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Home My WebLink AboutLocal Upgrade Approvals - 257 BOXFORD STREET 7/31/2018 Commonwealth of Massachusetts City/Town of North Andover �� ~��~�� Local Upgrade � �� Form~~~ --~ ~ Application ~��~ ��-~~�~�~ �~��^ ~~�~~� 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 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 a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CIVIR 15.404(1). is not feasible. System upgrades that cannot be performed in accordance with 310 CIVIR 15.404 and 15.405, or in full compliance with the requirements of 310 CIVIR 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 tmecesspool 0rprivy, orthe addition pf@new design flow above the existing approved capacity mfanon-site system constructed in accordance with either the 1978 Code or 310 CIVIR 15.000. A. Facility Information " Important:When ��Yw filling out forms 1. Facility N dAdd � ' - onthe computer, use only the tab Sharon Holland key tomove your mama ,- `- oumor-unn'� 257Boxford Street ��^ unemena�um key. S`.~.`'`....'~ North Andover Ma 01845 c�y/rn�n xtaa Zip Code 2. Owner Name and Address (if different from obove): C/OTerry,Holland 133Greene Street NodhAndover Ma Cityf'rown State 01845 978 360 1 g1 Terryholland@comcast.net Zip Code Telephone Number 3. Type ofFacility (check all that app|y): 0 Residential F-1 Institutional 0 Commercial [l School 4. Describe Facility: 4Bedrnoms 5. Type ofExisting System: Fl Privy 0 Cesspool(s) Conventional Other(describe he|ovv : 0. Type of soil absorption system (trenches, chambers, leach field, pits, etc): trench system t5fonn9u(1)nORTNuNDOVER^rev.708 Application for Local Upgrade Approval* Page 1uf4 Commonwealth of Massachusetts X . 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: Design flow of existing system: 440 gpd Design flow of proposed upgraded system 440 gpd Design flow of facility: 440 gpd B. Proposed Upgrade of System 1. Proposed upgrade is (check one): Z 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: new 1500 gallon tank and a 34' x 18, ft stone and pipe 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 ft Percolation rate minJinch Depth to groundwater ................... t5form9a(1)nORTH aNDOVER•rev.7106 Application for Local Upgrade Approval* Page 2 of 4 Commonwealth of Massachusetts CDfNorth Andover ' Form 9 & Application for Local Upgrade Approval DEP has provided this form for use bylocal Boards ofHealth. Other forms may beused, but the -�' information must besubstantially the same emthat provided here. Before using this form, check with your |nma| Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) El Relocation ofwater supply well (wxp|a|n): E] Reduction of 12-inch separation between inlet and outlet tees and high groundwater N Use Vfonly one deep hole inproposed disposal area F1 Use of sieve analysis as a substitute fora penu teat [l Other requirements of31OCMR 15.00Othat cannot bemet—describe and specify sections ofthe Code: |fthe proposed upgrade involves areduction inthe required separation between the bottom ofthe soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high groundwater elevation pursuant b) 31OOKAR15.4O5(1)(h)(1). The soil wvm/uatormvuatbe a member oragent mfthe local approving authority. High groundwater evaluation determined by: -Douglas J Smith April 17 2018 Evaluator's Name(type or print) ignature Date of evaluation C. Explanation Explain why full compliance, aadefined in31O (|K8R15.4O4(1). isnot feasible. (Each section must be completed) 1. Anupgraded system infull compliance with 31OCK0R1b.00Okanot feasible: in digging the deep soil test holes we could not dig soil holes I and 2 any closer to the proposed soil absorption area orvvewould have hit the exioUnAtnanoha 2. Analternative system approved pursuant to31UCMR 15.283to15.288isnot feasible: \ not0*aoibi|e on this lot 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: not an option ----------------------------- ..........----------- 4. Connection to a public sewer is not feasible: no access to sewer in the area ........... ............ 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): Z 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." ci icySi966tura Date Terg_Hollancl Print Name Douglas Smith June 18, 2018 Name of Preparer Date 98 Whittington Street Manchester Preparer's address City/Town NH 03104 603 487 2298 State/ZIP Code Telephone t5form9a(1)nORTH aNDOVER-rev.7/06 Application for Local Upgrade Approval* Page 4 of 4