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Building Permit #Exception - 14 WINDKIST FARM ROAD 5/1/2018 (3)
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received I Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION, . Print PROPERTY OWNER - � S r Old SttucturePrintw 10Yeayes _ � MAP NO: PARCEL-: ZONING DISTRICT:1��i Historic District yes - _ Machine Sho a Villa a yes p g n TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building U-bne family Addition [I Two or more family ❑ Industrial 11 Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ DemolitionElOther a. _ El-Ho'o' d ❑wetlands ❑ Watershed District epticWell Iain p aterksewer DESCRIPTION OF WRK TO BE,PERFORMED,l 6 x C.✓� v Identification JVlease Ty"r Print Clearly) OWNER: Name: �� �'S Phone: 7 Address: _ Phone: CONTRACTOR Name:_ N N Address: 5'—6� �3��/ Exp. Date: Supervisor's Construction License: � �- -- Home Improvement License:., a �t Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 3� 6" , ( FEE: $ ----- Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner _Signature of contractor n Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ .TYPE-OF::SEWERAGEDiSPOSAL Public Sewer Tanning/MassageBodyArt ❑ Swimming Pools ❑ Well ❑. Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc... ❑ - . _.Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED- DATE.APP _OVED PLANNING & DEVELOPMENT El 3 !3 G COMMENTS 0 0 .CONSERVATION Reviewed on #--,, �3 —Sinature i COMMENTS � \ �l v'� HEALTH Reviewed oni nature Si n COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water.& Sewer Connection/si nature Date Driveway Permit _ DPW Toiv;2 Engineer: Signature: Located 384 Osgood Street FIRE-DEPA T-ME**NT =Temp Dumpster on site Yes no , 6cated-at 124 Mair, Street Fire Department signature/date COMMENTS REFERENCES 1. Definitive Subdivision Plan recorded as Plan #12957, E.N.D.R.D.. + NOTES 1. PURPOSE: The purpose of this plan is to show the location for the Proposed Pool & Pool House shown in relation to zoning offset requirements. Offset dimensions shown shall not be used to mark g0.B4' lot lines, structures or any other features. Drainage 2. LOT LINES: Lot lines shown were derived from Easement reference 1, and not from the results of a property survey obtained by this office. The proposed 10.0' Proposed Q.0''\ structure locations have been provided by client's representative. Existing utilities have not been Poo determined or identified by this office. 35.0' Proposed 3. ZONING: The property shown is located in the 2 ZO' Shed p��k / OrQ Residential "R-2" Zoning District. ` S2' under Deck) ` �• X14. , / OF ./v D / Lot 17 DAVID BAY I J. Lot De BAY N 124 \ 1.00E ACRE / o No 33887 1L LAl1O � \ L=148.81 N Drainage R 265.00' o Easement \ n 0 126 Q1. Windkist Form Rood Proposed o Plot Plan 7� 0 2s 00• Scale: 1"=50' Date: Aug. 26, 2013 �- 14 Windkist Farms Road North Andover, Mass. Prepared for: Mike Pasco CORNERSTONE, Land Consultants,, Inc. Civil Engineering•Land Surveying•Land Planning t 61 Main Street • P.O. Box 657 • Pepperell,MA 01463•478-433-8100 Job No. 13-122 Dwg. No.9288 ' v y Commonwealth of Massachusetts RECEIYU N . Title 5 Official Inspection Form FEB 2 2013 Subsurface Sewage Disposal System Form - Not for Voluntary Assessment TOWN OF NORTH ANDOVER 14 Windkist Farm road HEALTH DEPARTMENT Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DiVincenzo use the return Name of Inspector key. Stewart Septic Service r� Company Name 58 South Kimball Company Address r Bradford Ma 01835 City/Town State Zip Code 978-372-7471 S113386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ deeds Furthe Evaluation `y the Local Approving Authority ' i t - 1( z�� — q i� ice ec ilgnat,re Date system inspector shall sub i copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Windkist Farm road Property Address --- - Elaina Bean Owner Owner's Name information atiis every North Anodover required for eve ma 01886 2/2/13 page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name --- information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Windkist Farm road Property Address Elaina Bean _ Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Windkist Farm.road _ Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 1 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Windkist Farm road M Property Address Elaina Bean Owner Owner's Name information is North Anodover ma 01886 2/2/13 required for every — page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 — Number of bedrooms (actual): 4-- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 541 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 e Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name -— information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 128 GPD Detail: Water meter readings. Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: — - - — Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Windkist Farm road . Property Address ---- Elaina Bean Owner Owner's Name required for is every North Anodover required for eve ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: -- Date Other(describe below): General Information Pumping Records: Source of information: Stewarts Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity Site guage on truck q y pumped determined? _ Reason for pumping: Inspect tank T Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 10 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: --- — years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 14 Windkist Farm road Property Address — — Elaina Bean Owner Owner's Name -- - informationis North Anodover required uired fofor every ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle -14" How were dimensions determined? Tape measure, Sluge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in good shape, no leakage, liguid levels good. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: - Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'w 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name information is North Anodover ma 01886 2/2/13 required for every page. CihdTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Commentsnote if box is level and distribution to outlets equal, ( any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No leakage, no ponding, no solids, carryover egual dist. Replaced cover raised D-Box wit concrete rizer. 6"from top. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-22x41 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding, no hydraulic failure soil conditions good. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth–top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Windkist Farm road _ Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions -- - Depth of solids --------- - ----- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 .� Commonwealth of Massachusetts G a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �N 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: June 5th 1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: pulled file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Ground water taken from plans drawn by chtistinsor and Serji system raised 4'over ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 P ` Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Windkist Farm road Property Address Elaina Bean Owner Owner's Name information is required for every North Anodover ma 01886 2/2/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Y ) p lete d ❑ System Information— Estimated depth to high groundwater P 9 9 ter ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 of- 3/...•K COMMONWEALTH OF MASSACHUSETTS JD EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_ 14 Aj»pK15T f:Wq l ap 00 R.T14 AN 00o c 2 1. Owner's Name: ZFoSEp14 12 IT Awl EIV Owner's Address: i'1 _S c 2T\-1 /�tiP 0, ( a Al PA Date of Inspection: (ol aO�c�i Name of Inspector:(please print)_ 13 e n�a m w C 0 (ro o A) Z-tL Company Name: e"— J=-7.m ,jo (sAN L-r' �N& R _ Mailing Address:: Iao 3e'�c low zu oc> _n2we N - AAjNa jet nyi)q Telephone Number: 3-7s- to Q 1-7b8 CERTIFICATION STATEMENT I certify that I have personally inspected.the sewage disposal system at this address and that the information.reported below:is true,accurate and complete as of the time of the inspection.The inspection was performed based on my train uag and qperieaucein the proper.function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000 The system: _ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: C Date: The system inspector shall submit a copy of this in ion report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies fto- buyef,l ap icable,and the approving authority. BOARD OF HEALTH Notes and Comments JUL 11 2001 ""This report only describes conditions at the time of inspection and anile'a&—e con it o sof use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PROPERTY ADDRESS:114 Windkist Farm Rd North Andover,MA Y FAam RLp OWNER Joseph L'Italien pnj E 2, M R DATE OF INSPECTION: 6/20/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: __�Zl have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: r B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,'as approved by the Board of -ealth,'will pass. Answer yes, or not deteimined'(Y,N,ND)in the for the following statements. of determined"please explain. The septic tank is and over 20 years old*or the septic tank( er metal or not)is structurally unsound,exhibits substantia filtration or exfiltration or tank failure is' inert.System will pass inspection if the existing tank is replaced with a plying septic tank as approved by a Board of Health. *A metal septic tank will pass in. if it is structurally soun of leaking and if a Certificate of Compliance indicating that the tank is less than 20 y s old is available. ND explain: Observation of sewage backup or break ou static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or even di ution box.System will pass inspection if(with approval of Board of Health): brok pipe(s)are replaced o ction is removed istribution box is leveled or replaced ND explain: The system requ' pumping more than 4 times a year due to broken or obstructed s).The system will pass inspection if(wi approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: • e Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 'ROPERTY ADDRESS:114 Windkist Farm Rd CERTIFICATION(continued) North Andover,MA OWNER Joseph L'Italien DATE OF INSPECTION: 6/20/01 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fait' g to protect public health,safety or the environment. I. Syst will pass unless Board of Health determines in accordance with 3 CMR 15.303(1)(b)that the system of functioning in a manner which will protect public health, fety and the environment: �r _ Cesspool rivy is within 50 feet of a surface water _ Cesspool or vy is within 50 feet of a bordering vegetated w land or a salt marsh 2. System will Adlunless the Board o ealth(an blic Water Supplier; an determines that the PP if Y) system is functioning in a manner that pr is a public health,safety and environment: _ The system has a septictic tank and tion em(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ce wat upply. _ The system-has a septic tank d SAS and the SAS within a Zone 1 of a public Water supply. The system has a septic and SAS and the SAS is wi 50 feet of a private water supply well. The system has a tic tank and SAS and the SAS is less than feet but 50 feet or more from a private water supply ell**.Method used to determine distance IIS **This system ses if the well water analysis,performed at a DEP certified ratory,for coliform bacteria and latile organic compounds indicates that the well is free from poll ' n from that facility and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, rovided that no other failure teria are triggered.A copy of the analysis must be attached to this form. Other: Page 4 of 11 `",K d. eA .r.. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 'ROPERTY ADDRESS:114 Windkist Farm Rd ' North Andover,MA ^ OWNER Joseph L'Italien DATE OF INSPECTION: 6/20/01 �S T D. System Failure Criteria applicable to all systems: You must indicate`yes"or`no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ,. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ✓ ,Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓_,.Any: portion of cesspool or privy is within 100 feet of a.surface water supply or tributary to a surface water supply. _✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. v- Any.-portion of a cesspool or privy is within 50 feet of a private water supply well. –, Any-portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water „supply well with no acceptable water quality analysis. [This system passes if the well water analysis, pgrSormed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds JdiFates that the well is free from pollution from that facility and the presence.of ammonia ogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other,faffare criteria fare triggered.A copy of the analysis must be attached to this form.] V–(YeslNo)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gPd You must indicate either "or`no"to each of the following: (lhe following criteria apply a systems in addition to the crit . above) yes no — _ the system is within 400 feet of a s g water supply the system is within 200 feet o butary to a ce drinking water supply the system is locat ' a nitrogen sensitive area(Interim ead Protection Area–IWPA)or a mapped Zone 11 of a p c water supply well If you have an Bred"yes"to any question in Section E the system is considered a s ificant threat,or answered "yes"in ion D above the large system has failed.The owner or operator of any large em considered a sign' cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 'ROPERTY ADDRESS:114 Windkist Farm Rd North Andover,MA OWNER Joseph L'Italien DATE OF INSPECTION: 6/20/01 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? •' Has the system received normal flows in the previous two week period? /Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the:system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? ✓_ Were the septic tank manholesuncovered,opened,and the interior of the tank inspected for the condition of the baffles br tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ Existing information.For example,a plan at the Board of Health. / _ ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of I I }< OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ;. . . . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C PROPERTY ADDRESS:114 Windkist Farm Rd SYSTEM INFORMATION North Andover,MA s OWNER Joseph L'Italien DATE OF INSPECTION: 6/20/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 1i Does residence have a garbage grinder(yes or no): y Is laundry on a separate sewage system(yes or no):hLo [if yes separate inspection required] Laundry system inspected(yes or no): -- Seasonal use:(yes or no): 00 Water meter readings,if available(last 2 years usage(gpd)): — Sump pump(yes or no):QL Last date of occupancy: 4 ,,r r c rT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): god Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: FE& b fL /vi A 2G 1-t Zov t Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1q.91 Pet As- I;u(t-1 Were sewage odors detected when arriving at the site(yes or no):Q[) Page 7 of 11 _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PROPERTY ADDRESS:114 Windkist Farm Rd North Andover,MA OWNER Joseph L'Italien — DATE OF INSPECTION: 6/20/01 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron -,/4'0 PVC_other(explain): Distance from rivate wa p ter supply well or suction fine: N A Comments(on condition of joints,venting,evidence of leakage,etc.): P�Pe Loo KS M Ow k t,, cK E tjT" « SEPTIC TANK:_(locate on site plan) Depth below grade:15 Material of construction: ✓concrete_metal_fiberglass_polyethylene _other(explain) ._ If tank is;metal list ager_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 15,6 o 6*' k�N s Sludge depth: l" Distance from top of sludge to bottom of outlet tee or baffle: 3�_ Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: a' Distance from;bottom of scum to bottom of outlet tee or baffle: ►4 How were dimensions determined: M g jqs o ra s Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TF}M X I N &M 0 D c o tJ T�, 5G M Ll Q P Uc rr c=S �A- Gr-0 0 D C D N 0,1)3(0. (LCC C)AA FJU n I N 1-0L L4'Q O N 6 F- 1z NS(FSL5 TC) L� GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping- Comments umpingComments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels, as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 '�C. �ry Y•. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C F SYSTEM INFORMATION(continued) PROPERTY ADDRESS:114 windkist Farm Rd North Andover,MA OWNER Joseph L'Italien DATE OF INSPECTION: 6/20/01 TIGHT or HOLDING TANK: NA (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: Qallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on sitelan P ) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): &X: f►J &00Q Cc7N"0k-"0A1, PUMP CHAMBER:Nn (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): ' ' •rut; Page 9 of 11 ' �a r{ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS :. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ - PART C eVSTEM INFORMATION(continued) PROPERTY ADDRESS:114 Windldst Farm Rd North Andover,MA OWNER Joseph L'Italien DATE OF INSPECTION: 6/20/01 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Type �< leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative./alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): bf- f'Q-Q I-on V-5 /U g 2AA A I CESSPOOLS: N�- (cesspool must be pumped as part of inspectionxiocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:Al A- (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): v Page 10 of 11 ' t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PROPERTY ADDRESS:114 Windkist Farm Rd North Andover,MA OWNER Joseph L'Italien DATE OF INSPECTION: 6/20/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. t;. A Town of North Andover, Massachusetts Form No.2 MORTq BOARD OF HEALTH -I 3? O O � A IQ DESIGN APPROVAL FOR ss,c""5`` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. Site Location l i Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Y em,Permit No. J Fee Slte Syst _ Town of North Andover t °RTM OFFICE OF 3�0`s a o tiO L COMMUNITY DEVELOPMENT AND SERVICES ° 30 School Street `. 9 aF North Andover,Massachusetts 01845 WILLIAM J. SCOTT SSACHUSE Director June 19, 1997 Christiansen & Sergi 160 Summer Street Haverhill, MA 01830 RE: Lot 18 Windkist Farms Road Dear Phil: This letter is to inform you that the proposed septic plans for Lot 18 Windkist Farm Road have been approved. _ If you have any questions, please do not hesitate to call the Board of Health office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator M. Wm. Scott, Dir. CD&S L.File Bill Barrett fYr-1q RVA7..T0V 68R_9�'3f I-A►_� 059R-954? PT ANNMCT ARR-9535 . x Town of North Andover, Massachusetts Form Nos NORTH BOARD OF HEALTH 3 .• - o� }J7L 19 Arn `. • � off..«�,::...- . # •��,,.o �'`� DISPOSAL WORKS CONSTRUCTION PERMITAcmUS n Applicant �iGL JigLlyE/� s _ NAME ADDRESS TELEPHONE Site Location i Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee 7.S-" D.W.C. No. _ • 1 r: p e.. • APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 1-- 17 CURRENT INSTALLER'S LICENSE# LOCATION: f LICENSED INSTALLM. / ` w SIGNATURE: TELEPHONE# jy = 79Go2 CHECK ONE: REPAIR: NEW CONSTRUCTION: IF,NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only w $75.00 Fee Attached? Yes No Foundation_ As-Built? Yes / No ` Approval _ /�, Date: 9/0//,F,7 r Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH November -4.8--19 97 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X) or repaired ( ) by Bill Sawyer INSTALLER at Lot 18 Windkist, North . Andover, MA 01845 SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 951 dated June 9 , 1997 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BO RD OF HEALTH ENGINEER b TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System(xj constructed; ( )repaired; by - _ Pte` located at was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# ,dated ,with an approved design flow of yyy .gallons per day. The materials used were in conformance with those specified on the roved - _. . sP approved plan;the system was installed in accordance with the provisions of 310 CMR 15.000,Title 5 and — -" " - - local regulations, and the final grading agrees substantially with the approved plan. All work is -accurately represented on the As-built which has been submitted to the Board of Health. _ Installer. x7Lic. #: Date:3 16-"c Design Engineer: _ -�� __ Date: l l 1 - SOIL EVALUATOR FORM FORM 1 f : - Page 1 of 3 Date: No. Commonwealth of Massachusetts lq�,q Massachusetts Sewa a Dis osal Soil Suitabili Assessment or On-site Date: j49 1J.-13J . 7 Performed By: ... . .... .......CA e1c............... Witnessed By: Colo n%al (S�ll�� ��� • �Yms o�t�s Na.. _ {., �uon Address Or �1�d Nl-5-t �d-W.lnd Id_7 y /41"Iy ,��� . aost� sr � � TeicP�� �o• �nd��u, �9 0/�� ✓end s�-�-, 1� ow construction [2 Repair ❑ Office Review Published Soil Suryey Available: No Yes ❑ Publication Scale f �Stp. O Soil Map Unit H _........._......... Year Published • ��� Soil Limitations .- .- ........................................ ...... Drainage Class Well - Surf'icial Geologic Report Available: No Yes ❑ Year Published Publication Scale • Unit ................................................................ Geologic Material (Map ....................... ... ................ LandformYGZn4.(!.1 ........................................... Flood Insurance Rate Map: ❑Yes Above 500 vear flood boundary No �-�/ ❑ Within 500 year flood boundary No u Tes Within 100 year flood boundary No es ❑ ... ......... Wetland Area: Inventory ma unit) ...................... ............ .............. National Wetland ................................................. Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Normal 11 Normal ❑Bel`../ Normal ❑ Other References Reviewed- DEP EP APPROVED FORM•12107/95 FORM 11 - SOIL EVALUATOR FORM r . Page Z,of 3 Location Address or Lot No./aOM'Jtl� r-4,fm On-site Review Deep Hole Number 19'7/ Date: S /3/i?7 Time: �o Weather Location (identify on site plan) 00 S Slope Surface Stones(%) ���� . Land Use ..W�,Dd n Vegetation (u , Pi�� ball J /jap i As p Landform - Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Weil feet Other - DEEP OBSERVATION HOLE '—OG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones. BouldeBoulders, Consistency, °N0 to -tri' m y root 7 C3� F 5.L, to\l� Mo Canmrn r0° ti ivt:iiypKupubEL AREA / 1 \ Parent Material.(geologic) DepthtoBedrock: 7 )P/l/�21 /� 1i Weeping from Pit Face: 7U Depth to Groundwater: Standing Water in the Hole: Estimated Seasonal High Ground Water: DEP APPROVED FORA)•12107/95 jr FORM 11 - SOIL L� ALL.A 1 Ux rUf-1» Pa-e 3 of 3 Location Address or Lot No. f TP /8- t Determination for Seasonal bio* Water �`adle Method Used'. ,J Depth observed standing in observation hole inches of observation hole inches Depth weeping i �n from sid Depth to soil mottles /Sinches Ground water adjustment - feet Reading Date Index well level index Well Number ..... g .. . . Adjustment factor .... Adjusted ground water level Deoth of Naturally Occurrino Pervious Material Does at least four feet of naturally occurring-pervious material exist in all areas observed throughout the area proposed for the soil absorption system? J If not, what is the depth of naturally occurring pervious material? .,rfiCat1O - / I certify that on �'� �`� (date) I have passed the a°a� evaluator h that above an lysis approved by the Department of Environmental Protection was performed by me consistent with the required training, expertise and experienc: described in 310 CMR x.017. L� 7 � Date � , /�i �gnat re — DEP APPRONT-D FORA- 12107195 FORM 11 - SOIL EVALUATOR FORM Page Z.Of 3 Location Address or Lot leo%,�lr'1��IS rG . UG On-site Review Deep Hole Number ._a Date: /s _J l7 Time: c? ,'60 Weather Location (identify on site plan) Land Use . lips: Slope (%) 8'/J� Surface Stones Vegetation (/�f.pi�e) f>Q � Mr. j rTse&I'J Landform . Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE _OG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones. G avlel�rs, Consistency, 0/0' l� L l0 Y� �/6 . yo a,s U) roods HOLES [EQUIRED AT EVERY t L REA l� n r� �� _ DepthtoBedrock:� Parent Material-(geologic) 93 �� A Death to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM-12107/95 Ir DORM 11 - SOIL PURIM Pale 3 of 3 Location Address or Lot No. -TP If'�- Determination "or Seasonal .high Water Table Method Used: Depth observed standing in observation hole inches I i Deptn weeping from side of observation hole inches Depth to soil mottles inches Ground water adjustment - feet index Well Number Reading Date ................ Index well level Adjusted around water level Adjustment actor ..._ .... 1 Deoth of Naturally Occurring Pervious Material Does at least four feet of naturallosedcforithe ng-pervious absorption ptionmaterial system. observed throughout the area prod in all areas If not, what is the depth of naturally occurring pervious material? �ortiflCatlCn I certify that on (date) I have passed the soil n and that the above an lysi 1 ental Protection ,. nt o A approved by the Dep artme � A was performed by me consiss1�t with the required training, expertise and xp. ri..n.,. desc ibed in 310 CMR , Date Signature DEP APPROVED FORA- 1:!07195 X fr Page 2 of 3 Location Address or Lot No. J� �/�'►�� � 7P 1g--3 On-site Review / P m• Deep Hole Number l7-IJ'3 Date: �/ 3j Time: Weather Location (identify on site plan) Land Use ... Slope (%) ffl/s Surface Stones /?U Vegetation W.- Ae, , Oaks Landform - Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE -OG� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches( (USDA) (Munsell( Mottling (Structure, Stones Gravlel�rs. Consistency, 0- 7 S.L . //0 Y��L fJpAsd NJ m� r 7 lb �drn „ t t t ii • r t t ';7 !�a �/,/1� 1 � DeptMoBedrock: Parent Material (geologic) Depth to Groundwater: Standing Water in the Hole: • Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED F0R1\1-12/07195 Pa2u 3 of 3 Location .4ddress or Lot No. Tloterminalion For Seasonal 'i�h �i%ater Fable Method Used'. Depth observed standing iion hole inches n observat i I peatn weeping from sid observation hole inches Depth to soil mottles inches urounc water adjustment _........ .. ... feet Reading Date ..... ...... Index well level I index Well Number _ ...... 9 ...... Adjustment `actor Ad1justed ground water level _ Beath o' Naturally Occurring °envious Material Does at least four feet of naturally occurring pervious material exist in all area observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? ^aniiilcati�i^ I certify +hat on %��� ` (date) I have passed the soil evaluator examinatio n -Hent of environmental Protection and that the above anaiy i aporeved by the Depart, o a ex erose and experienc was aerformed by me consistent with the r.,auir.,d framing, p r� "10 CMR 1 :;.017. Date �%•.:� i� 7 �,Ianature' DET,APPROVED FORM- FORM 12 - PERCOLATION TEST Location Address or Lot No. %� �rY►aP� r� r,.r COMMONWEALTH OF MASSACHUSETTS NOV'. ]nAt4-;"`1Massachusetts Percolation Test* Date: .. "l 13/ 47 Time:, Observation Hole # P tg _1 P 18'_4 PU—Z Depth of Perc �' ��r g Start Pre-soak q� End Pre-soak Time at 12" f f , S Time at 9" �,�7 1 3 Time at 6" Time (9"-6") Rate Min./Inch x /I M 11�1 11-4 r6L;1eY_ * Minimum of 1 percolation test must bo performed ed in both the primary area AND reserve area. Site Passed Er Site Failed ❑ ` NYIJ7� &_nj-e_-YI...................................................................................................................................... ........_......._. Performed By: i0k/t-j2 Witnessed By: CS"dyq .�1�f� /�'U,nGl�-r Comments: ...:,:::::.:.:::.:::::::.::::::::::::::.:::.::.::::::::.:,:..::::::.::.::.::.::.::::::: ::::.:::::::::::::.:::.:::::::.::::...:.:..:_:::::::.:::. DEP APPROVED FORM-12/07/95 PITS MIN 440 LEACHING MIN 1 (13 'x16 ' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x ##) (2x(L+W)xD x ##) (G/ft2 ) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE . 005 BED/TRENCH (Bed max. 60 ' X 60 ' ) MIN 13 ' X 16 ' PIT BOT + SIDE X LOAD = TOTAL (L x W x ##) (2 x (L+W)xD x ##) (G/ft2) FIELDS r � MIN 440 GPD 900 ft2 BED GW MIN 4 ' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4-�4" PEA STONE? 4---' DIST LINE SLOPE .005? >3 'COVER-VENT — SCH 40 C--' MIN 12" COVER RATE ( 4-/ X , � ) X = TOTAL L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY Spm L W D Vol . DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME Spm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. l ' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP . SWITCH ENUF STORAGE? TDH WEIGHTED? Copyright © 1996 by S.L. Starr FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: ��iG'ILLi 14 2�, LZdV LZ G Phone -LOCATION: Assessor's Map Number Ile % Parcel Subdivision Lot(s) _ 1. Street St. Number ************************O ficial Use Only************************ RECOMMENDATIO S OF GENTS: Date Approved Conservation Administrator Data Rejected Comments s Date Approved 10Town Planner Date Rejected Comments C C21� Date Approved Food Inspector ---Health Date Rejected Date Approved Septic Inspector-Health Date Rejected Comments Public Works - sewer/water connectionsi - driveway permit /r7 re Department Jtl/le Received by Building Inspector Date f I1�lVFD"r /EVATIOMS Ig8. 16, ---- I u . h-BOX = I q 7.4,Z aOx117-q4, - -- ►�uc�T 19 7.4 Z. - 19 7,qN l97.4y , Eur C�,tt� _ ►q 7.4 3 • ' 197, 17 , 1 14-7, 17 147,17 i , 2'$o I � 43,So0-S& 4 11JV, �vN� c hotTae•'A / 27,3 , 32.) Tmy X11 SEPTI G TAkOC - F f' { AS BUILT PLAN c OF ' SUBSURFACE DISPOSAL SYSTEM LOCATE( IN -NQRTH AwwvE; , MA, AS PREPARED FOR COLO W I AL Y�11.AGE Dt-�r �.M E1�rT" GofLP, DATE: hlovsm BE2 lo, 1 qq'7 !. SCALE:._ LST' IS 1.,1i �ov�ST c�eM (2O1� ! s- MERRIMACK ENGINEERING SER VICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 IvinrTir�s'iO�S t....�-=1V_ ......... .....-- - +-.x._3.7,y.3_.. . .. __- . .. = 1:870.17 . 1.9 1, 17 ..117,1-7 I _ Z�2 $ g3,S60 � r �a = zoo -I (,�AC►{iuG, �EC.?� � o � Fla,.Ca>z.._ .i . .,� � B . 4..5- 2, Z7,3.' 3s'. CD Z-_Bo_x_.. ... ; 3G.G sz,Z TSE ,G' 1 ,9 (;D' -ray 3 5- lSce Gtat yl' S PTiG TAUW_ L=ILI 85.81 ' AS- B U ILT. P OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN AS PREPARED FORM; DIVEL DT?MF_J. 7r CARP j DATE: Nav>=raf3E.2__ to, 1 aq-7 07' 10 1-111`DEI S7 FA-OH MERRIMACK E'NGINEE'RING SER VICE'S 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 19 7.4,z 12 i�tt,ET tr�ttE = l R 7,41 - - - __ t�7�yy T7,43 43 t ?7. 17 11-7, 17 qp, ' 147,17 �2,20 Z 3,Seo 0 IL4 r BOD6. VIE, 9.7rKH.._c-Tt. 49,Z' Z7,3 , Trm N 1 GeaC / SFTTI C TAUK AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN __Nofzri. ANDovf I ,_ mK. AS PREPARED FOR G�1..oti►lAt�_v�U.,A,G� DE�ELo.�M�uT" Go2P. DATE: Naysm ae,'e- ►a, t qq'7 SCALE: __t "=Z_o' 1L. "_" IB 1,11LIDLIS7 FA2M RO&O MERRIMACK ENGINEERING SER VICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810