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Home My WebLink AboutForm 9A - Local Upgrade Approvals - 597 FOSTER STREET 10/26/2020 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 Code oihR 15.000. A. Facility Information 6 d�1 Important:When ��PN jo filling out forms 1. Facility Name and Address: OFNOEpNS on the computer, use only the tab Ms. Jod_y_Bradstreet key to move your Name cursor-do not 597 Foster Street _ use the return - - -------- key. Street Address North Andover MA. 0 � City/Town State Zipp Code 2. Owner Name and Address(if different from above): Street Address CiVl5wn U � State _ `�--7-7 Zip Code Telephone Number 3. Type of Facility(check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: 3 Bedroom Residence 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 Bed t5form9a.doc•rev.7106 Application for Local Upgrade Approval* Page 1 of 4 A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: 9P33d0 Design flow of proposed upgraded system 330 gpd 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: For Sale of Property date of inspection 2. Describe the proposed upgrade to the system: Gravity Leaching Bed 3. Local Upgrade Approval is requested for(check all that apply): Reduction in setback(s)—describe reductions: El 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'to 4' Percolation rate min./inch Depth to groundwater n B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 2 of 4 - _ .. _ �?•.� y. .r�:may., t. t 1 10/23/2020 CCF10222020_00000.jpg Commonwealth of Massachusetts CityfTown 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 sotl evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by:A Michael O'Neill P.E. �, , May 21,2020 Evaluator's Name(type or print) signattue ` ' Date of evaluatton 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: Restricted area to place system due soil conditions,wetlands, property lines and existing house. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: Restricted area to place system due soil conditions,wetlands, property lines and existing house. t5form9a.doc rev.7/06 Application for Local Upgrade Approval,Page 3 of 4 https://mail.google.com/mail/u/0/?pli=1#sent/FMfcgxwKjBLSxbdjhLmghBWQvGwLbklZ?projector=1&messagePartld=0.1 1/1 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: This is a single family residential neighborhood on individual lots. 4. Connection to a public sewer is not feasible: No Public Sewer. 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." l WnT-btra46hw,�- e Date � Print Name Thad Berry .E. 10.21.2020 Name of Preparer Date 18 Oak Street Reading, MA. Preparer's address City/Town 01867 978-500-8419 State/ZIP Code Telephone t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4