HomeMy WebLinkAboutForm 9A - LUA - Local Upgrade Approvals - 160 CARLTON LANE 6/20/2019 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.
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 t xlsting approved
capacity of an on-site system constructed in accordance with either the 197 CMR 15.000.
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A. Facility Information SUN
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Important:When oFNo�0M�l
filling out forms 1. Facility Name and Address.-
on the computer,
use only the tab Darren Winnie
key to move your Name
cursor-do not 160 Carlton Lane
use the return
key. Street Address
North Andover MA 01845
r� City/Town State Zip Code
2. Owner Name and Address (if different from above):
etum
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:
Single family 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):
Trenches
t5form9a(2)•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:
Proposed installation of a new 1,500 gallon septic tank and two (2) 69.5' leaching trenches.
3. Local Upgrade Approval is requested for(check all that apply):
® Reduction in setback(s)—describe reductions:
Due to site constraints, we are requesting a reduction from the required 20' setback from a leaching
facility to a foundation to 16.9'.
❑ 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.
Percolation rate min./inch
Depth to groundwater ft
t5form9a(2)•rev.7/06 Application for Local Upgrade Approval, Page 2 of 4
Commonwealth of Massachusetts
f
City/Town of North Andover
Form 9A - Application for Local Upgrade Approval
wM 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:
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:
Due to a limited area between the property line and foundation, a reduction in the required setback to
one is necessary. We've designed the system as narrowly as possible.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
t5form9a(2)•rev.7/06 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
M
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 surrounding homes have the capacit to support this dwelling as well.
4. Connection to a public sewer is not feasible:
There is no public sewer available nearby.
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."
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Facility Owne 's ignature Date
Darren Winnie
Print Name
Thorsen Akerley 6/12/19
Name of Preparer Date
189 North Main Street North Andover
Preparer's address City/Town
01845 _ (978) 539-8088
State/ZIP Code Telephone
t5form9a(2)•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4