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HomeMy WebLinkAboutLocal Upgrade Approval Form 9A - 9.21.2018 - Local Upgrade Approvals - 50 SAW MILL ROAD 9/13/2019 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 1978 C V 5.000. A. Facility Information SEP 2 12018 Important: When filling out 1. Facility Name and Address: TOWN OF NORTH ANDOVER forms on the Mark and Heather LaRosa HEALTH DEPARTMENT computer,use only the tab key Name to move your 50 Sawmill Road cursor-do not Street Address use theretum North Andover 01845 key. MA City/Town State Zip Code VQ 2. Owner Name and Address(if different from above): (Same as above) Name Street Address City/Town State Zip Code Telephone Number 3. Type of Facility (check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: 4 Bedroom single family house 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Leaching field (pipe and stone system) t5form9a.doc•rev.7/06 Application for Local Upgrade pg Approval*Page 1 of 4 If Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval M 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: 440 Design flow of existing system: gpd 440 Design flow of proposed upgraded system gpd 440 Design flow of facility: gpd B. Proposed Upgrade of System 1. Proposed upgrade is(check one): ® 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: Add new 1, 500 gallon conc. septic tank, new H-20 rated concrete d-box, and leaching field (pipe stone system) 3. Local Upgrade Approval is requested for(check all that apply): ® Reduction in setback(s)—describe reductions: Reduction in setback from foundation to septic tank (10 feet required 6 . 8 feet proposed) ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction © Reduction in separation between the SAS and high groundwater: 1 Separation reduction ft 20 Percolation rate min./inch 3 feet proposed Depth to groundwater ft t5form9a.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) ❑ 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 ❑ 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 )(h)(1). Tfte soil evaluator must be a member or agent of the local approving authority, High groundwater evaluation determined by: John D. Sullivan III 7-12-2018 Evaluator's Name(type or print) Signature y' Date of evaluation 4,V 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 system as designed will allow a gravity system without a pump. The groundwater separation reduction allows a gravity system- - -atherwise a pump system would he required - A I -,r) we are within wetland buffers and this will reduce grading. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: An alternative system is not needed. The system as designed will meet public health needs . t5form9a.doc•rev.7106 Application for Local Upgrade Approval*Page 3 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. C. Explanation (continued) 3. A shared system is not feasible: Other system in the neighborhood have similar site conditions . 4. Connection to a public sewer is not feasible: No Public sewer is available 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes).- FA 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 1, 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." M /1-- 9-19-18 Facility owner's Signature Date Mark LaRosa Print Name Jack Sullivan, PE 9-19-18 Name of Preparer Date PO Box 2004 Woburn Preparer's address Citylrown MA 01888 781-854-8644 State/ZIP Code Telephone t5form9a.doc•rev.7/06 Application for Local Upgrade Approval*Page 4 of 4 0-4 NORTh,y V V 00 w 1 ' 9 • � . Town of North Andover HEALTH DEPARTMENT s1CMU5f CHECK#:B58 DATE: 9_ /8 LOCATION: -0 H/O NAME: ka,Ac,S q CONTRACTOR NAME: So I11 VCLO Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $_ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector 1 $ ❑ Title 5 Report O 11 $ 1 Other:(Indicate) $ �O- i Health Agent Initials White-Applicant Yellow-Health Pink- Treasurer