Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Building Permit #Exception - 51 WELLINGTON WAY 5/1/2018
BUILDING PERMIT �� •'� •_� :• �� TOWN OF NORTH ANDOVER 1 . p APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 44racH s Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION S1 �i (t"I�4'�'o�.J• :tai �y , L a PROPERTY OWNER ! -R\on)`� iAlul3�ftTY, r _. ' PPint MAP NO: / C PARCEL: 8`7 ZONI1IG'DISTRICT* . ". Historic District. -.Yes ;d? Aachine°Sfiop•VillagA 'yes_. TYPE OF IMPROVEMENT PROPOSED USE Residential Non-Residential 2 New Building n One family ❑Addition ❑Two or more family ❑ Industrial ri Alteration No. of units: ❑Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑Demolition J4 Other C Septic (2 Well ❑Floodplain bVellknds�" q,'VVatd • d:Pi 'qdt.A• 'E C Water/Sewer z�� u n vn a sW irn o� 0 � cer e Identitiication Please Type or Print Clearly) OWNER: Name: /)oaMZ ld�i belk Phone: °l 79 V117- 2 72_y Address: CONTRACTOR Name: •Phone: iJi la�1 wP�A-I�l pcsr�\s 1 r,c• `" !�.�,. ��" 'a Address: i L Supervisor's Constructibrf•License: 'Exp. AaW4 Home Improvement'License: . .3 'E)C "b�fe ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.512.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $_~7 8 o . Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund i na urp of Agent/"Qwner i nature of n c The Commonwealth ofMassachusetts ?R1`tf Department of Indushlal Accidents Offwe of Invadgadons 1 Congress Stree4 Suite 100 Boston,MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers Annlicant Information Please Print Lea,blv Name(Businesslorganiutiodlndividud):__E n�J mon,,,—,4s A VoA S Address: 2� Ci /State/Zi : ,�- 2s1k2 Phone#: 7 S Z Sts Are you an employer?Check the appropriate box: 1.al am a employer with `25— 4. (] I am a general contractor and I Type of project(required): employees(full atrd/orpsrt-time). * have hired the sub-contractors 6. M New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These subcontractors have 8. (]Demolition working for mein any capacity. employees and have workers' 9. 0 Building addition �o Av-o insurance. �d.] ��� 5. ❑ Weeaare a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance requfird]t c. 152,§1(4),and we have no employees.[No workers' 13.[1 Other Sw a-` comp,insuranCe require •My applicant that who box 01 must also fill out the section below showing their workers'compensation policy information. t 13omeawners who submit this affidavit indicating they arc doing all work and then hire outside canftctm must submit a new affidavit indicating such. :Contmctara that check rhie cmc must auschod an additional sheet showing the name of the Ors and date whether or not those entities have � employees. If the subvontnictom have employees,they must provide their workers'comp.policy number. I anrarrxnrrployer dhatispraviding workers'compemation insurance for my employees Below is thepolky and job site information. `\ �{ c Insurance Company Name: 1 G•s 14 � A.-,���� -.,.J —x--,Yr. 1,21 A Policy#or Self-ins.Lic.#: W ub Z 2 19 Z Expiration Date:_ 6r//V / /7- Job Site Address: City/Sta!&Zip: Attach a copy of the workers'compensation policy declaration page(showing the poliicy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do h cerdfy under the pow WeexaMw o-tpeam that the in ormation provided above is true and correct Si Date T� 20/ Mae#: Ofyl W use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issning Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: DATE(MMIDDNYYY) AC40R O CERTIFICATE OF LIABILITY INSURANCE 5/12/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT Service Team PRODUCER NAME_.. - AIMS Insurance Inc.Managers,Pro ramPHONE (602)635-4848 - FAX (480)991-0634 Program _[A/C No,Ext);._.... —•..- -- -- _ .. ;_(_AIC-No); 1418 N Scottsdale Rd - E-MAIL serviceteam@aimsinsurance.com Suite 100 _ __ INSURERS)AFFORDING COVERAGE_— _ _• -.. NAIL 0 Scottsdale AZ 85257 INSURER A:Hart ford Accident and Indemnity 22357 _— INSURED INSURERB:Twin City Fire Insurance Comeany_ {29459 Environmental Pools, .Inc. INSURER C: 184R Riverneck Road INSURER E: I Chelmsford MA 01824 1 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS_SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR' ADDL SU9R— _ POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ' POLICY NUMBER I MMiDD/YYYY IMM/ODIYYYY LIMITS j COMMERCIAL GENERAL LIABILITY - I EACH OCCURRENCE $ _ 1,000,000 I DAM,4GE TO RENTED 300,000 A CLAIMS-MADE X ';OCCUR PREML$E$.(Ea occurrence)- i$ _ 59UENOJ2180 j 5/24/20161 5/14/2017 ED EXP(Arty one person) $ 5,000 1---- PERSONAL 8 ADV INJURY '.$ 1,000,000 I GEN-L AGGREGATE LIMIT APPLIES PER: j ` 'GENERAL AGGREGATE I$__ 2,000,000 f--- R X POLICY. I PRP LOC ! ' L—. 2,000,000 i PEC I PRODUCTS-COMP/OP AGG _$ I 1 OTHER: I $ I COMBINED SINGLE UMI AUTOMOBILE LIABILITYEa accident - $_..... I ' : _ )---'---- - I`r_--ANY AUTO '. - BODILY INJURY(Per person) $ l ALL OWNED .SCHEDULED BODILY INJURY(Per accident) $ AUTOS HIRED _�.'NON-OWNED PROPERTY DAMAGE j$ —— L—P _'AUTOS I Per accident)_-,... __ ___—_,_..._ i '$ UMBRELLA UAB OCCUR j i EACH OCCURRENCE EXCESS LIAB CLAIMS-MADEf: i i ' L AGGREGATE _ S __-__ ___ RETENTION S $ r WORKERS COMPENSATIONj i X I PER OTH- AND EMPLOYERS'LIABILITY Y/N i _._.:.STATU-TEERi ANY PROPRIETORtPARTNER/EXECUTIVE —' ! 1 + - 'E._L.EA_C_H_A_C_CID_E_NT_____+S__ , •1,000,000_ OFFICER/MEMBER EXCLUDED? N/A ' B I(Mandatory in NH) 59WEOJ2162 5/14/2016 i 5/14/2017 I E.L.DISEASE-EA EMPLOYEE_$ 1".000,000 If yes,describe under PERATIONS below j I i E.L.DISEASE-POLICY LIMIT i$ 1,000,000 DESCRIPTION OF'OPERATIONS ! I � I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) This certificate is only a representation of coverage afforded by the insurance companies noted on it. Terms of coverage are defined in the policies(ies] shown and those terms may or may not comply with the requirements of any contract entered into by the named insured. II i CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood St. ACCORDANCE WITH THE POLICY PROVISIONS. Building 20, Suite 2035 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Kimberly Birk/JSZUMI ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) Office of Consumer Affairs and Business Regulation 10 Park Plaza.- Suite 5170 Boston, Massachl''setts 02116 Home Improvement ContrActor Registration - - Registration: 107083 _ Type: Private Corporation - Expiration: 7/29/2018 Tr# 419291 ENVIRONMENTAL POOLS INC. Andrew Everleigh 184R Riverneck Road Chelmsford, MA 01824 --" '—� Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA 1 C 2OM-05/11 /e C�A!!!•71101Kth'Q!1/r G/(��crzrrc/rrilelb Office of Consumer Affairs&Business Regulation License or registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: •107083 Type: Office of Consumer Affairs and Business Regulation :,Y7ir� I #8 Private Corporation, 10 Park Plaza-Suite 5170 Expiration:_ f x = Boston,MA 02116 ENVIRONMENTAL PO«E5 INC ;'s Andrew Everleigh 184R Rivemeck Road ; Chelmsford,MA 01824 Undersecretary Not valid without signs I I I I I i a37 � ?o 0 i I i I OPEN SPACE B ' � SITE PLAN N zP 0 20' 41Y - . SCALE:i"=21Y c9 LIMIT OF 1w BUFFER ZONE _ WeuW07-M WAY \� 2'WIDE X 60•LONG Lacus / 149' rQ:t HIND TRENCHES Nod "D4fOX j .�`77q'" ` tttBERVE N/F emaloND WREe} C^``` AREA6T TOWN OF NORTH ANDOVER LOCUS MAP \ \ 1 NOT TO SCALE 126-- ASSESSORS REPERE� \�`` EXSR IN08809.F: ` \ MAP 105C,PARCEL 87 OUT INFILTRATION \ \\ Br 1 // \. AREA 1 �N.H.E.S.AREA / �,_�,7 ♦ ` LL LLLLLI ' ♦ PROPOSED FENCE TO BE SELF -LLLLLLLLat LLL ft - MEET ALEING&SEL CLOSING To L __,33\\\\ \ LL LLL �� - \\ 11 - 1500GALLON _, \ \ \_ L PROPOSED -L� SEPTIC TANK -- 74?\ \ \ LLL 4D'X24' LL`- \ \ O LL PoOL Lu 1 1D LLL LOT 4 LL l - LLL AREA=9.9.048 S.F. \ LLLL. IJP \ BOULDER BENCHMARK: \ \ \ \ LLLL LLL _ -13p- RETAINING l"T CUTSfgKE IN 24'PINE \ \\ ; 7 L I_ WALL ELEVATION�143.3D' \ (NAND 1888) PROPOSED 28D S.F. \\ \ \ \ INFILTRATION ARFA• DECK -134 x-\ \ BOTTOM ELEV.=134.0 1 EXISTING LOT HousE#s1 TOP FND.+144.1' 1 GAS SERVICE ! S EDGE OF 1 I, UNDERORrU D a DRIVEWAY _ \ UTILITY SERVICES j PAVEMENT `• a"1—,o• ` WATER SERVICE LOT 5 SITE PLAN iw•�a I D p\ FOR PROPOSED SWIMMING PO( AT 51 WELLINGTON WAY(LOT F °°•�F2\ IN WELLINGTON NORTH ANDOVER, MASS, WAY \ DATE MARCH 18,2017 L a \ PROFESSIONAL ENGINEERS 8 LAND Su 19•W CHRISTIANSEN& SERG/, 780 SUMMER ST.HAVERHILL,MA 01830 VNNW.CS C TEL 978-373-0310 FAX 978372-3980 COPYF DWG i i PUBLIC HEALTH DEPARTMENT Town of North Andover 1 Community and Economic Development Division 1 CERTIFICATE OF COMPLIANCE 11 As of: /9/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Construction of an On-Site Sewage Disposal System By: Dave Maynard At: 51 Wellington Way Map 105C Lot 87 North Andover, MA 01845 The Issu ee of this c c shall not be construed as a guarantee that the system will function satisfactorily. Br' n La rasse Public Health Director 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov RECEIVED Nov 0 3 2016 air �v^ TOWN OF NORTH ANDOVER TM MMTMIENT 1 PUBLIC HEALTH DEPARTMENT (ommunity Development Division TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM-INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System .constructed;( )repaired; By: ffl I`$y A/I-K0 Co k 57-,q J c.-7-7 (Print Name) Located at: ELI.ll-,l G nc� to, (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated and last revised on 61,20 ,with a design flow of gallons per day. The materials used were in conformance with those specified on the 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. Bottom of Bed Inspection Date: Engineer Representative(Signature) And—Print Name Final Construction Inspection Date:41Z/ �/So FgWer Representative(Signature) And—Print Name Installe (Signature) Date:..../Q �r And—Print Name Enginee Signature) Date: //;' ? � And—Print Name 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.northandoverma.gov i North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 51 Wellington Way (lot 4) MAP: 105C LOT: 87 INSTALLER: Dave Maynard DESIGNER: Christiansen & Sergi PLAN DATE: 1/8/16, Rev. 6/8/16 BOH APPROVAL DATE ON PLAN: 6/22/16 INSPECTIONS TANK INSPECTION: 9/9/16 (6" base only inspection) DATE OF BED BOTTOM INSPECTION: 9/9/16 (B.LaGrasse) DATE OF FINAL CONSTRUCTION INSPE TI N: 9/15/16 DATE OF FINAL GRADE INSPECTION: ��� SITE CONDITIONS ® Contractor reports any changes to design plan N/A Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: Moved building sewer outlet pipe to rear corner of the house closer to the septic tank (IR) SEPTIC TANK ® Building sewer in continuous grade, on compacted firm base See note® Cleanouts per plan X Bottom of tank hole has 6" stone base ❑ Weep hole plugged X 1500 gallon tank has been installed H-10 loading X Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port f (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ?' ❑ Hydraulic cement around inlet & outlet Comments: located 33'6" off corner of house, building sewer moved outlet to northwest corner of foundation (B.L.) Cleanout located on inside of house, bend about 6 feet from foundation (IR) ,DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box N/A Inlet tee (if pumped or>0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution N/A Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: SOIL ABSORPTION SYSTEM (General) X Bottom of SAS excavated down to C soil layer, as provided on plan X Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan N/A 40 Mil HDPE barrier installed N/A Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/concrete /timber/ block) ❑ Final cover as per plan Comments: field measured approximately 93' off corner of house, bed is 60x20 i i I i FINAL GRADE Loamed Seeded Cover per plan Comments: DOCUMENTS NEEDED E" /' Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer EV As-Built Plan BM = 128.05 HR = 4.62 HI = 132.67 SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT 0.77 131.55 131.55 Septic Tank IN 1.60 130.72 130.76 Septic Tank OUT 1.79 130.53 130.51 Distribution Box IN 9.05 123.27 123.23 Distribution Box OUT 9.22 123.10 123.06 Lateral 1 TOP 9.27 / 9.52 Lateral 1 INVERT 123.05 / 122.80 123.05 / 122.80 Lateral 2 TOP 9.27 / 9.52 Lateral 2 INVERT 123.05 / 122.80 123.05 / 122.80 Top of Chamber Bottom of Bed/Chamber 120.80 120.80 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh,Inland/Coastal Bank3 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot.Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10(5) 20(10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws �. GED, Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALTH z � Permit No North Andover BHP-2016-0275---- ---------------P.1. FEE it 4 F.I. $350.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Dave_Maynard----___ _______________________________ to(Construct)an Individual Sewage Disposal System. at No 51 WELLINGTON WAY as shown on the application for Disposal Works Construction Permit No. BHP-2016-02 September 08,2016 t ----------------------------------------------------------------- Issued On: Sep-08-2016 BOARD OF HEALTH I • � �: • Application for Septic Disposal System 1 � TODAY'S DATE Construction Permit — TOWN OF C0. -Full Repair NORTH ANDOVER, MA 01845 .00-Component Important: Application is.hereby made fora permit to: When filling out FrConstruct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your E] Repair or replace an existing system component—What? cursor-do not use the return A. Facility Information key. S� IA2 r<�•+�J �^'� - Address or Lot# � City/Town RECEIVE D 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump Enravity(choose one) SEP 0 8 20 ***If pump system, attach copy of electrical permit to application*** ➢ Hnonventional System (pipe and stone system) TOWN OF NORTH ANDOVER ➢ ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy,of your certification to install this ' I!°�F� �A'4NDOVE . MENT ➢ ❑ Pressure Distribution S.A.S.(No D-Box) ❑ Pressure Dosed(D-Box Present)S.A.S. ➢: ❑.Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info,needed) NO=(installer must specify brand of filter before DWC issuance) Whatis.theMake? - Wha t is the Model? 2. Owner Information Name/1. Address(if different fro above) _e® ity/Town State Zip Code ti ;? Ema address Telephone Number 3. Installer Information -/ f �'-'� fvtf.�"` C �-�/ K-c✓ �.c t e sem- �Q Name �J Name of 06mpany 22- vw Address l City/Town State Zip Code Telephone,Number(Cell Phone#if possible please) 4. Designer Information Ma'me Name of Company //ze J�/�'taAtY"t Address / City/Town' State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 „y�-°��: Application for Septic Disposal System TODAY'S DATE °x Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 $;75 00-component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: [<esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. 1 understand that until'a final Certificate of Compliance has been issued by this Board of Health, the installed syste is not approved. Q — Name Date App ion Ap o y: (Board of Health Representative) a Date A plicati n Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes- No 2. Project Manager Obligation Form Attached? Yes t/ No 3. Pump System? If so,Attach copy ofElectrical Permit Yes_ No Applicantreceived copy of "Electrical Inspection Notes for Septic Systems” Yes_ No Handout? 4. Reviewed approvalletter, all paperwork received.? Yes No Mlssing: 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only) Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by Gy�lnrsf�.•--8 e-� r: J�/Y�J / (Engineer) Relative to the application of Z�, �: X417 7 (Installer's na e) And dated jp rigina ate Dated /,� 2Q f �p +�— (Ioclay's ate) With revisions dated Cs (Last revised date) I understand the following obligations for management of this project: 1. 1 As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first(V5 inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept a@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) fy _G 4, (Name, -e � �. —Print) (Name—Signed) �RATEp� . North Andover Health Department Community and Economic Development Division June 22, 2016 Messina Development Corp 277 Washington Street Groveland, MA 01834 Re: Subsurface Sewage Disposal System Plan for 51 Wellington Way—Lot 4 (Map 105C, Lot 87) t To Whom It May Concern: The proposed wastewater system design plan for the above site dated January 8, 2016 with a final revision date of June 8, 2016 and received on June 9, 2016 has been approved. The design has been approved for use in the construction of a new on-site septic system for a 4- bedroom (max 9-room) home utilizing a gravity leach trench system. This design plan approval is valid until June 22, 2019. During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. This approval is also subject to the following conditions: 1 1. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit a foundation as-built at the same scale as the approved plan 2. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit the floor plans of the proposed dwelling showing no greater than 4 bedrooms or a total of 9 rooms. Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 51 Wellington Way—Lot 4 June 22, 2016 3. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 4. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely, h � rian J. LaGrasse, CEHT Director of Public Health Encl. Installers list cc: Philip Christiansen, P.E. File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 CHRISTIANSEN & SERGI, INC PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET,HAVERHILL,MA 01830 tel:978-373-0310 www.csi-engr.com fax 978-372-3960 June 9, 2016 Mr. Brian LaGrasse Health Director 1600 Osgood Street Building 20; Suite 2035 North Andover, MA 01845 Re: Lot 4—51 Wellington Way—SSDS revision Dear Brian The developer has decided to put a house with a smaller footprint on Lot 4. The system design for the lot was previously approved. The original footprint was 1797 square feet and the new footprint is 1549 square feet. The new house will be a four-bedroom house as was the original design. The house is in the same location as on the approved plan but it is shorter than the original house and thus the pipe from the house to the septic tank needed to be lengthen and the invert at the house adjusted. These changes are reflected in the site plan and in the profile. Very t r P p . Christiansen P.E. RECEIVED JUN 0 9 2016 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT i I • . / A(P N North Andover Health Department S$ Community and Economic Development Division �10 March 24 2016 Messina Development Corp 277 Washington Street Groveland,MA 01834 Re: Subsurface Sewage Disposal System Plan for 51 Wellington Way—Lot 4 (Map 105C,Lot 87) To Whom It May Concern: The proposed wastewater system design plan for the above site dated January 8, 2016 with a final revision date of March 22, 2016 and received on March 23, 2016 has been approved. The design has been approved for use in the construction of a new on-site septic system for a 4- bedroom(max 9-room)home utilizing a gravity leach trench system. This design plan approval is valid until March 24, 2019. During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. This approval is also subject to the following conditions: 1. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit a foundation as-built at the same scale as the approved plan 2. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit the floor plans of the proposed dwelling showing no greater than 4 bedrooms or a total of 9 rooms. Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 �y 51 Wellington Way—Lot 4 March 24, 2016 3. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 4. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission,Zoning Board, Planning Board,Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely, ;} q��La— I Michele Grant Health Inspector Encl. Installers list cc: Philip Christiansen, P.E. File Page 2 of 2 North.Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 1/14/16 TOWN OF NORTH ANDOVER PERMITTED SEPTIC INSTALLERS- RENEWED FOR 2016 Doing Business As Phone City Bill Hall (978)360-5280 METHUEN,MA 01844 Daniel A. Giard (978)423-8588 NORTH ANDOVER,MA 01845 David Maynard (978) 375-7228 BARNSTEAD,NH 03225 David V. Zaloga, Jr. (603) 772-4884 EXETER,NH 03833 James Boraczek (978)479-5236 HAMPSTEAD,NH 03841 James H. Currier (978) 774-6685 MIDDLETON,MA 01949 James Kellett (781)953-7146 LYNNFIELD, MA 01940 Jason White (978)474-5020 ANDOVER,MA 01810 Jay Wadsworth (774)287-6384 ACTON,MA 01720 John Chongris (508) 509-9443 ANDOVER, MA 01810 John J. Soucy (603) 898-9339 SALEM,NH 03079 John L. DiVincenzo (978) 807-9722 HAVERHILL,MA 01835 John T. Shaw III (978) 815-7411 ANDOVER,MA 01810 Joseph Surianello (617) 799-3900 DRACUT,MA 01826 Joseph Watson (508)932-3204 ANDOVER,MA 01810 Matthew Manning (603)231-8596 HAMPSTEAD,NH 03841 Michael W. Reilly (978)375-4811 ANDOVER,MA 01810 Peter Breen (978) 687-7774 NORTH ANDOVER,MA 01845 Robert K.Daigle,Jr. (978)423-6933 HAVERHILL,MA 01835 Robert T.Amor (978)479-7853 ROWLEY, MA 01969 Robert Innis (508) 572-8224 BILLERICA,MA 01821 Rocci DeLucia, Jr. (603) 974-1580 SALEM,NH 03079 Serge R. Beaulieu (603)235-3740 DERRY,NH 03038 Stephen Iacozzi (978)479-4407 METHUEN,MA 01844 Timothy Quinlan (978)457-0528 NORTH ANDOVER,MA 01845 Todd Bateson (978) 815-2703 ANDOVER,MA 01810 Warren Pearce Jr. (978)-664-5264 NORTH READING,MA 01864 William(Tom) Sawyer (603)642-8910 NORTH ANDOVER&KINGSTON,NH 03848 CHRISTIANSEN & I SER INCG , PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET,HAVERHILL,MA 01830 tel:978-373-0310 www.csi-engr.com fax 978-372-3960 March 22, 2016 Michelle Grant RECEIVED Health Inspector MAR 2 2 ZU16 North Andover Board of health 1600 Osgood St, Suite 2035 ��HWN DLTH DEPARTMENF NORTH T North Andover, MA 01845 RE: (Lot 4) 51 Wellington Way Dear Ms. Grant: In response to your letter of March 18, with Comments on the Septic System Design, I offer the following: 1 The address should reflect the correct street name of Wellington Way instead of Wellington Woods The address has been changed. 2 On sheet 1 of 2, the foundation drain location and elevation are not shown on the design plan (NA 3.2). A Foundation drain has been added and the invert elevation specified 3 An inspection port was not shown.on the design plan (3 10 CMR 15.240(13)). An inspection port has been added 4 The reserve leach trenches should be clearly shown on the design plan. The reserve trenches are marked on the plans. 5 The breakout elevation for the leach trenches are not depicted on the design plan. The breakout elevations are now shown on the plans 6 It appears a sand overdig will be required and should be shown on the design plan. The sand overdig has been added to the plan 7 On sheet 1 of 2, existing and proposed topography should be added and clearly labeled to the area adjacent to the leach trenches to confirm the breakout elevation is met. The existing topography is now labeled. There aren't any proposed contours in the area of the system. Spot elevations have been added 8 On sheet 1 of 2, the proposed grading around the septic tank in the site plan view does not snatch the profile view. The grading around the septic tank has been corrected 9 On sheet 2 of 2, the leach field longitudinal section does not depict the required base material under the distribution pipes (3 10 CMR 15.247(a)). Labeling of the base material has been added 10 Label all proposed drainage areas on the lot and depict the setbacks to the septic tank and leach trenches. The flat area is not a drainage area in the traditional sense. It is not an infiltration area as defined by Stormwater Management standards and no credit for infiltration was taken in the approval process. I have added dimensions to it I and the septic tank is greater than 5 feet from the area and the septic system is greater than 10 ft away from the area, so that if it were to be considered a drainage area it complies with Title 5. 11 An access riser to within 6" of finish grade is required above the septic tank (3 10 CMR 15.228(2). 310CMR15.228(1) requires 9 inches of cover. Risers are required only if cover is greater than 9 inches. From the regulations: Septic tanks shall have a minimum cover of nine inches. Systems buried greater than nine inches below grade must be equipped with risers on all tank top openings and the distribution box.310CMR15.228(2) does not apply 12 On sheet 1 of 2, the schedule of elevations and the profile indicate no slope from the outlet of the distribution box to the inlet of the leach trenches. It is recommended to have a minimum slope of 0.01 (1/8 inch per foot). The outlet from the D-Box is level for two feet. The schedule of elevations has been adjusted by 0.01 ft. The distribution pipe is 50 feet long at 0.005ftfft. There is 4 ft between the d- box and the beginning of the trench. Two of those 4 feet are required to be level, leaving only 2 ft of piping in which we have chosen to maintain the.005 ftfft of the trenches. I hope this answers all of your concerns. If you have any additional questions, please do not hesitate to call me. Sinc , hil' G. Christiansen i a. • . 'PAQRA7.LD"A�,V North Andover Health Department I Community and Economic Development Division March 18, 2016 I Philip Christiansen;P.E. Christiansen and Sergi, Inc. 160 Summer Street Haverhill, MA 01830 Re: (Lot 4) 51 Wellington Way(Map 105C, Lot 22) i Dear Mr. Christiansen, The proposed wastewater system design plan for the above site dated January 8, 2016 and received on March 10, 2016 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected: .The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that:isnot met by this design follows each item where applicable. 1. The address should reflect the correct street name of Wellington Way instead of Wellington Woods. 2. On sheet 1 of 2,the foundation drain location and elevation are not shown on the design plan(NA 3.2). 3. An inspection port was not shown on the.design plan (3 10 CMR 15.240(13)). 4. The reserve leach trenches should be clearly shown on the design plan. 5. The breakout elevation for the leach trenches are not depicted on the design plan. p g 6. It appears a sand overdig will be required and should be shown on the design plan. 7. On sheet 1 of 2, existing and proposed topography should be added and clearly labeled to the area adjacent to the leach trenches to confirm the.breakout elevation is met. 8. On sheet 1 of 2,the proposed gradingaround the septic tank in the site plan view does not match the profile view. 9. On sheet 2 of 2,the leach field longitudinal section does not depict the required base material under the distribution pipes (3 10 CMR 15.247(a)). Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover,MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 1 10. Label all proposed drainage areas on the lot and depict the setbacks to the septic tank and leach trenches. 11. An access riser to within 6" of finish grade is required above the septic tank(3 10 CMR 15.228(2). 12. On sheet l of 2, the schedule of elevations and the profile indicate no slope from the outlet of the distribution box to the inlet of the leach trenches. It is recommended to have a minimum slope of 0.01 (1/8 inch per foot). Please feel free to contact the office or Mill River Consulting at 978-282-0014 with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. /Sincerely - Michele Grant Health Inspector cc: Messina Development Company File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 I TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ' 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER,MASSACHUSETTS 01845 978.688.9540—Phone 978.688.8476—FAX E-MAIL:healthdept@noilhandoverma.gov northandoverma.gov WEBSITE: http://ww-w.northandoverma.gov SEPTIC PLAN SUBMITTAL FORM RREEEIVED Date of Submission: — ';rOAR 11 0-2016 Site Location: �Of S5 / u.Io 11l�(� 0Y(_ �/V l� TOW VER NT Engineer: C.h r(S47a/n5eirz &AcG , , . V15 U - New Plans? Yes !� $ZWPlan Check# (includes 1St submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes No Telephone#: R 7 r- 3 73 -6 3 16 Fax#: E-mail: �i Homeowner �n Name: M SS Y?C4-- �)C Ve� o OFFICE USE ONLY When the submission is complete (including check): ➢ _Date stamp plans and letter ➢ Complete and attach Receipt ➢ �'// Copy File; Forward to Consultant ➢ T/ Enter on Log Sheet and Database No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH L DW KI OF 1'Unan-1 Aw DaV4 I2 _ APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - omplete System ❑Individual Components ocationuOw Nam105e. Q-77 W&AjqI4, 54rje Map/ arcel# q-1g, � C A ress i Lot# r # L� Installer's Name ��, Zjelephone sjgrier's N�a�e Address ( .dress h ` Telephone# Telephone# Type of Building: tA),O4T4 �-- Lot Si Sq.feet Dwelling—No.of Bedrooms Garbage drindV(Njz-) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.red) gpd Calculated design flow gpd Design flow provided pd Plan: Date 1 Number of sheets Revision Date Title ` 4C A-V Descripion of Soil(s) �— Soil Evaluator Form No. It 'I- /Z. Name of Soil Evaluator t i • aKSWAqluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 an her agrees nottoplace the system in operation until a Certificate of Compliance has been issuej by the Board of Health. Signed Date Inspections MAR 1 n ?ti 1 R TOWN OF NORTH ANDOVE FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 HEALTH Commonwealth of Massachusetts City/Town of North Andover RE(% --- W Percolation Test Form 12 a'W TOWN;.. . Percolation test results must be submitted with the Soil Suitability Assessment fo -A 6t'e'W"age Disposal. 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& k with the local Board of Health to determine the form they use. Rr_%CJVED Important:When A. Site Information filling out forms MAR 10 �o on the computer, use only the tab Gordon family Trust key to move your Owner Name cursor-do not 602 Boxford Street LOT 4 HEALTH DEPARTMENT use the return key. Street Address or Lot# North Andover MA01845 _Q City/Town State. f Zip Code Philip Christiansen 978.373.0310 Contact Person(if different from Owner) Telephone Number " B. Test Results 1/13/2015 1:40 1/13/2015 1:50 Date Time Date Time Observation Hole# 6A 6B Depth of Perc 46" 46". Start Pre-Soak 1:40 1:50 End Pre-Soak 1:55 2:05 Time at 12" would not would not Time at 9" maintain maintain Time at 6" water level water level Time(9"-6") Rate (Min./Inch) <2 min/inch <2 min/inch Test Passed: ® Test Passed: Test Failed: ❑ Test Failed: ❑ -Philip Christiansen Test Performed By: Isaac Rowe Witnessed By: Comments: t5form 12.doc•06/03 Perc Test•Page 1 of 1 Commonwealth of Massachusetts City/Town of North Andover - - Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Gorton Family Trust Owner Name 602 Boxford Street LOT 4 Map 105C Lot 87 Street Address Map/Lot# North Andover MA 01845 City State Zip Code B. Site Information 1. (Check one) ® New Construction ❑ Upgrade ❑ Repair 2. Soil Survey Available? ® YesNCRS 421 B&C ❑ No If yes: Source Soil Map Unit CANTON LARGE STONES Soil Name Soil Limitations 3. Surficial Geological Report Available? ❑ Yes ® No If yes: Year Published/Source Publication Scale Map Unit Geologic/Parent Material Landform 4. Flood Rate Insurance Map Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ❑ No Within the 500-year flood boundary? ❑ Yes ❑ No Within a velocity zone? ❑ Yes ❑ No 5. Wetland Area: Wetlands Conservancy Program Map Map Unit Name 6. Current Water Resource Conditions(USGS): Month/Year Range: ❑ Above Normal ❑ Normal ❑ Below Normal 7. Other references reviewed: tp lot 6-rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal -Page 1 of 8 Commonwealth of Massachusetts City/Town of North Andover -- Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: 6-A 1/13/2015 1:30 32 SNOW Date Time Weather 1. Location Ground Elevation at Surface of Hole: 123.0 Location(identify on plan): 0-3 2. Land Use WOODS NO (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) OAK, W PINE OUTWASH PLAIN BOTTOM Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body >100 Drainage Way 1000 Possible Wet Areafeet feet Property Line >50feet Drinking Water Well feet Other feet ALLUVIAL 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: 113.0 inches elevation tp lot 6•rev.3/13 Form 11 Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8 Commonwealth of Massachusetts City/Town of North Andover - Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: 6-A Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) Consistence Other (USDA) Cobbles& Structure Moist Depth Color Percent Gravel Stones (Moist) 0-5 A 10YR3/2 FSL 5-35 BW1 10YR4/4 FSL 35-120 C 10YR6/6 MED SAND Additional Notes: tp lot 6•rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts UqCity/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: 6-B 1/13/2015 1:30 25 OVERCAST Date Time Weather 1. Location Ground Elevation at Surface of Hole: 122.80 Location(identify on plan): 2. Land Use WOODS ; NO 0-3 (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) OAK, W PINE OUTWASH PLAIN BOTTOM Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body >100 Drainage Way >100 Possible Wet Area >100 feet feet feet Property Line feet 0 Drinking Water Well f e00 Other 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 84 SEASONAL 115.80 Estimated Depth to High Groundwater: inches elevation tp lot 6•rev.3/13 Fonn 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 Commonwealth of Massachusetts ugCity/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: 6-B Redoximorphic-Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) %by Volume Soil Depth in. Soil Texture Soil p ( ) Munsell Consistence Other Moist Layer y (Munsell) (USDA) Cobbles 8 Structure Depth Color ercent Gravel Stones (Moist) 0-6 A 10YR3/2 FSL 6-16 BW1 10YR4/4 FSL 16-120 C 10YR6/6 MED SAND Additional Notes: tp lot 6•rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: 6-C 1/13/2015 1:30 25 OVERCAST Date Time Weather 1. Location Ground Elevation at Surface of Hole: 123 00 Location(identify on plan): 0-3 2. Land Use WOODS NO (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) OAK, W PINE OUTWASH PLAIN BOTTOM Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open;Water Body feet00 Drainage Way 1000 Possible Wet Area feet >50 Property Line feet Drinking Water Well t e00 Other feet 4. Parent Material: ALLUVIAL 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: 113.00 inches elevation tp lot 6•rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: 6-C Redoximorphic Features Coarse Fragments Depth(in.) Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Layer Moist(Munsell) (USDA) Cobbles& Structure Consistence Other Depth Color Percent Gravel Stones (Moist) 0-10 A 10YR3/2 FSL 10-40 BW1 2.5Y6/6 FSL 40-62 C 1 2.5Y5/6 G C SAND 62-120 C2 2.5Y6/4 MED SAND Additional Notes: tp lot 6•rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater.Elevation 1. Method Used: ® Depth observed standing water in observation hole A. NONE B. 96" C: NONE inches inches ❑ Depth weeping from side of observation hole A. NONE B. C: NONE inches inches ElDepthin Depth to soil redoximorphic features (mottles) NONE C: NONE inches nches ❑ Groundwater adjustment(USGS methodology) A. B. C: NONE inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level 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: 6cnes Lower boundary: 120s tp lot 6•rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 6'of 8 Commonwealth of Massachusetts -upCity/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F. Certification I certify that l am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are acc at nd in cc ance-wit 5.100 through 15.107. 1/13/2015 S' nature luator Date PHILIP HRISTIANSEN #378 11/1994 Typed(Printed Name of Soil Evaluator/License# Date ofSoil Evaluator Exam ISS ROWE NORTH ANDOVER - Name of Board of Health Witness' Board of Health 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. tp lot 6•rev.3/13 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8