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Home My WebLink AboutLocal Upgrade Approvals - 60 DEER MEADOW ROAD 6/21/2018 Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval - n 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 RECEIVED Important:When filling out forms 1 Facility Name and Address: S E P '12 70'1.1 on the computer, use only the tab Sumeeta & Sunit Mukhe 'ee INN key to move your Name ............................... T(owwo E HEALTH DEPARTMNT cursor-do not 60 Deer Meadow Road use the return Street Address .......... key. North Andover MA ' 01845 VQ City/Town State Zip Code 2. Owner Name and Address (if different from above): Tanen Name Street Address .......... ............... .......... City/Town State Zip Code Telephone Number 3. Type of Facility(check all that apply): 0 Residential F1 Institutional El Commercial El School 4. Describe Facility: Single.'FamiV Dwelling ............ 5. Type of Existing System: n Privy El Cesspool(s) Conventional El Other(describe below): ............- 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Leach Trenches t5form9a(1).doc•rev.7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of North Andover 42 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: Design flow of existing system: 440 ---------- gpd Design flow of proposed upgraded system 440gpd Design flow of facility: 440gpd ........................................................... ............. B. Proposed Upgrade of System 1. Proposed upgrade is (check one): E-1 Voluntary El Required by order, letter, etc. (attach copy) Required following inspection pursuant to 310 CMR 15.301: unknown date of inspection 2. Describe the proposed upgrade to the system: New Septic Tank, D-Box and Leach Bed ...................................................................................1-1.......................- --------------- ...................... 3. Local Upgrade Approval is requested for(check all that apply): E Reduction in setback(s)–describe reductions: To allow greater than 36 inches of cover of the septic tank. 5.4 feet is proposed. F-1 Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction ❑ Reduction in separation between the SAS and high groundwater: Separation reduction -–---------—------------------ ............. Percolation rate minAnch Depth to groundwater t5form9a(1).doc-rev.7/06 Application for Local Upgrade Approval, Page 2 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. B. Proposed Upgrade of System (continued) F-I 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 F-I 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: The extreme slope behind the dwelling_does�,not make it possible to comply with 310 CMR 15.00. ................... 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: X (p �tan�ki§_.pro osed to allow installation on the slope) p ................- t5form9a(1).doc-rev.7/06 Application for Local Upgrade Approval* Page 3 of 4 ` . Commonwealth of Massachusetts ' Cof 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 hare. Before using this form, check with your |uma| Board of Health to determine the form they use. C~ Explanation (coDtiUUed) 3, Ashanad system is not feasible: N/A 4. Connection to m public sewer is not feasible: N/A- 5. \5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ED Application for Disposal System Construction Permit Z Complete plans and specifications Z Site evaluation forms Fl A list ofabutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant tu81OCKAR15.4O5(2). Other(List): D. Certification "|, the hanUb/qvvn�� dU' c� � under penalty of of|ewthat this document and � attachments, to the best ofmy knowledge and � ndba|ieangtnuu. acuunabe' ondonmp|eta. | 8nnavoonethatthenenlaybeaiQnUicmnt consequences for submitting false information, inn|uding, but not limited to, penm|Uma or fine and/or imprisonment for deliberate vio|atione." 9/12/2017 Facility&nn/eSignature nmo i Print Name NomeofPmpemr Dmha 189 North Main Street Middleton P�pa�/oo��nyao CKyOlxwn 01949 978-539-8088 stehgZ|PCudo Telephone t5«unn9o(1).dvu`rev.70O Application for Local Upgrade Approval* Page 4of4 � Town of North Andover .. HEALTH DEPARTMENT SAC140 z , 4,,/ : 9. CHECK#- ........... DATE LOCATION: 1-1/0 NAME: CONTRACTOR NAME: ,Z,)"�"(')`c —Tv—pe of Permil or Licen5e:Wheck lox) 0 Animal $ 0 Body Art Establishment 0 Body Art Practitioner 0 Dumpster $ 0 Food Service-Type:— $ 0 Funeral Directors 0 Massage Establishment 0 Massage.Practice $ 0 Offal(Septic)Hauler $ 0 Recreational Camp $--- 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco 0 TrasIVSolid Waste Hauler 0 Well Construction SEP77C�tems.- 0 Septic-Soil Testing 0 Septic-Design Approval 0 Septic Disposa I Works Construction(DW0 $ 13 Septic Disposal Works Installers(DM) $----- 0 Title 5 Inspector $ IJ Title 5 Report $ Other. (Indicate) cz,rieci�i eo, HealithAgent Initials White-Applicant Yellow-Health Pink- Treasurer