HomeMy WebLinkAboutSoil Testing Results - 127 TUCKER FARM ROAD 5/16/2017 TOWN OF NORTH ANDOVER
i ', Coinin�unity & Ec�onoinie Development
\ �n', 1 HEALTH DEPARTMENT,0.0011
120 Mainn Street
NORTH ANDOVER, MASSACHUSE"1"T'S U1845
q a�k L 978.688.9540—Phone , .
978.688.9542--FAX
4
C V�--IO'11 (aa '� 'l{�4 w � x °- liealtlidept@northaiidovei-ina.gov
northandover•rna,gov
www.northandoverma,gov
APPLICATION FOR SOIL TESTS � f �; „
DATE:_ �� .. MAP PARCEL.: c; �� a
LOCATION OF SOIL TESTS: i z a.I — v" '-' t.:— e k-A
OWNER: t` t c:: ";. \._�may....._.t" � u°�►k -i .', Contact#:
APPLICANT: Contact#:
ADDRESS: ~z�.�. .:.�✓ r' t .r, ..t 'g ` w t _ � vb
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ENGINEER: 1_
rr _l_. Contact#
_
CERTIFIED SOIL EVALUATOR: CU` t t.
Intended Use of Land: Residential Subdivision Single Family IIonl., Commercial
- n
Is This: Repair Testing: V/ Undeveloped Lot Testing: Upgrade for Addition:
In the Lake Cochichewick Watershed? Yes No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
➢ Proof of land ownership(Tax bill,or letter from owner permitting test)
➢ 8.5".v 11"Plot plait&Location oLTestincj(please indicate test pit sites on the plat
> Fee of$585.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of$440.00 per lot for repairs or upgrades.
GENERAL INFORMATION
> Only Certified Soil Evaluators may perform deep hole inspections.
S> Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
➢ At least two deep holes and two percolation tests are required for each septic system disposal area.
➢ Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH
representative.
➢ Full payment will be required for all additional tests within two weeks of testing.
➢ Within 45 days of testing, a scaled plan(no smaller than 1"-100')shall be submitted to the Board of Health
showing the location of all tests(including aborted tests).
➢ Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
2„0,
N.A. Conservation Conunissiou A roval Dater
Signature of Conservation Agent. U4
Date back to Health Department: tan in):
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Commonwealth of Massachusetts
City/Town of RECEIVED
a :
Form 1 € tlSo-i o-itabillity Assessment for Cin-Site Sewage Disposal -117
A. Facility Information
S> - lit Baa
Owner Mame
L
Street Address Map/Lot#
City State Zip Code
B. Site Information
1. (Check one) El New Construction &Upgrade ❑ Repair
� --,c <= t
2. Soil Survey Available? Coes ❑ No If yes: _50., IS
#t
Source Soil Map Unit
Soil Name Soil Limitations
Geotogic/Parent Material Landform: --
3. Surficial Geological Report Available? ❑ Yes ❑ No If yes:
Year Published/Source Publication Scale Map Unit
4. Flood Rate Insurance Map
Above the 500-year flood boundary? -Yes ❑ No Within the 100-year flood boundary? ❑ Yes ❑ No
If Yes,continue to#5.
5. Within a velocity zone? ❑ Yes OLNO
6. Within a Mapped Wetland Area? ❑ Yes 4 .;�, "D MassGIS Wetland Data Layer:
Wetland Type
7. Current Water Resource Conditions (USGS): Range: E] AboveNormal F-1Normal ❑ Below Normal
Month/Year
8. Other references reviewed:
t5form11 •rev.8115 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8
Commonwealth of Massachusetts
CitylTown of
b 'its° sse,::�,-g ent for On-Site Sewage Disposal
C. On-Site Review (minimum of two holes required of every proposed primary and reserve disposal area)
Deep Observation �9oie Number: °`1 -_5j
Date Time Weather
1. Location .4 Z= c=-�4-4v-t
'_ -7 Z?
Ground Elevation at Surface of Hole: t om,` Latitude/Longitude: /
feet
Description of Location: _._._.. _ "Z ""i G�� _Z__ tr �.•J--�-- _ ? t �y_ sc_Z
2. Land UserZ_�,:-
(e,g.,woodland,agricultural field,vacant lot,etc.) Surface Stones(e.g.,cobbles,stones, boulders,etc.) Slope(%)
Vegetation �� Landform Position on Landscape(SU,SH,BS, FS,TS)
3. Distances from: Open Water Body Drainage Way i+=�C;�`k Wetlands t 'Vc�'
feet feet feet
Property Line _ Drinking Water Well Other _
feet feet feet
4. Parent Material: _ + ;_ ,�,5:%j Unsuitable Materials Present: Ayes ❑ No
If Yes: ❑ Disturbed Soil XFi11 Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
5. Groundwater Observed: ❑ Yes ( No If yes: a a ;I= �-j
Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater: 4= Vii` raj y -- �
inches elevation
t5form11 •rev.8115 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8
Commonwealth of Massachusetts
City/Town of {{' ��'aa¢¢JJ�qqw� ��pp �+ +o
til �"=C f�•w�. J! 4 A= ', 4'+ 'i.� �,L!� .. ? !!s —�CiiRw;ca+.+t- for 'Zr'ri,-&t'=.4'R.r S�LYT�Y?6'�tgyG IIsF.3�E�l
P ✓`t r u�^Pr..Q G 2 WS �i'v 4 l F.i Y 4
C. On-Site Review (continued)
Deep Observation Hole Number: .__.
Coarse Fragments �
tn.
Depth soil Horizon/Soil Matrix: Color- Soil Texture y
Volume Soil
P� { ) Redoximorphic Features %by
Structure Consistence Other
Layer Moist(Munsell) (USDA) Cobbles
Depth Calor Percent Gravel (Moist)
&Stones
S-0 't
Additional Notes:
41
t5form11 •rev. 8115 Form 11 —Soit Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8
Commonwealth of Massachusetts
C ity/Town of Disposal r�
�1 '`1 a– -� _ a•►_x`9 ..,. Ci: ,..E '• ' a w _-".moi rte;` ' =J'H %J L1 4..�'Sewage
^, On-Site Review (continued)
Deep Observation Note Number:
Date Time Weather — —
1. Location
Ground Elevation at Surface of Hole: Latitude/Longitude: 1
feet ----
2. Land Use
(e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones(e.g.,cobbles,stones,boulders,etc.) Slope(%)
Vegetation Landform Position on Landscape(SU,SH, BS,FS,
3. Distances from: Open Water Body Drainagee]p(��Well
---. Wetlands
feet -- '-� feet feet
Property Line :���Drinking WateOther _
feet feet
4. Parent Material: - Unsuitable Materials Present: ❑ Yes ❑ No
If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
5. Groundwater Observed: ❑ Yes ❑ No If yes:
Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater:
elevation
t5form1l •rev.8115 Form 11 –Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 3
Commonwealth of Massachusetts
City/Town of
q
Sewage DISPoSal
%Jr
C. On-Site Review (continued)
Deep Observation Hole Number:
Redoximorphic Features Coarse Fragments
Dcoth Soil Horizon/Soil Matrix: Color- TSoil Texture %by Volume Soil
L Soil Structure Consistence Other
. V�',
Syer 100iStlWnsell) (USDA) Cobbles
Depth Color Percent Gravel (Moist)
&Stones
Additional Notes-_______'_
t5form 11 •rev,8115 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8
Commonwealth of Massachusetts
City/Town of �g
I' � ..Y r -�-' .. �� � � ` � _ •J � ...•vC.�G.:�i'�41�7 �_� ..J � :T w'C:'���� ��� 'kf�3 ..�_�'�a ���'-�gG�.u�L ��v A'4..���a��
D. -Defarminatior, Of High Groundwater Elevation
1. Method Used: Obs. Hole# Obs. Hole#
❑ Depth observed standing water in observation hole
inches inches
❑ Depth weeping from side of observation hole
inches - ��---- --� inches
Depth to soil redoximorphic features (mottles) .5 v
inches inches
❑ Depth to adjusted seasonal high groundwater(Sh) _
(USGS methodology) inches ___ inches
Index L'Wel2 Number Reading Date
Sh = Sc—IS,X (OW,—OWmax)/OWrl
Obs. Hole# SC S, OW, Owl. OWf Sh
Obs. Hole# S, Sr OWC OKI. OW, Sh
E. Depth of pervious Material
1. Depth of Naturally Occurring Pervious Material
a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil
absorption system?
Yes ❑ No
b. If yes, at what depth was it observed? Upper boundary: Li V
pp y _.. .�J _ Lower boundary: �q�„
inches inches
c. If no, at what depth was impervious material observed? Upper boundary: _ Lower boundary:
inches inches
t5form11 •rev.8115 Form 11 W Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8
Commonwealth of Massachusetts
n - City/Town of
�'1 � . r 3 .f s? "a 4 �'! '� _ e ■pp F,:r w'r- — F c: _-§ .r1. s+�1 �wp� � �+
�. j�✓ - -'! o _ _ -� .._ .. :.C.-t...-'.9 y a .._� � .. _:3�C.::..� ° �` ;� S` ';,,)rL✓ 4.5 s3a -t t��a s..d$`�w"�sa.19
r: Bot-rd of. Health fitness
�-�-L�Li✓ �,�� +�.a� � ?cam a-{�. >J R���.
Name of Board of Health Witness Board of Health
. �c=I � ��a ®r Ce�iii�a ��IN
I
CC-:1:!f',/ tha; I ars Cu rentiy approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil
& ?uations and that the above analysis rias been performed by I"ne consistent with the required training, expertise and experience
descr;_.cl ;: 310 CARR 15.017. 1 fu,-the,--erti`,that the results of; v si evaluation, as indicated in the attached Soil Evaluation Form,
are accurate and in accordance with 310 CMR 15.100 through 15.107.
4 r-
Signature o€Soil Evalu'at o Date ----
--- �L
Typed or Printed Name of Soil Evaluator/License# Expiration Date of License
Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and
to the designer and the property owner with Percolation Test Form 12.
t5form11 -rev.8115 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal -Page 7 of 8
Commonwealith of Massachusetts
City/Town of
WW
Field Diagrams
Use this sheet for field diagrams:
>
IL
t5form 11 •rev.8/15
Form 11 —soil Suitability Assessment for On-Site Sewage Disposal •Page 8 of 8
Commonwealth of Massachusetts
City/Town of
Fora 9A - Application for Local Upgrade Approval
DEP has provided this farm 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.
Systern 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 th 3 ed
capacity of an on-site system constructed in accordance with either the 1978 Code or
A. Facility Information
Important:When TOWN OF NORTH ANDOVER
filling out forms 1, Facility Name and Address:
HEALfH DEPARTMENT
on the computer,
use only the tab 'I�ti ?
key to move your Name
cursor-do not
use the return .___ ....._—.Z�.__.t_s��...�,,:._�� t--_+-
key. Street Address
lb Q10
City[Town State Zip Code
2. Owner Name and Address (if different from above):
rer n l (cam - t -_ .;_ - .
Name �C- Street Address
Cityfl own State
03-1 ek
Zip Code Telephone Number
3. Type of Facility (check all that apply):
Residential ❑ Institutional [l Commercial School
4. Describe Facility:
L -31. 36--1._c::_
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) conventional [] Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
t5form9a rev. 7/06 Application for Local Upgrade Approval, Page 1 of 4
Commonwealth of Massachusetts
r� City/Town of
Farb 9A Application for Focal 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: ----_-
gpd
Design flow of proposed upgraded system ---._-�—
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)
Requi,ed following inspection pursuant to 310 CMR 15.301: - 3.
date of inspection
2. Describe the proposed upgrade to the system:
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 f Bio reductor
Reduction in separation between the SAS and high groundwater:
Separation reductions
Percolation rate
min./inch
Depth to groundwater – - -- --__.
ft.
t5form9a•rev.7106 Application for Local Upgrade Approval, Page 2 of 4
Commonwealt[i of Massachusetts
City/Town of
Form 9A - Application for Local Upgrade pgrade 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 waler 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
cKUse 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
ode: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 to cal approving authority.
High groundwater evaluation determine by:
€7a�
Evaluator's Name(type or print) Si nature �...m__
9 IDate of eval tion
C. Explanation
Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be
compin'�ed)
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:
t5form9a-rev. 7106 Application for Local Upgrade Approval, Page 3 of 4
Commonwealth of rinassachusetts
--- _r City/Town of
- ' Fore 9A - Application for Local Upgrade Approval
p
DBP has provided this form for use by local hoards 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:
4. Connection to a public sewer is not feasible:
5. The App;ication for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
,pplic.tion for Dispcs€ti System Construction Permit
Complete plans and specifications
1�1Site 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 _
"l, 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. l 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 O er's Si -u Date
cr-
Print Name
17
Name of Prepare€ Date
LS
Preparer's address City/Town �
State/ZIP Code Telephone
t6form9a•rev. 7/06
Application for Local Upgrade Approval* Page 4 of 4