HomeMy WebLinkAbout- Local Upgrade Approvals - 1015 FOREST STREET 2/13/2019 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.
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 197
Code or 310 CMR 16.000.
nrr
A. Facility Information
Important,When filling out y
1 Facility Name and Address:
forms on the
computer,use Steve Cunha
only the tab key Name
to mono your
cursor-do not 1015 Forest Street
c
use the return Street Address
key. North Andover MA 01845
CityfTown State Zip Code
r� 2. Owner Name and Address (if different from above):
rcnan
Name Street Address
city/Town State
Zip Code Telephone Number
3. Type of Facility (check all that apply):
X Residential Institutional Commercial School
4. Describe Facility:
4 Bedroom Single Family House
i
5. Type of Existing System:
I
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Privy Cesspool(s) Conventional Other (describe below):
Conventional - 1,000 Gallon Septic Tank, D-box, Pit
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1
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Leaching Pits (3 Total)
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A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: 440
gpd
Design flow of proposed upgraded 440
system gpd
440
Design flow of facility: gpd
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
X 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 1,500 Gallon Conc. apticTana H2O rated root rt-box infiltrators
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
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2. An alternative system approved pursuant to 310 CNIR 15.283 to 15.288 is not
feasible:
The remamoder of the upgraded sVstem is fully complaint with Title 5. An alternative system not
C. Explanation (continued)
3. A shared system is not feasible:
Surrounding septic systems re only sized for the des'gn flows they presenfly rec6vp.
4. Connection to a public sewer is not feasible:
IRIffifir qpwpr 6 not available in this area
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 there may be significant consequences for submitting false information, including,
but not limited to, penalties or fine and/or imprisonment for deliberate violations."
z� 12-11-18
Facility Own is Signature Date
Steve Cunha
Print Name
John D. Sullivan 111, PE 12-11-18
Name of Preparer Date
Date
25 Clover Circle Reading, MA
Preparers address CitylTown
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01167 7
State/ZIP Code Telephone
1
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