HomeMy WebLinkAboutForm 9A - Application for Local Upgrade Approval - Local Upgrade Approvals - 469 BOSTON STREET 6/6/2019 Massachusetts Department of Environmental Pro,tectio,n
Bureau of Resource Protection, —Wastewater Management Program
Form 9A — Application for Local Upgrade Approval
Required by 310 CMR 15.403(1)
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
s,e�ptic system,with a deslig n flow of less tha n 10 1 000 g pd, where full compliance, as def i ned in 310 CM R
5.40,4(1), is not feasible.
System upgrades that cannot be per formedin accordance with 310 CM R 15.404 and 15.405, or in to
compliance with the requirements of 310 CMR 15.0100, require a variance pursuant to 310 CIVIR 15-410
through 15.417.
NOTE* Local upgradle 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 d sign flow above the existing approved
capacity of a septic system constructed in accordance with either the 1978 Code or 310 CM R 15.0100.
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A., FacHity, Information Kh'
Import anit.,When If
filling out forms 1. Facility Name and Address
on the computer,
use only thile tab, Matthew Quinlan T0VV1',,,1,OF 1`10
................ ........................... .......
key to move your Name
cursor-do,not 469 Boston Street
use the return
key'. ............ ............. .......... ............ ............... ...............
North Andover MA 01845
....
..........City State Zip Code
Wf W
2. Owner Name and Address"
Same
...............Name Street Address
City State
Zip Telephone Number
3. Type of Facility (check all that apply):
d.
Residential Institutional M: Commercial School
4. Describe Facility:
Single Fam Dwellin ........
g
5. Type of Existing System,-
El Privy 0 Gesspool(s) Conventional Other(describe below):
6. Type of soil absorption, system (trenches, charmblers, lean' field,1 pits, etch.
.......... ................... .................. ...... ..............
upgrade foirm.doc rev. 5/02 Application for Locall Upgrade Approvalle Page 1 of 4
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Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Wastewater Management Program
Form 9A Application for Local Upgrade Approval
Required by 310 CMR 15.403(l)
A. Facility Information ation (continued)
. Design Flow per 310 CMR 1 . 3:
440
Design flow of existing system: ..�..... ...... ...,� _„N,,�
gpd
440
Design flow of proposed upgraded systemgpd
440
., w..
Design flow of facility gp
B. Proposed Upgrade of System
1. Proposed upgrade is Deck one):
® Voluntary El required by order, letter, etc. (attach copy)
[:1 Required following inspection pursuant to 310 CMR 1 .30 : date of inspection
.' Describe the proposed upgrade to the system:
Construct new soil absorp for system
3, Local Upgrade Approval is requested for:
El Reduction in setbacks —describe reductions:
❑ Percolation rate for 30 to BOO min./inch: min./inch
❑ Reduction in SAS area of up to %p SAS size,sq.ft. %r duetion y��
❑ Reduction in separation between the SAS and high groundwater:
Separation reductiont.
Percolation rate .......
...N..
min./inch
Depth to groundwater
El Relocation of water supply well (explain):
upgrade for .doe•rear.5/02 Application for Local Upgrade Approvals 'age 2 of
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Massachusetts Department of Environmental Protection
Bureau of resource Protection —Wastewater Management Program
Form 9A � Application for Local Approval
Required by 310 CMr . l
Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
Conduct one test Bole in proposed disposal 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, are Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 1 . 0 1 i 1 . The soil evaluator must be a member
r agent of the local approvingauthority.
High groundwater evaluation determined by:
Evaluator's Name(type or print) signature N.m.._..� Date of evaluation
C. Explanation
Explain why full compliance, as defined in 310 C MR 1 . 01 , is not feasible. (Each section rust be
completed
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
cost prohibitive
. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
cost prohibitive
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3. A shared system is not feasible:
na
. Connection to a public sewer is not fusible:
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upgrade form.dee rear.5/02 Application for Local Upgrade Approval* Page 3 of
Massachusetts a air me of Environmental Protection
Bureau of Resource Protection —Wastewater Management ent Program
Form 9A ---, Application for local Upgrade Approval
Required y 310 e R 15.403(1)
. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
0 Application for Disposal System Construction Permit
Complete plans and specifications
J Site evaluation forms
F] A list of abutters affected by reduced setbacks to private water supply ells or property lines.
Provide proof that effected abutters have been notified pursuant to 310 CM R 15.4 o .
El Other(List):
D. certification
1
} the facility owner, certify under penalty of lave 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."
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Facility weer Signature �v ... Date
fir+ r
Print Name
James Kavanaugh 619
Name of Preparer ...mn. Date V..
14 Shad Hill Drive
_ . N. Leading
Preparer's address Cityrrown
MA 0166 9 -66 - 926
State/ZIP Telephone
NOTE: 19 CMR 1 . 9 requires the system owner to provide a copy of the local upgrade
approval to the appropriate Regional office of the Departrnent of E nv1ronr entaI Protection, Bureau of
Resource a Protection, Division of Watershed Management, upon issuance by the local approving
authority and before commencement of construction.
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