HomeMy WebLinkAbout- Local Upgrade Approvals - 2198 TURNPIKE STREET 9/6/2018 »w� Commonwealth of Massachusetts
City/Town
' of
Form 9A
— Application for -c -U Upgrade Approval
DEP has provided this form for use bvlocal Boards ofHeahh. Other forms nxaybeused, but the
information must b8auhobanU8||yth8^ ane as that provided hone. Before using this form, check with your
local Board ofHealth todetermine the form they use.
Form 9A is to be su..bmitted 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(l), 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 nf31DCyWR 15.000. require evariance pursuant bo310CK8R 15.410
through 15.415,
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
enew design flow tomcesspool nrprivy, orthe addition nfanew design flow above the existing approved
capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CIVIR 15.000.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address:
on the -- , Jorge |
�eon��emw /
key wmove your Name
numor-donot 21A8Turn ike St
use the return
St o
key. North Andover Ma 01845-
City/Town State -'
Code
VQ
2. Owner Name and Address (if different from above):
Some
------- Name »«"="""'"""
Sm0a
-------------- Telephone Number
Zip Code
3. Type ofFacility (check all that apply):
0 Residential Institutional E] Commercial El School
4. Describe Facility:
Residential Septic System
5. Type nfExisting System:
El Privy F] Fl Conventional F-1 Other below):
Unknown
G. Typeofsoi| abeorotinnoystem (trenohea, ohambera. lemchfieN, oita. eto):
Infiltration Chamber Trenches
Local Upgrade Approva|.doc^rev.7/06 Application for Local Upgrade Approval, Page I of
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City/Townof � �����~������� ��� �����8 QU���������� � ������vaU
R����k�� ���� �� ��n.n�u8&~m�un~~. . u�u^ ����~~=.0 �w�=��"°~~~~~ Approval
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DEP has provided this form for Use bv
local Boards of Health. Other forms may be used, but the
iOfornnet|onmust besubstantially the
^sae asthat provided here. Before using this form, check with your
local Board ofHealth tVdetermine the form they use. �
�
Facility information (continued)
7. Design Flow per 31OCMR 15.203:
330
Design flow ofexisting system: upd
330
Design flow ofproposed upgraded system gpd
330
Design flow offacility: gpd
B. Proposed Upgrade of system
1. Proposed upgrade ie (check one):
Z Voluntary [I Required by order, letter, etc. (attach copy)
Fl Required following inspection pursuant to 310 CMR 15-301:
2. Describe the proposed upgrade tothe system:
Existing leaching facility and septic tank to be removed and replaced with 1500 gallon septic tank and
four infiltration trenches.
_
3. Local Upgrade Approval isrequested for (check all that epp|y):
Fl Reduction insetbook(s)—describe reductions:
` [� Reduction in SAS area ofuphz 25W ��mmuction
El Reduction inseparation between the SAS and high groundwater:
Separation reduction M
Percolation rate min/inch
Depth togroundwater �
*ppuoo*vnfor Local Upgrade Appmva\, Page 2of4
Lnoa\Upgrad*Approvo|.doc-mv.7/Vn
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Commonwealth of Massachusetts
City/Town of
Form 9A
- Application for Local Upgrade Approval
�
DEP has provided this form for use by |0co| Boards of Health. other forms may be used, but the ith your
information must besubstantially the same oethat provided here, Before using this form
o��c�w
local Board of Health to determine the form they use.
B. Proposed Upgrade of System \^".."'`"e./ �
F1 Relocation nfwater supply well (explain):
M Reduction of 12-inch separation between inlet and outlet tees and high groundwater
Z Use ofonly one deep hole inproposed disposal area
�l
Use ofasieve analysis as asubstitute for aperctest
--
Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
_per test within the proposed disposal system area.
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 to31OCMR 15.4Ob(1)(h)(1). The soil evaluator must be
member oragent ofthe local approving authority.
High groundwater evaluation determinjpd
Evaluator's Name(t��Oe or print) Sign 7ture
C. Explanation
Explain why full compliance, asdefined in31OCW1R15.404(1). ionot feasible. (Each section must be
completed)
1. Amupgraded system infull compliance with 318CK8R15DDDienot feasible:
Aconventional system was cona �na
considered but due to excessive fill being placed on the lot in the past the
site had limited area.
rSUen�to31O �N1� 1�28� t� 1�
2. An alternative system approvedpursuant ' ,288isnot feasible:
| Thwss\�system is in feasible and in compliance with the exception of only one test pit being excavated
! »Vithinuoeproposed leaching system and the perctest being
'a�nrnnedoutside nfthe proposed leaching
�yS �m� re
| � [ct*atcou|dnotbepe�ormodduntomnexcossiv ornountoffill. Second test pit could not be
�
performed due to proximity of
the existinghamage 3 of 4
Local Upgrade Appmva|.uuo~rev.//um Application_
'
Commonwealth of Massachusetts
C°v' "~~ ' Of
-omunA
— Application for Local Upgrade ApU
DEP has provided this form for use bylocal Boards of Health. Other forms may be used, but the
information must besubstantially the same as that provided here. Before using this form, a/eu^with your
local Board ofHealth k» determine the form they use.
C~ Explanation /coMtiDUBd\
3. A shared system is not feasible:
4. Connection hoapublic sewer|snot feasible:
Prohibitive cost. _
5. The Application for Local Upgrade Approval must be anoonnpeniwdbyall ofthe following (check the
appropriate boxes):
• Application for Disposal System Construction Permit
• Complete plans and specifications
• Site evaluation forms
- A\i8t��8&u��rB���otodbyr�dU��Uaetbochstopr|vatevvGterGVpp|yvvgUaVrp[opedvU
LJ nes.
Provide proof that a�ectedabu�erahave been notified pursuant to31O (�N1R1�.4O�/2>.
Other(List):
D. Certification
"| the foc|�yowner ma�Uyunder pena�Voflaw that this document and all a�oohmentsignificanttothe best cfrny
knowledge and belief, are true accurate, and complete. | em aware that there may be e;�noonu
consequences for
~ m|�ing -false information, including, but not limited to, penalties orfine and/or
imprisonment for deliberate vio|a8ons.^
Date
acility Owner's Sig
Print Nanne
J Asso, Ztes 731-17
Date
N �h R d|n
325K8ainSt "
Ma 1864
Telephone
Local Upgrade Appmva\duc^rev.70O Application for Local upgrade Approval* Page 4of4