HomeMy WebLinkAboutForm 9A - Application for Local Upgrade Approval - Local Upgrade Approvals - 130 REA STREET 9/17/2019 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.
C. Explanation (continued)
3. A shared system is not feasible:
No area exists for a shared system
4. Connection to a public sewer is not feasible: WN�F Np�t1Nt�;`N�R
Sewer is too far away
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
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."
C t 9/16/19
Facil,09rownerpngnature Date
/?, wI L-- C
Print N me
Benjaminm C. Osgood, Jr. 9/16/19
Name of Preparer Date
157 Bluff STreet Salem
Preparers address City/Town
NH 03079 978-435-1324
State/ZIP Code Telephone
t5form9a•rev. 7/06 Application for Local Upgrade Approval- Page 4 of 4
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.
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 Code or 310 CMR 15.000.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address:
on the computer,
use only the tab Robert Woodcock
key to move your Name
cursor-do not 130 Rea Street
use the return Street Address
key.
North Andover MA 01845
raa City/Town State Zip Code
2. Owner Name and Address (if different from above):
Robert Woodcock
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 home
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
leach field
t5form9a•rev.7/06 Application for Local Upgrade Approval* Page 1 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.
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):
® 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:
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 2 --
ft.
Percolation rate >120
min./inch
Depth to groundwater 2
ft.
t5form9a•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(1)(h)(1). The soil evaluator must be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Erin Kirchner August 13, 2019
Evaluator's Name(type or print) Signature Date of evaluation
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:
No other area available on lot
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
An alternatiove system is proposed
t5form9a•rev.7/06 Application for Local Upgrade Approval*Page 3 of 4