApplication for Local Upgrade Approval J. 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. ...........--- B. Proposed Upgrade of System (continued) F] 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: Isaac Rowe 9/22/17 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: no area on the lot available ----------- ------------ 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: cost is prohibative t5form9a-rev.7106 Application for Local Upgrade Approval# Page 3 of 4 Commonwealth of Massachusetts City/Town of North Andover 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: no adjacent property available for ashared system 4. Connection to a public sewer is not feasible: sewer is too far away . .. .. ........ ------------------- 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 F-I 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." 11/6/17 racility Owner's Signature Date _Bq_9jq'min-C Osgood, Jr., gent for owner Print Name Benjamin c. Osgood, Jr 11/6/17 Name of Preparer Date 157 Bluff Street Salem Preparer's address City/Town NH 03079 978-435-1324 -State/ZIP C-oc"e Telephone t5form9a-rev.7106 Application for Local Upgrade Approval, Page 4 of 4