HomeMy WebLinkAboutSeptic Plan Submittal Form - Receipt - 469 BOSTON STREET 7/3/2019 TOWN OF NORTH ANDOVER
Community& Economic Development
HEALTH DEPARTMENT
120 Main Street 40
NORTH ANDOVER,MASSACHUSETTS 01845
978.688.9540—Phone
978.688.9542—FAX
E-MAIL:healthdept@northandoverma.gov
WEBSITE:b=://www.northandovenna.gov
SEPTIC PLAN SUBMITTAL
FORM
Date of Submission: 7
Site Location: l�6
Engineer: ilan,/Y')2.S
c
New Plans? Yes $275/Plan Check# (includes lst submission and one re-
review only)
REGE�v�D
Revised Plans?Yes /$125/Plan Check# 7-0
Site Evaluation Forms Included? Yes No
.1pWN�p�\pEPPRtMEN
Local Upgrade Form Included? Yes No
Telephone#: 9 7 ��'/ - ��a`S Fax#:
E-mail:
Homeowner
Name:
OFFICE USE ONLY
When the s9bmqsion is complete (including check):
➢ Date stamp plans and letter
➢ Complete and attach Receipt
➢ - Copy File; Forward to Consultant
➢ Enter on Log Sheet and Database
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(1)
® Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
Conduct one test hole in proposed disposal area - LOCAL UPGRADE APPROVAL
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)(i)(1). The soil evaluator must be a member
or agent of the local approving authority.
High groundwater evaluation determined by:
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:
CURRENT TEST DATA FOR SITE, PROPOSED SYSTEM GOING IN SAME LOCATION NOT
FEASIBLE TO CONDUCT ADD. TESTING
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
REPLACING CURRENT ALT. SYSTEM WITH TRADITIONAL SYSTEM
3. A shared system is not feasible: U
19
n/a 0
- H
4. Connection to a public sewer is not feasible:
n/a
upgrade form.doc•rev. 5/02 Application for Local Upgrade Approval* Page 3 of 4
O``MORTN
? 1y V 6 r/ V
O �
FO • •` ,••• Lp
Town of North Andover +
HEALTH DEPARTMENT
CHU
CHECK #: -,/p d DATE: 7-3 - ,20i9
LOCATION: y� 9 S O 34
i
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
A
❑ 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 fQ.-svd• $
Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
H'e4fth Agent Initials
White-Applicant Yellow-Health Pink-Treasurer