HomeMy WebLinkAboutLUA - Local Upgrade Approvals - 83 ACADEMY ROAD 2/2/2026 Commonwealth of Massachusetts
City/owe of
Form 9A Application for Local Upgrade Approval
Af DES' has provided this form for use by local Boards of Health.. Other forms, may be used, but the
�� information must he substantial) the same as that provided here. Before using this form check with our
y � y
local Board of health to determine the form they use.
Form 9A is to he 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 CIVI
1 5.4041 , is not feasible.
System upgrades that cannot he performed in accordance with 310 CI IR 15.404 and 15.405, or in full
compliance with the requirements of 310 CIVIR 15.000, require a variance pursuant to 310 CIVIR 15.410
through 15.415.
NOTE.- local upgrade approval shall not he 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 flora above the existing approved
capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CIVIR 15-000.
A. Facility Information Town of Nofth Andover
Important:
When filling out 1. Facility Name and Address:
fore s on the Kathy Stevens FEB 17 2026
computer,use
only the tab key Name
to move your 83 Academy Road
cursor-do not _...___._....___.__.._..__..__..__.____.e......_...__._. ._..._..._..__ _._._ ...............,_____...__..___
use the return Street Address
---- . .It '__D_6paft1ment--
key. North vet MA
_.._..._ _ _. .._._._. .__....._....__..._....__.._..._._._.__ .__.W.___. ___._ _.......__.._______.. .. _...._._......................._ __..___..__..____._ ._.__._._._._____ __.._.__._.__ .__._.._.__...............__._____.............____.___.....
City/Town State Zip Code
2. Omer lame and Address if different from above):
same
r . ._._.._.. .. _.________.._____.___.__.__._._.__.___. _._._.._._......._._..__._....___._....._.. _........__._.__.._. _.__ ..... .. _ ...._...._..___.. .... _._..__..._.__... _
__....._.......�..w_.w. __....__.._.._.._..___._..__..___..._.._..
Street Address
.. _... __........
City/Town/Tc�v rr .. _-._._______ . _........._....._..m_....._. ._. ....__. _. _...__. _.___....___..._..._.. .___.._....____.. .__._____._... .. .w_... _.. . _._.._.______.___._...__-__.__.__.____.._-___-___..___.._.______.__..____.. _
State
._. __....__........... ...... _, _._.. .. .w. .......v._..... __. _..._... _....._... µ....._. _...__..._...._..__. .._.._.__.. ...___...___.. ..._._._.__._..___.._,__._..___. _.__..._ _..
Zip Code Telephone Number
3. Type of Facility (check all that apply)-
KI
Residential Institutional El Commercial D School
4. Describe Facility-
single family
Type of Existing System:
Privy Cesspool(s) Conventional El Other(describe below).-
unknown
6. Type of soil absorption system (trenches, Chambers, leach field, pits, etc),
a
t5f arm9a.doc-rev.7/06 Application for Local upgrade Approvalo Page I of 4
Commonwealth of Massachusetts
City/Town of
■
Form 9 - Application Local Upgrade novel
ro Z'
, - - DEFT has provided this form for use by local Boards of Health. Other forms may be used but the
information roust 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. 3:
Design flaw of existing stem: pd
7
Design flaw of proposed upgraded system pd 770
Design flow of facility: pd
B., Proposed Upgrade of System
1. Proposed upgrade is (check once):
Voluntary required by order, letter, etc. (attach copy)
Required following inspection pursuant to 310 CMR 15.3 1- _. - i�r�f__._.__.._..._.�pect___ca n _.
ate .1,
11,
2. Describe the proposed upgrade to the system-
new system-
new tank, dbx and aes field
3. Local Upgrade Approval is requested for(chock all that apply)-
El
Reduction in setback(s) describe reductions.
Reduction in SAS area of up to 25�'f�: SASW,I .q. _._�_._._.._.. . °41rr
Deduction in separation between the SAS and high groundwater:
Separation reduction _-__.__ _____ _._____.._...._... __......._.._..... __._.... ._._._.__ _.____...._____ ___..............._.........
ft
Percolationrate __.... ......_._... _.. �.._...._�. ..._.._.._.w__ ___._
miry./inch
Depth to groundwater
t5form9a.doc.rev.7/ 6 Application for Local Upgrade Approval Page 2 of 4
Commonwealth of Massachusetts
__....._.__...._. ..._... City own of
Form 9A Application for Locale 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)
El Relocation of water supply well (explain)-
.
Reduction of 12-inch separation between inlet and outlet tees and high groundwater
El Use of only one deep hole in proposed disposal area
91 Use of a sieve analysis as a substitute for a perc test
El Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
C ode-
...._. .._. 1,)A WAIVER IS REQUESTED STE TO ALLOW THE SYSTEM TO BE DESIGNED N ACCORDANCE
WITH THE AE S PE E SBY DESIGN MANUAL(TRANSMITTAL#X255470 )SECTION 4.22 TO ALLOW
_.__.._....__m.....M.__REDUCTION FROM GROUNDWATER OClNDWATEI FROM C 4 FT TO 2 FT. _._....__... ..___.
2. RELIEF F IS REQUESTED FROM LOCAL REGULATION DESCRIBED E D IN PAGES 6 OF TIDE.:N.A.
LOCAL REGULATIONS TO ALLOW A SYSTEM BE DESIGNED WITHIN 100 FT OF A BVW(56 FEET
--PROPOSED).
If the proposed upgrade involves a reduction in the required separation between the bottom of the wail
absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 C MR 15.405(1)(h)(1). The soil evaluators must be a
member or agent of the local approving ovin authority.
ity.
High groundwater evaluation determined by:
_..___.........
Evaluator's flame(type or print) Signature Date of evaluation
C. Explanation
Explain why full compliance, as defined in 310 C R 15. C 4(1), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
aes pesby proposed
t5form9a.doc.rev.7/06 Application for Local Upgrade Approval* Page 3 of 4
CommonwealthMassachusetts
City/Town of
tv
W:-.�:. ........... Form 9A Applacation for Local Upgr 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:
n/a
4. connection to a public serer is not feasible:
no sewer n front of street
5. The Application for Local Upgrade Approval mint 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 c R 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."
Facility Owners Signature Date
_............... .............. - _.w.__w_.._ _.._...._ _.......m.. _.. _.. ....__... ... ._... _.........
Print Name
Name of Preparer Date
56 Beacon St Andover
.._ .._.. ...- _._ _ _.___.. _. ___ ------_ .. ._ _.___._.-..
Preparer's addressCity/Town
----------------- ....... 9'7"8--655-08185-1--.�1--l�.,-----"-,-�................................ .........................
State/ZIP Cade Telephone
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4