HomeMy WebLinkAboutSeptic Full Repair - Local Upgrade Approvals - 53 MARIAN DRIVE 12/28/2021 e�IE D
Commonwealth of Massachusetts
City/Town of y OF NORT: -OVM.
Form 9A — Application for Local Upgrade Approval NT
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 CM 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 1. Facility Name and Address:
forms on the
computer,use John Motola
only the tab key Name
to move your
cursor-do not 53 Marian Drive
use the return Street Address
key. North Andover MA 01845
City/Town State Zip Code
m 2. Owner Name and Address (if different from above):
Same
Name Street Address
C ity/Town State
Zip Code Telephone Number
3. Type of Facility (check all that apply):
�Residential Institutional Commercial School
4. Describe Facility:
Existing 4 bedroom home
5. Type of Existing System:
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Application for Local Upgrade Approval' Page 1 of 5
Privy Cesspool(s) Conventional Other (describe below):
conventional tank with leach field
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
field
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: Unknown
gpd
Design flow of proposed upgraded 440 GPD
system gpd
Design flow of facility: gpdy
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 Unknown
CMR 15.31 date of inspection
2. Describe the proposed upgrade to the system:
Install new septic tank distribution box and leach field
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
ft.
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Percolation rate min./inch
Depth to groundwater
ft.
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: N1
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:
Ground was ton wPt to Perform a PPrrolatinn test at the time of-,nil Pvaltiation
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2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not
feasible:
C. Explanation (continued)
3. A shared system is not feasible:
Camp rnnrlitinnq on ad{macent propertmes
4. Connection to a public sewer is not feasible:
Nnt availahlp
5. The Application for Local Upgrade Approval must be accompanied by all of the
following (check the appropriate boxes):
NApplication for Disposal System Construction Permit
Zcomplete plans and specifications
✓Site evaluation forms
NOA list of abutters affected by reduced setbacks to private water supply
wells or p operty 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."
0, /&j,6'Z rZ/23/a/
Fac y wner's Sig ature Date
V���H
Print Name
Benjamin C. Osgood, Jr. 12/23/21
Name of Preparer Date
Date
13 Red Roof Lane Salem, NH 03079
Preparer's address City/Town
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State/ZIP Code Telephone
t5form9a.doc•rev.7/06
Application for Local Upgrade Approval• Page 5 of 5
