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Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. iezun Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner's Name N. ANDOVER MA 01845 03/30/16 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. A. General Information RECEIVE® Inspector: APR 14 2016 V�-�`� � John J. Soucy TOWN OF NORTH ANDOVER Name of Inspector HEALTH DEPAR I MtNI Soucy's Sewer Service Inc. Company Name 78 North Broadwav Company Address Salem City/Town 603-898-9339 Telephone Number B. Certification NH State 13397 License Number 03079 Zip Code 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 ❑ Nepds) Further Evaluation by the Local Approving Authority 3/30/16 Date TIA system inspector shall submit a 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner's Name N.ANDOVER MA 01845 03/30/16 City[Town 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is N. ANDOVER MA 01845 03/30/16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): 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 16.303(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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner's Name N. ANDOVER MA 01845 03/30/16 Cityrrown 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins • 3/13 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 �M 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/30/16 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 II 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is N. ANDOVER required for every page. City/Town C. Checklist nnn 01845 Zip Code 03/30/16 Date of Inspection 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): 440 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/30/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use?. Water meter readings, if available (last 2 years usage (gpd)): Detail: SEE ATTACHED Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) 3 ® Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No ❑ Yes ® No Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 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 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/30/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: CURRENT Date Soucy's Sewer Service Inc 1500 gallons PLANS ❑ Yes ® No Type of System: ® Septic tank, i 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 1/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '1M , 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is N. ANDOVER MA 01845 03/30/16 required for every 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: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below rade: 30" OR 2.5' De p g feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 18" OR 1.5' feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 6'X 10.5' Sludge depth: 2" ❑ Yes ❑ No t5ins • 3/13 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 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is N. ANDOVER MA 01845 03/30/16 required for every 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 39" 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 71- Distance "Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? TAPE & SLUDGE TOOL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK IS STRUCTURALLY SOUND, NO APPARENT LEAKS, TIES IN PLACE. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 3/13 Date Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 100 RALEIGH TAVERN LANE Property Address LESLIE WON DOLOWSKI Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/30/16 page. City/Town 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No 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 - 3113 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 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/30/16 page. Cityfrown 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 N/A 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.): 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.): ALL TESTED GOOD * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Type/name of technology: BIO MICROBES Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF ANY HYDRAULIC FAILURE. PRESSURE DISTRIBUTION SYSTEM MEETS PRESSURE TEST. 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 • 3113 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 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/30/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 77 QUICK 4S ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ® innovative/alternative system Type/name of technology: BIO MICROBES Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF ANY HYDRAULIC FAILURE. PRESSURE DISTRIBUTION SYSTEM MEETS PRESSURE TEST. 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 • 3113 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 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is N. ANDOVER MA 01845 required for every page. City/Town State Zip Code D. System Information (cont.) 03/30/16 Date of Inspection 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <�^M 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI _ Owner Owner's Name information is N. ANDOVER required for every page. CitylTown MA 01845 03/30/16 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 .7A— _ 601 OMI.RY,: fRONI LOFT 1'r)RI TER 1F 11 601 Om FRONT STEP. CLEV. IOf.I.M. io rt 4 F`OSPDN r Cf -IJ TROL 4 S (t,P1 \ \ \� \\ % —_Lvl�. FOUR SILT. ELF'!. 09.49 . \ IPI �.. —. _ _ - — ) — _ .. =� _ AI'I'Rn;;IInnTE LOC11101I C 100EkIS11N0 SEf'tIC 1!,HK ------------- 00 C o ' w o arw / �� :{Xhlrlc E 1000 �N LOIJ� -- i0 4 I UMP f WMBER I ' I MICRO ___ _____....... .. . �- I FAST �i'•I1,^, Tt4l, _ S41°58'00'E --E�— E — — 1.7 i 19 \ P2 v — 7 FTI / � w 10 MIL IIIPERVIOUS PRESSUP.E wgTER SERVICE OARRIER. TOP Et0'. 49.67 APFROXIMAT O E LOCATION EXISfI1JO LEACH AREA \.. CC) RALIJIG �I T11 VF 1� _'� LL�1ht1_ SYSTEM TIES 3 TO TANK 27.7' 1 TO PUMP 41.8" 2 TO TANK 47.9' 2 TO PUMP 40.7' 1 TO A 60.4' t TO H 113.8' 2 TO A 47.0' 2 TO H 107.8' 1 TO G 44.6' ! TO 1 106.0' . 2 TO G 35.8' 2 TO 1 103:1' INSPECTION PORTS 1 TO T 105.1' 1 TO U 104.6` 1 To V 102.1' 1 TO W 100.8' 2 TO T 98.5' 2 TO U 98.5' 2 TO V 96.5' 2 TO W 95.8' 1 TO X 100.5' 1 TO Y 99.2' TO Z 98.0' 2 To 96:]' 2 TO Y 95.3' 2 TO Z 95.0' t5ins • 3/13 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 100 RALEIGH TAVERN LANE Property Address LESLIE WONDOLOWSKI Owner Owner's Name information is N required for every. ANDOVER MA 01845 page. Cityrrown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 03/30/16 Date of Inspection 34" OR 2.83' Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: R [a INK Obtained from system design plans on record 8/03/04 If checked, date o eslgn p an reviewe . Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: DUG HOLE WITH AUGER IN LOW DROP OFF AREA, WATER AT 20" (2' ELEVATION DIFFERENCE). Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 100 RALEIGH TAVERN LANE Property Address LESLIE WON DOLOWSKI Owner Owner's Name information is N. ANDOVER required for every page. CityrTown MA 01845 State Zip Code E. Report Completeness Checklist 03/30/16 Date of Inspection ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 I June 18, 2015 North Andover Board of Health 1600 Osgood Street North Andover, MA 01845 44 Commercial Street Raynham, MA 02767 Tei: (508) 880-0233 Fax: (508) 880-7232 Attention: Health Agent Reference: FAST° Wastewater Treatment System - Serial Number: 24277 Attached please find the Field Inspection & Service Report with field test results for services performed on 4125/15 at the property of David Wondolowski located at 100 Raleigh Taven; Lane, North Andover, MA. Please call if you have any questions or require additional information. Sincerely, li , u `' AOee9 d2C��7iiLesr c�e2t�,r�eo Wastewater Treatment Services, Inc. Seiviee Department Enclosures Copy to: David Wondolowski Massachusetts DEP 1 f10 O A i 0 A A i C 0 8450 Cole Parkway, Shawnee, KS 66227, Phone 813-422-0707, Fax 913-422-0808 e-maiLonslie,Ablomlcroblcs.co% vrww.biomicrobics,com, 800-753-FAST(3278) FIELD INSPECTION & SERVICE REPORT For Bio-Micr obics Single Home FAST® System 23617 ................ ^ t. - �rxoRlz�DSaRvtc`r:`'�d ri� - Au .� Installation Address: 100 Ralclglt Tavcnt Lane North Andover, MA 01845 Name: wastowaterTreaunent Services, Inc. Owner-Nmne: David Wondoioaski Mail Address: 100 RaleiWi Tavem Lune North Andover, MA 01845 Mail Address: 44 Commercial Street Raynham, MA 02767 Phony 617.821-1617 Fax: a -mail: - " _...._.... Phone: (508) 880.0233 rax. -(508)880-7232 e -snail: '.s:. x:.-..,. r.:�.:... .-.. 1 .... [. _ ..._...._ _aa .. _.. ,,. .:,'t:'... _ . 1 .it';'1•-:{'i'= - �'T:r.^_ ":.<':a[:�<rf.. Model No. Serial No. Date of lostallation Date oflast pump out _ MIcroFAST.5 _.............. .......-................. ._....._......_.._............... _.__. 24277 11/11/2004 912312013 E`t"11TIMT�u- Electrical Partel(s) - Visual Alarm Operiting x -1,0 — Audio Alarm Operating (ifpresent) x Air inlet Filter Clem x �Blower Hood Vents Clear - x Excessive Noise _ x - Excessive Vibration - x TYeattucut unit($) Unusual Odor s Punrpout Required Primary Settling Zone Aerobic Tteatment Zone 0" Estimated Daily Flow 440 gpd pH (Standard Units) µ 6.89 Color Clear Temperature ---- __..-............... ............ __..__ Odor Earthy Comments: i V., Mieltael Foisy _ - 4125115 Summary Record Card generated on 3/22/2016 8:29:54 AM by Karen Hanlon Town of North Andover Tax Map # 210-107.A-0109-0000.0 Parcel Id 17934 100 RALEIGH TAVERN LANE DAVID & LESLIE WENDOLOWSKI 100 RALEIGH TAVERN LANE NORTH ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.03 Acres FY 2016 UB Mailina Index Name/Address DAVID & LESLIE WENDOLOWSKI 100 RALEIGH TAVERN LANE NORTH ANDOVER, MA 01845 ARSNOW, BRYAN 100 RALEIGH TAVERN LANE N. ANDOVER, MA 01845 UB Account Maint. Type Loan Number Owner Previous Customer Active/Inact. From Inactive 11/17/2004 Account No Cycle Occupant Name Active/Inactive Bldg Id. 13247.0 - 100 RALEIGH TAVERN LANE Last Billing Date 3/14/2016 2100200 02 Cycle 02 Active UB Services Maint. Account No. 2100200 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 64.60 /1 UB Meter Maintenance Until Account No. 2100200 Serial No Status Location Brand Type Size YTD Cons 16336835 a Active ERT METE METE w Water 0.63 0.63 773 Date Reading Code Consumption Posted Date Variance 2/2/2016 1352 a Actual 17 3/28/2016 -46% 11/2/2015 1335 aActual 31 12/30/2015 -14% 8/4/2015 1304 a Actual 37 9/14/2015 113% 5/4/2015 1267 a Actual 17 6/22/2015 9% 2/3/2015 1250 a Actual 16 3/20/2015 -42% 11/3/2014 1234 a Actual 28 12/15/2014 -51% 8/1/2014 1206 aActual 54 9/11/2014 207% 5/5/2014 1152 a Actual 18 6/12/2014 7% 2/4/2014 1134 a Actual 18 3/17/2014 -39% 10/31/2013 1116 aActual 28 12/20/2013 -6% 8/1/2013 1088 aActual 30 9/18/2013 80% 5/1/2013 1058 aActual 15 6/18/2013 0% 2/7/2013 1043 a Actual 18 3/13/2013 -36% 10/30/2012 1025 a Actual 25 12/13/2012 -28% 8/2/2012 1000 a Actual 36 9/26/2012 41% 5/2/2012 964 a Actual 25 6/20/2012 36% 2/2/2012 939 a Actual 19 3/14/2012 -31% 11/1/2011 920 aActual 27 12/15/2011 -43% 8/2/2011 893 a Actual 48 9/14/2011 167% 5/2/2011 845 a Actual. 17 6/13/2011 -12% 2/4/2011 828 a Actual 21 3/15/2011 -23% 11/1/2010 807 aActual 26 12/13/2010 -54% 8/3/2010 781 a Actual 58 9/13/2010 310% 5/3/2010 723 a Actual 14 6/9/2010 8% 2/1/2010 709 aActual 13 3/11/2010 -19% 11/2/2009 696 aActual 16 12/11/2009 -26% �00 cl�'Kbkc- v a a � C b H N U W e g a m V C— g� o LL- . co - O '13 C ' r i co 2: e 0 z 4 Z it m d o ,o co to 41 - - - -� N Q ,30z cc 8 U. ;-1 m z :..a m r /a t7 . d.. v U C O -. co ® O LL d j- Y E be0 H r'1 . .. 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Contract North Andover MA 01845 Wondolowski_2015-081.4 978 852-4491 ffMK www,TMKremodeling.com REMODELING CONTRACTOR AGREEMENT THIS AGREEMENT made this //211/& 20_ by and between TMK Remodeling, LLC, Construction Supervisor License # 105086, 214 Sutton Hill Rd, North Andover MA 01845 hereinafter called the Contractor, and Leslie & David Wondolowski hereinafter called the Homeowner. WITNESSETH, that the Contractor and the Homeowner for the consideration named herein agree as, follows: ARTICLE 1. SCOPE OF THE WORK The Contractor shall perform all of the work described in the specifications entitled Exhibit A - Statement of Work, as annexed hereto as it pertains to work to be performed on property located at 100 Raleigh Tavern Lane North Andover MA 01845. Work Scope Summary:Remodel basement into new living space approx 884 SF with 8 rooms as shown on plan SK -6.3 dated 01/07/16. Install 8 new doors and 6 new windows. Construct new bathroom with ejection tank. Construct full bedroom. Finish floor as shown on plans ARTICLE 2. TIME OF COMPLETION The work to be performed under this Contract shall be commenced on or before February 29, 2016 and shall be substantially completed on or before June 17, 2016 ;ARTICLE 3. THE CONTRACT PRICE The Homeowner shall pay the Contractor for the labor and materials to be performed and supplied under the Contract the estimated sum of One Hundred Twelve Thousand Seven Hundred Eighty Five Dollars and No Cents ($112,785.00), subject to additions and deductions pursuant to authorized change orders. The contract price includes two components; Fixed cost of One Hundred One Thousand Three Hundred Fifteen Dollars and No Cents ($101,315.00) for the building materials and construction labor as specified in Exhibits A and B. Variable cost of Eleven Thousand Four Hundred Seventy Dollars and No Cents ($11,470.00) for the allowance items listed in Exhibit B Allowances and will be 110% of the actual invoice price paid by the Contractor to his suppliers. Exhibit B lists the allowance items and budget costs the Contractor will purchase for the Homeowner. Sales tax and freight are not inlcuded in allowance budget. Contractor will furnish and install all building materials, fixtures and finish items unless noted otherwise. Any Homeowner supplied materials will be charged a 10% handling and coordination fee based on actual invoice. ARTICLE 4. PROGRESS PAYMENTS Payments of the Contract price shall be paid in the following manner from the Homeowner to the Contractor: Payment 1: 25% upon contract acceptance and signature; $28,196.25 Payment 2: 25% upon rough building inspection;$28,196.25 Payment 3: 25% upon completion of wall finish, ceiling finish and millwork;$28,196.25 Payment 4: 25% upon final building inspection and 95% completion of finish; $16,726.25 plus the actual contract price for allowance items as defined in Article 3; Budget:$11,470.00 The contract cost for mutually agreed to change orders will be paid 50% at time of change order signature and 50% after completion and Homeowner sign -off. 164' Copyright TMK Remodeling, LLC 2016Page 1Initials All Rights Reserved 214 Sutton Hill Rd Contract North Andover MA 01845 TAK Wondolowski 2015-081.4 978 852-4491 11EA�QIIE�ING www.TMKremodeling.com ARTICLES. GENERAL PROVISIONS 1. All work shall be completed in a workmanship like manner and in compliance with all building codes and other applicable laws. 2. To the extent required by law all work shall be performed by individuals duly licensed and authorized by law to perform said work. 3. Contractor may at its discretion engage subcontractors to perform work hereunder, provided Contractor shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this Contract. 4. Contractor shall furnish Homeowner appropriate releases or waivers of lien for all work performed or materials provided at the time the next periodic payment shall be due. 5. All change orders shall be in writing and signed by both Homeowner and Contractor. The cost for mutually agreed to additional work, required due to unknown conditions or substantive change orders, will based on the current bill rates for the actual time used. Additional materials will be billed at contractor cost. All change orders subject to 10% markup for overhead. 6. Contractor warrants it is adequately insured for injury to its employees and others incurring loss or injury as a result of the acts of Contractor or its employees and subcontractors. 7. Contractor shall at its own expense obtain all permits necessary for the work to be performed. 8. Contractor agrees to place all debris in an on-site trash receptacle (dumpster) and leave the premises in broom clean condition. 9. In the event Homeowner shall fail to pay any periodic or installment payment due hereunder, Contractor may cease work without breach pending payment or resolution of any dispute. 10. The Contractor and the Homeowner hereby mutually agree in advance that in the event that the Contractor has a dispute concerning this contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the Homeowner shall requir d to s bmi to such arbitration as provided in MGL c 142A. 1 f/2 Home Date: Notice: The signatures of the parties above apply only to the agreement of the parties to alternate dispute resolution initiated by the Contractor. The Homeowner may initiate alternative dispute resolution even where this section is not signed by the parties. 11. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes, casualty or general unavailability of materials, or inclement weather. 12. Contractor warrants all work for a period of 12 months following completion. 13. Contractor may post small signage (36x36") on property advertising services during the duration of the project. Copyright TMK Remodeling, LLC 2016 Initials' All Rights Reserved Page 2 214 Sutton Hill Rd ON Contract North Andover MA 01845Wondolowski_2015-081.4 978 852-4491 F-RMK www.TMKremodeling.com REMODELING 14. The Contractor and subcontractors shall be registered and any inquiries about a contractor or subcontractor relating to a registration should be directed to: Office of Consumer Affairs and Business Regulation Ten Park Plaza, Suite 5170 Boston, MA 02116 Phone: (617) 973-8700 15. The Contractor or Homeowner may terminate this contract at any time for any reason by giving 3 days notice in writing to the other party. If either party terminates the contract as provided herein, then the contractor will be paid for work (labor and materials) completed as of the date of termination plus any materials or equipment that are backordered and not delivered. Payment is defined as actual job costs for the project plus 10% overhead charge. The contractor will provide a written report detailing actual job costs plus overhead for payment. The Contractor will refund any funds paid by the Homeowner that are a remaining balance for the labor and materials used as of the date of termination, plus any materials or equipment that are backordered and not delivered, plus 10% overhead charge. The Contractor will make arrangements for the backordered items to be delivered to the Homeowner. 16. The Homeowner is responsible for maintaining adequate access to the property including snow removal, personal property storage, and working doorways, stairways and walkways. In the event the contractor is required to provide access or repair to the doorways, stairways and walkways, then the Contractor will bill the Homeowner at the hourly bill rate for same. ARTICLE 6. OTHER TERMS ARTICLE 7. ACCEPTANCE Signed this day of J4 - 20/6 . NOTICE: The signatures of the p6rties above apply only to the agreement of the parties to alternate dispute resolution initiated by the contractor. The Homeowner may initiate alternative dispute resolution even where this section is not signed separately by the parties. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES �� Copyright TMK Remodeling, LLC 2016 Initials All Rights Reserved Page 3 n O (o D � CD (% CCDO to a C, CD 2 CD CL 0 N O 0) AAAA J Q) CP W AAA N —� W O CO W 00 W J W W O) CP W W A W W W N —' WNNNNNNNNNN-�•�-•-�w O CD W V M (7) A CO N w wy co coJmtnA W Nw 00000� vZ0A wTTTTwO w0 O O O�0.Z1 :11 ;i7p�0 �+ Os ODQON W N '�0 O W C C C C N N O V A (D N N O �� O n• N Cygo cn O (D y 3 oZ-'m r0 0 000 00 to N O S (D 3 '• O Z7 � N N N c y 3 C ° O° fU '� fA O 3 3 3. 3• Q N fmc C O O O O O° 0 T Q S� �- N O Cl Q �' "O �D 'D 111 C. fQ N `2 Q. (D co Co D p'�j �L O i rn N N N O' O O 1" O (D (p CL N N N N N �'• is i`c' T`: ° m m CD CR I=D' cd � Q �'m 'm ° � � r2 � N �. 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Z a r L O U a' w o p fq North Andover MIMAP 'y RALEIGH TAVERN LN 107.A-0107 1 9� 107.A-0108 18 82 RALEIGH TAVERN LN p8, 90. 7 RALEIGH TAVERN 207.A-0117 ~7. �d 93 RALEIGH TAVE\LNdip 107.A-0116 E3 MVPC Bo LT Municipal Boundary Rall Line Interstates — I —SR Roads k t Easements ❑ Parcels 0 Hydrographic Features Streams Wetlands C Exempt Lands 1"=89ft March 10, 2016 r -- :•,lit..: 107.A-0109 RALEIGH TAVERN LN_:. =='.`._. -._: -- •. 123' p� 1 � 48- 99 RALEIGH TAVERN LN 307.A-0115 169' 307.A-0113 109 RALEIGH TAVERN LN 107.A-0114 Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is I., planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION -:...3b` E3 MVPC Bo LT Municipal Boundary Rall Line Interstates — I —SR Roads k t Easements ❑ Parcels 0 Hydrographic Features Streams Wetlands C Exempt Lands 1"=89ft March 10, 2016 r -- :•,lit..: 107.A-0109 RALEIGH TAVERN LN_:. =='.`._. -._: -- •. 123' p� 1 � 48- 99 RALEIGH TAVERN LN 307.A-0115 169' 307.A-0113 109 RALEIGH TAVERN LN 107.A-0114 Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is I., planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION The Commonwealth of Massachusetts Department ofXndustrialAceldents M = F 1 Congress Street, Suite 100 02114-2017 Boston, MA- �< www mass.gov/dia rs/CoOIM Sy�v Workers, Compensation)(nsuxanceAff davit: BuildejNGAUTiIORi) S'. txacioxs/Flectxicians/Plnmbexs. TO BE FILED WITH THE PERMITTING Please Print LeAN A''licani Xnfoxmaiaion �/' ff ss "' i Na711e(Busiriessl0xganizatiov/Indivi.dual): , Address: 2l s �/� oL4ciL MA otift'1 Phone #: �'? 8 '1 S -Z City/State/Zip: // —� ;......, r ��.. n . r Typeo projee; (7eciiired):' Axe you an employer? Checl tTi!e appropriate box: em to ees full and/or part time).* 7. ❑ Ind--W.'d6nstrddion. 1. I am a employer with . • � P Y ( 2. U I am a sole proprietor or partnership and have no employees or foz me in 8.KkelnOdCIMP;anca achy.[Noworkers'comp. insurance required.] 9•Demolition Y P " 3. Q I am a homeowner doing all work myself [No workers' comp. insurance required.] ' 10 ❑ Building addition 4. Fj I am a homeowner and wilt be hiring contractors to conduct all work on my property. I will 11.❑ Elecirical'xepaixs or additions ensure that all contractors either have workers' compensation insurance or are sole , xE' k " 12. r3 'dumbing repair's' dr additi'ons proprietors withino,employees; 5•❑I am a general contractor nand IHavehiredthe sub -contractors listed onthe attached sheet. 13; 0 Rbo£repairs These sub -contractor have employees andhaveworkers' comp. insurance.: 14.0 Other 6•Q We are a corpozatigri anti its, ofCcers have exercised their right of exemption per MGL c. 152, §1(4), andyveliav@brio employees: [No workers' comp. in -I=ce required.] *Ary applicant that chealcs bbx#1 must also fill out the section below showingtheirworkers' compensationpolicyinformation. icating they are doing all work and i Homeowners who submit;tiiis adavrt indthen bice outside contractors must submit a new affidavit indicating such - I that check this box trust attached an additional sheet showing the name of the sub -contractors and state whether of not (hose entities have provide their workers' comp. policy number. • • •- employees. If the sub -contractors have employees, they must X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and j0h site information. Tnsuxance Company Name: G Policy # or Self -ins. Lic. #: Ger GG S'LiD SZ/� B?Z — Z--,( A Expiration Date. Job Site Address, --Z fl0 ,C'f/� i, � fR City/State/Zip: -evoxkexs' compensation policy ldeclaration. page (showing the policy number and expiration date). Attach a copy of the by a fulb up to Failure to secure coverage as teas asd �� P realties?inthe form oal ViolatiO £raaSS'T-'OP WORK ORDER and a fine o£up to $250.00 a and/or one-year inaprisonmeni, well day against the violator. A copy of this statement may be forwarded to the Office o£Tnvesiigaiions of the DTA for insurance .AF;naiinn _ ..,....z,- ---. do hereby certify under thepains andpenaldes o PeeYjtt that the infoYmatton pYova e a - u -1--i Official use only. Do not write in this area, to he completed by city or town off"aL City or Town: PermitUcense # issuing A.uthtoxityy (circle one): i 1. Board of Health 2. Building Department 3. City/`I'own Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other Phone #• ContactPerson: m ILI Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CS -105086 Construction Supervisor $ THEODORE M KELLEY �. 214 SUTTON HILL RD�1 �, NORTH ANDOVER MA �018ry45 r ��! r � y' Expiration: Commissioner 10/0812017 C�//e W.,-1?,on veat9 o1QAa'J.d'dee?4 Office of Consumer Affairs & Business Regulation HOME IMPROVEMENT CONTRACTOR Registration: 16.5887 Type: Expiration -7__475/2Q_1_8: DBA TMK REMODELING i�')7- THEODORE KELLEYZ� 214 SUTTON HILL RD''`•.. NORTH ANDOVER, MA 01 Undersecretary License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MA 02116 Not valid without signature U a m aq Ln I Z5 X xNr L a� Z 61 w � F .4,6T a Y w a O 9 O do • a n z o @ � U _____ __________ N _ O. l - o c ` E O O ¢ a - o - 00 E •:Y N m N 60 x a O W c V Y O �vY C N ELnw u 00 .a m u _ m° (ry 2r N a O 5 C_ CL $ _ . O,9-.9 _ .OI -,6 V v Y j m E 0 N¢ 32 Y 3 w N c c g ___ ----- •CY__________________.Y� _______ 0 M - O CL - ' H GoE m O/ lD � O a+ O L N 4.91 3 _x 6 N E 76 075 =Yo O` 3 �� m n m u c 0 0 N T 0 Y LL - zoo o D m o m 2 > m O fD V � n - £ N 6 rn � p n n 3 0 v r tJ 'm C N w A x � m a 3 L] o zi m o -- '- - --- '- _y v 0 4 N 0 u z R maxO � N mr �^ r 16'-2° 0 0 == 3 N m n' m S O. e zi -- '- - --- '- _y 03 ® ' H o, 0, , 3' D 60 S 11 t� ' u n c. Up 0 0 == 3 N m n' m S �, v c 0 0 Z a° o m 0 0 — p. O O 0 n S Da o q v 0 0 0 rn Co c m CL fD 7 Cl 0 O O T.' X O w O O O —I C N 7 (D? Cb D j N N N 0C: O C2 a w > = O N f p A j n ¢ 3 v OO v O O CJI CD CD rn — 3 7 O w 2- 4l -11P '-6" n N ro y Vf X W W N`` I D rn I 4' 1]' 1 a i m m 111 1 11 A 11 1 II n v 1 3 �p O ZO N O............... ....... .............. O tC) -i CCD 3 a oc m cc N CD O 7 Cn N Z cn O fl7 m 0 1 "0 v w p X 0 Ln A � P » 5 b�+d Z O 3 r N N W D A rCD00 -e o�� 7iC N p 15. S r 0 N, CIl O QiIQ N r r O �Q NEW ENGLAND ENGINEERING SERVICES INC September 10, 2004 Susan Sawyer North Andover Board of Health 27 Charles Street North Andover, MA 01845 Re: 100 Raleigh Tavern Lane, North Andover Septic System Design Dear Susan: RECEIVED SEP 10 2004 TOWNHEALTH L NRTH H DER EPARTM NT The following plans and enclosures for the above referenced property are being submitted for approval. 1. (5) Copies of the Septic System Design Plans. 2. (1) Copy of the soil evaluator sheets. 3. (1) Form 9A - Application for Local Upgrade Approval 4. (1) Check for payment of the Town approval fee. If you have any comments or questions please do not hesitate to contact this office. Sincerely, Steven E. Pouliot Project Manager 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 5 Town of North Andover HEALTH DEPARTMENT 27 Charles Street North Andover, MA 01845 978.688.9540 healthdepWownofnorthandover. com R � ED SEP 10 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SEPTIC PLAN SUBMITTAL FORM DATE OF SUBMISSION: g I to l 04 SITE LOCATION: 10 ® RA -V--1 Cwt ' 1 A U C-1-- N L -/N4--) e ENGINEER: New �u4-c-�r> NEW PLANS: YES $225.00/Plan Check #: (Includes 1 e and one Re -Review Only) REVISED PLANS: YES $ 75.00/Plan Check #: SITE EVALUATION FORMS INCLUDED: ES NO LOCAL UPGRADE FORM INCLUDED: YES NO Telephone #: q -I 8 - 65cn - 1-16 �a Fax #: (4- IS - G 9)S —I o q 9 E-mail: I'*--tfi-q-SCW t 0 AOL - g C" HOMEOWNER NAME: S P t A M �--r- t-1 0 cj OFFICE USE ONLY When the submission is complete (including check): 1. _! Date stamp plans and letter 2. ,Complete and attach Receipt 3.Copy File; Forward to Consultant 4. '� Enter on Log Sheet and Database NEW ENGLAND ENGINEERING SERVICES INC Elevation of the PUMP OFF SWITCH, in feet? Elevation of the upper LATERAL, in feet? DELIVERY PIPE distance, from pump to manifold, in feet? DELIVERY PIPE diameter, in inches (if not 2" -use 2" min)? Design DISTAL PRESSURE, in feet (if not 2.5)? (hd) IS MANIFOLD CENTER -FED & SYMETRICAL (yes or no)? How many orifices in the MANIFOLD? MANIFOLD ORIFICE diameter, in inches (if not 5/16") MANIFOLD DIAMETER (if not 2" -use 2" min)? TOTAL LENGTH OF MANIFOLD Does MANIFOLD drain to FIELD after dose (yes or no)? How many LATERALS? Pumping chamber weep hole size (usually .25") PROGRAM WILL CALCULATE UP TO 26 LATERALS AND UP Your HIGHEST elevation lateral MUST be LATERAL 1: (first orifice from lateral 1/2 of orifice spacing) Length of each LATERAL, in feet? Diameter of each LATERAL, in inches (1.5" min)? Elevation of each LATERAL, in feet? Number of ORIFICES per lateral Distance from Manifold to closest Orifice, in feet ORIFICE SPACING, in feet Diameter of ORIFICES, in inches? (D) Square feet of leachfield per laterals (can ignore) Maximum number of orifices in any one lateral Minimum lateral diameter 440 Calculated by: SEP & TKH Date: 9/2/ 93.1 Checked by: f Date: CAI 99.42 68.75 _66.75 F 53 '68.75 1.5 3YES 1.5 RECEIVED yes 1.5 1.5'•, 0 99.421 99:421 0 4 0.3125 4 SEP 1.0 2004 20 22 22 no 7 22 TOWN OF NORTH ANDOVER 0.1875 USE O IF FORCE MAIN DOES NOTID IN HEALTH DEPARTMENT 50 ORIFICES PER LATERAL 1.56 Lateral l: .,. Lateral 2: Lateral 3: Lateral 4: Lateral 5: Lateral 5: Lateral 5: 68.75.x.- 68.75 68.75 68.75 _66.75 F ..__ 66.75_ '68.75 1.5 1.5 1.5 1.5 1.5 1.5 1.5'•, 99.428 99.421 99:421 99.42( 99.42; 99.421 99.42 22 22 22 22 22 22 22? 1.56 1.56 1.56 1.56 1.56 1.56 1.561 3.13; 3.131 3.131 3.131 3.131 3.131 3.13 0.125 0.125 0.125 0.125 0.125 0.125 0.1251 324.5[ 324.51 _ 324.5 32451 324.5! 324.5 3245 _ „ 1.5 AE"y5O�t l , 021721 k FRICTION CALCULATIONS (using Hazen Williams friction ft= Ld((3.55Qm/Ch(Dd^2.63)))^1.85 PRESSURE CALCULATIONS (using orifice dischage equation Q=11.79 D^2 hd^.5 Laterall: Lateral 2: LATERAL DISCHAGE (first approximation) 7.02 7.02 MANIFOLD ORIFICE DISCHARGE 0.00 TOTAL SYSTEM DISCHAGE (first approximation) 49.14 TOTAL DISCHARGE PER LATERAL DISCHARGE PER SQUARE FOOT OF LEACHFIELD ORIFICE MAXIMUM DISCHARGE BY LATERAL ORIFICE MINIMUM DISCHARGE BY LATERAL ORIFICE % DIFFERENCE DISCHARGE within LATERAL MAXIMUM DISCHARGE LATERAL MINIMUM DISCHARGE LATERAL MAXIMUM DISCHARGE PER SQUARE FOOT MINIMUM DISCHARGE PER SQUARE FOOT • DIFFERENCE DISCHARGE for SYSTEM by orifice • DIFFERENCE DISCHARGE for SYSTEM by laterals • DIFFERENCE DISCHARGE for SYSTEM by square feet WEEP HOLE DISCHARGE (usually a 1/4" weep hole) VOID VOLUME IN DELIVERY PIPE VOID VOLUME IN MANIFOLD VOID VOLUME IN EACH LATERAL TOTAL LATERAL VOID VOLUME Hole Hole Lateral 3: Lateral 4: Lateral 5: Lateral 6: Lateral 7: 7.02 7.02 7.02 7.02 7.02 7.03 7.03 7.03 7.03 7.03 7.03 7.03 0.02165091 0.02165091 0.0216509 0.0216509 0.0216509 0.0216509 0.0216509 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.32 0.2% 0.2% 0.2% 0.2% 0.2% 7.03 7.03 0.02 0.02 #REF! as percent of maximum orifice in system 0.0% as percent of maximum lateral in system 0.0% as percent of maximum square foot in system 1.12 weep hole= 0.1875 inch 19.46 13.06 6.31 6.31 6.31 6.31 6.31 31.55 MINIMUM DOSE VOLUME (based on void volume) 157.77 to 315.54 MIN ACTUAL MINIMUM IS BASED ON DAILY DESIGN FLOW (weep hole, usually 1/4", not counted for dose, effluent is repumped during process and not counted for friction, except as fitting headloss) TOTAL HEAD LOSS IN EACH LATERAL 0.14 0.14 0.14 0.14 0.14 0.14 0.14 MAXIMUM TOTAL LATERAL HEADLOSS IN SYSTEM 0.14 MANIFOLD HEADLOSS (center -fed unless manifold design) 0.01 DELIVERY PIPE HEADLOSS 0.33 w/ delivery 3 inch diameter FITTING LOSS (headloss'.15) 0.45 add extra head if fittings are more than absolute minimum DISTAL PRESSURE HEAD 3.00 STATIC HEAD (OFF -SWITCH TO HIGH LATERAUMANIFOLD) 6.32 HEADLOSS PUMP TO WEEPHOLE (assume 3' run) 0.02 PUMP MUST BE ABLE TO PASS SOLIDS AT or After OTIS (network losses=1.3'distal head) 50.30 G.P.M 10.27 FEET OF HEAD 50.30 G.P.M. 13.60 FEET OF HEAD 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 -'"�- 0 Commonwealth of Massachusetts City/Town of Form 9A — Application for Local O Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR 5.404(1), is not feasible. 310 CMR 15.403(4) requires the system owner to provide a copy of the local upgrade approval to the appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before commencement of construction. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.417. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. A. Facility Information Important: When filling out 1. Facility Name and Address: forms on the computer, use Brian Arsnow only the tab key Name to move your 100 Raleigh Tavern Lane cursor - do not Street Address use the return key. North Andover MA 01845 Cityrrown State Zip Code 2. Owner Name and Address (if different from above): IL same ren Name Street Address Cityrrown State Zip Code Telephone Number 3. Type of Facility (check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: Installation of new residential subsurface sewage disposal system. 5. Type of Existing System: ❑ Privy ❑ Cesspooi(s) ® Conventional ❑ Other (describe below): Current residential sewage disposal system is in failure. 100 RALEIGH TAVERN LN - FORM 9a • rev. 5/02 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of Form 9A - Application for Local Upgrade Approval .y y.0y`0 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Leach field 7. Design Flow per 310 CMR 15.203: Design flow of existing system: Design flow of proposed upgraded system Design flow of facility: B. Proposed Upgrade of System 1. Proposed upgrade is (check one): Unknown gpd 440 gpd n/a gpd ® Voluntary ❑ Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: 2. Describe the proposed upgrade to the system: 3. Local Upgrade Approval is requested for (check all that apply): date of inspection ® Reduction in setback(s) — describe reductions: Request reduction in setback distance between leach field and wetlands from 50 feet required by Title 5 Section 211 (1) to 32 feet. ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. % reduction ❑ Reduction in separation between the SAS and high groundwater: Separation reduction Percolation rate min./inch Depth to groundwater ft 100 RALEIGH TAVERN LN - FORM 9a • rev. 5/02 Application for Local Upgrade Approval* Page 2 of 4 0 Commonwealth of Massachusetts City/Town of Form 9A - Application for Local Eel Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Other requirements of 310 CMR 15.000 that cannot be met— describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(i)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by: Andrew McBrearty Evaluator's Name (type or print) Signature C. Explanation 8/3/04 Date of evaluation Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: No other location available on the lot for the system size reauired. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: A 1500 gallon Micro Fast Septic tank is included in the design. 100 RALEIGH TAVERN LN - FORM 9a • rev. 5/02 Application for Local Upgrade Approval* Page 3 of 4 O O Commonwealth of Massachusetts City/Town of a Form 9A - Application for Local Upgrade Approval �N DEP has provided this form for use by local Boards of Health: Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: 4. Connection to a public sewer is not feasible: Town sewer is not in the area of the property. 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ❑ Application for Disposal System Construction Permit ❑ Complete plans and specifications ❑ Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other (List): D. Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for deliberate violations." 9/9/04 Facility Owner's Signature Date Benjamin C. Osgood, Jr. (Agent for owner) Print Name New England Engineering Name of Preparer 60 Beechwood Drive Preparer's address MA State/ZIP Code 9/9/04 Date North Andover City/Town 978-686-1768 Telephone 100 RALEIGH TAVERN LN - FORM 9a • rev. 5/02 Application for Local Upgrade Approval* Page 4 of 4 68x27!2604 98:57 178133¢9.115 TANGARDF' PAGE' 01 Q FORM 11 -.S01 -L EVALUATOR FORM Page 1 of 3 No. � u.to:Y� Commonwealth of Massachusetts Al 0 Ar_-,c:;/� ,Massachusetts Soil Suitabillo Assessment or_ On-site Sewaze_ Dismal Performed By: Lc� �:.... `.. ,r .�� Date: 06100 witnessed By: .. ... .../%G: �"-�. �G iIr- ..... ............._ ..... . LteaaOn AeW/Ei5 a !�r"' �� / o•ot Name, i tol f C^�,�, �1� � /��F7�'� 4��+' ,•QCM,fs. Ld �v �P' %7`�G ✓✓K fr' / ,�� - ew construction El Repair Repalr r e Office Review � Published Soil Survey Available: No ❑ Yes �Y Year Published �� . , .......... Publication Scale Soil M p Unit l')rainage Class . Soil Limitations Surficiai Geologic Report Available: No Yes Year Published Publication Sc— :... . Geologic Material (Map Unit).---- ... ..... ..::... ..... ...............:...:.:.. Landform -- Flood Insurance Rate Map: ,Above $00 year food boundary No Dyes 1 Within 500 year flood boundary No Dyes ❑ U l&jin 100 year flood boundary No [1 Yes Wetland Area: National Wetland Inventory Map (map urtit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): TAontt: 7 Range ;Above Normal Normal ❑Bek�v Norma 15 Other References Reviewed: 1)EP APPRoi'£ts FORS 12197195 VVl Lff iV VT-, .'VL!. Jf .Lf V1JJYV1IJ ,HI{t-�fiRlJjC - r(.yi,'a�„ L'I�. FAIL q II - SOILI�NALUATOR FORM Page 2 (If vt AlLocation Address or Lat ,Ja. A ,A -site Rei{iew Beep Hole Number Date: Time: Weathel Location (identify on site plan) r,• .....`-`'-..(.":.. . 'Land Use o� ` !��<� 77—A::� Slope 1%) SUrface Stones 'Vegetation v t3,04�, . ——...... Landform Position on landscape ��T Distances from: Open Water Body �� fee? Drainage way feet Possib a Wet Area 4�ff feet Property Line .. ��.. . feet Drinking Water Well �/14 feet Other ... DEEP OBSERVATION! HOLE LOG Depth `rpm Surfeoe (InCheS) Soil Horizon Soil Texture (USDA) Soil Color (Munsall) Soil Mottling ot"r IStructure, Stones, Souiders. Consistpney, % � (3rave.l) i s� f ~~ f 5?4 I L5 41 .,, latent Nf8tOr181 {gyologic) �6/9 �G - _ DepthtoOedrock: Dgath to Grourdwat"r: S.an+ding Water in the. e, _— Weeping &am Pit Face - Hol Estimated Seasonal High Ground Water UEP APPROVED FORA, , LV07,95 ti �XU4 .pct: b i 1 03:i3j4N11`-- TANGAARUR F9GE 03 0 FORM 11 - SOIL EVALUATOR FOR.M Location Address or Lot No. On -.sate ReNa�� C)eep Hole Number �' Do e• �� Time: / 1/ Weather !,�-�- / f,2 T Location (identify on site plerlf x _.. ,, ,....�.::.:.::.:::....,::. ,c-� ..:,......... .... .... .:.. Land Use,-�tr?kSlape (gib) Surface Stones Vegetation Landform Positron or. landscape Distances from: 0 Open Water body feet Drainage wey�feet Possible Wet Area feet Proper*.y Line ..�.. feet Drinking Water We11*4 feet. Other ....::--.........:...:........:: } DEEP OBSERVATION HOLE LOG Depth fro?+ $lirface (Inches] toil HorirOn Sall Texture IUSDA,) $oil Calor JAuneagt Soil Mottling Dther i (Structure, acnes, 9ovltiers, Consi*vartv;: Gravel; 4 Y� 49 1 IL I rr ! i Parent Material (geologic) —e -L DepthtOSed.ock: Depth to Groundwiter: Standing Water iz the Ho!e: _ weeping from ph !'ace: Estimated Seasonal High Ground Water - IMP A,PPRC}M F0101 - 1210735 11�1 G r/ ZUIU4. : 00. O I i b JJ4U11--, 1 AIIAUAKIf •Hat_,; t74 O Page 3 of 3 Location Address or Lot No, Determing ions for Seasonal Hieh Water Table Method Used: Depth observed standing in observation hole,..... inches Q Depth weeping from side of observation hole. inches Depth to soil mottles ... -L<� inches 4;&1— Ground, water adjustment .................. feet Index Well NLmber ............ Reading Date ...... Inaex well level ,Adjustment factor ..........•.... Adjusted ground water level Depth of Naturally Occurring Pervious Material Does at least four fleet of naturally occurring pervious material exist In it�areas observed throughout the area proposed for the soil absorption system? If not, what Is the depth of naturally occurring pervious material? Certification I certify that on �(. �a (date) I have passed the soil evaluator examination approved by the Department cif Environmentalrotection and that the ab . e analysis was performed by me consistent with the required training, expertise and experience ddscribed in 310 CMR 15.017. >� signature _ �✓ C3ate�.--- DEP kPPFONID FORM - 12MV95 NEW ENGLAND ENGINEERING SERVICES INC September 17, 2004 Susan Sawyer North Andover Board of Health 27 Charles Street North Andover, MA 01845 Re: 100 Raleigh Tavern Lane, North Andover, Local Bylaw Waiver Request Dear Susan, j jE- VE® SEP 2 0 2004 TOWN OF NORTH ANDOVER HEALTH DEP�� The purpose of this letter is to request that the above referenced property be included in the upcoming Board of Health meeting agenda to discuss the following variances: Local Bylaw Waivers Required 1. Allow reduction in offset distance between leach bed and wetlands from 100 feet required to 32 feet. If you have any comments or questions please do not hesitate to contact this office. Sincerely, -'00�/ Steven E. Pouliot Project ivia7nager 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 NEW ENGLAND ENGINEERING SERVICES INC September 17, 2004 Susan Sawyer North Andover Board of Health 27 Charles Street North Andover, MA 01845 e�1,�!Q.Ialeigh Tavern Lane, North Andover 69 Oakes Drive, North Andover Dear Susan, SEP 2 0 �Q TOWN of EAST(- Enclosed please find original copies of request letters for the aforementioned properties previously sent, via fax, to your office. Sincerely, Steven E. Pouliot Project Manager 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 C) TOWN OF NORTH ANDOVER o� NoeT Office of COMMUNITY DEVELOPMENT AND SERVICES � s 9 HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 'aS�ceusst Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX September 28, 2004 Benjamin C. Osgood, Jr, P.E. New England Engineering Services, Inc. 60 Beechwood Drive North Andover, MA 01845 RE: 100 Raleigh Tavern Lane, North Andover, MA Dear Mr. Osgood, The proposed septic system design plans for the above site dated September 8, 2004 and received on September 10, 2004 has been reviewed. Unfortunately, it cannot be approved until the following items are corrected. Each item is followed by the specific section in Title 5: 310 CMR 15.000, or North Andover regulation which is not met by this design. 1. Please show the offset of the system to surface water. (3 10 CMR 15.211). 2. The plan includes the use of a DEP-approved wastewater pretreatment unit and gravel - less chambers (Infiltrator brand). The Design Data shows the a reduction of leaching area is calculated for both features. This is a "double credit" and is not allowed under Title 5. Infiltrator Chambers may be used, but are not allowed to reduce leaching field size when using pre-treatment. 3. The LTAR as given in this plan is 0.20 when it should be 0.15. The "Bio-Microbics Remedial Use Approval MicroFAST" approval letter states in the Design Standards (section 11.4): The System may be used in soils with a percolation rate of up to 90 min./inch. For soils with a percolation rate of 60 to 90 min/inch, the effluent loading rate shall be 0.15 GPD/ sq. ft. 4. The dose volume for the pump chamber does not meet the minimum dose volume required by the calculations provided (109 gal —vs- 157.7 gal) (3 10 CMR 15.254(c)(2)). 5. Pump chamber does not specify a maximum cover. (3 10 CMR 15.221(7)). 6. Treatment tank does not specify compact base and stone beneath tank. (3 10 CMR 15.221(2)) 7. Access manholes are not specified on treatment tank. (310 CMR 15.228(2)) 8. Cover over treatment tank (max & min) is not specified (310 CMR 15.228(1) & 15.221(7)) 9. Location of blower unit and vent for the treatment device is not specified. 10. Tank size indicated on design plan is not in accordance with Micro -Fast approval documents as issued by the Massachusetts Department of Environmental Protection. 11. Please clarify your intended treatment unit as both MicroFAST and Single Home FAST are indicated on the design plan. C) 12. The tank detail provided does not have the inlet tee to the sewptic tank designed in accordance with standards in Title 5 (3 10 CMR 15.227) 13. Please.include a copy of the approval letter for use of the treatment unit with subsequent submissions. 14. Construction note 8 should be removed, as it references a Distribution Box, which is not present on this plan. 15. Please clarify the notation to the existing septic tank and whether it is to be removed or re -used. 16. Please specify the tank loading (3 10 CMR 15.227) 17. Please provide water department records or other documentation to confirm the existing water line route as depicted. 18. Please provide a draft operations and maintenance agreement for the treatment unit and pressure distribution system. 19. Please indicate the date of wetland delineation, name of delineator, and whether this has been accepted by the Conservation Commission. Although not a reason for disapproval, the following items might be considered to aid the contractor in construction of this system: 1. Please provide a detail of the rip rap slope at the low side of the SAS. 2. Please provide a design squirt height on the plans. 3. This design might consider available credits when using a treatment unit under the Remedial Use Approval such as reducing the size or ground water separation. If such a credit is being utilized, please indicate this on the design plan. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a septic system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. VSincerel�HS/ alth Director cc: Owner File NEW ENGLAND ENGINEERING SERVICES INC October 7, 2004 OCT 0 1 ��WPV flr`NOr_. . Susan Sawyer yAtrN:�l North Andover Board of Health�vl 27 Charles Street North Andover, MA 01845 Re: 100 Raleigh Tavern Lane Lane, North Andover Dear Susan: Enclosed are 5 copies of revised plans for the above referenced property. These plans have been revised to address the comments of your letter dated September 28, 2004 as follows. . The surface water is some distance away but the swamp between the surface water and the project is to thick to negotiate and take an accurate measurement. A leader showing a distance of 100' + to the surface water has been added. ,i2. The design notes have been revised to reflect the proper computations. The Fast System has been used to reduce the required field size by 50% and the infiltrator credit has been eliminated. -,-3. The long term acceptance rate has been changed to 0.15 gallons per day in the design calculations. Although the design calculations have changed the size of the system remains the same. v-* The dose volume has been revised to a minimum of 5 times the system volume. 1115. The maximum and min cover over the pump chamber have been specified. .-6: The stone is specified beneath the treatment tank. 1-7: The access manholes are specified on the treatment tank. ,i8. The maximum and minimum cover over the treatment tank have been specified. V-91. The location of the blower unit and vent have been shown. 10. The tank size for the Micro Fast has been changed. ' ,,,�l 1. The treatment system is a micro Fast and has been specified as such in both locations. 12. The inlet tee design has been revised to meet title 5. ,,13. The approval letter for the fast treatment system is enclosed. l/14. Construction note # 9 has been removed. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 Ce ,'15. The note regarding the reuse of the existing septic tank has been removed. i 6. The tank loading is specified. X17. The water line was marked in the field as shown, however the records do not provide the detail of its location. A note has been added that the location will have to be verified in the field by the contractor and relocated if required. ✓18. A copy of the draft operation and maintenance agreement is enclosed. --19. The wetland delineator has been identified. The line has been accepted by the commission. Several additional comments were noted in the letter. The design squirt height has been added to the plans. The calculations were revised to reflect an additional comment. Your quick review of these plans would be appreciated since the owner is anxious to commence construction. If you have any questions please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr., P.E. President x TOWN OF NORTH ANDOVER °' a°R*M , Office of COMMUNITY DEVELOPMENT AND SERVICES F HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX October 13, 2004 Brian Arsnow 100 Raleigh Tavern Lane North Andover, MA 01845 Re: 100 Raleigh Tavern Lane, Map 107A, Lot 109 Dear Arsnow, The North Andover Board of Health has completed the review of the septic system design plans, for the above referenced property, submitted on your behalf by Engineering & Surveying Services dated September 8, 2004 (Last Rev. October 5, 2004, received October 7, 2004). In addition, at a Board of Health meeting held on September 23, 2004, the BOH members voted to approve a local upgrade and a local variance as follows: 1) Local Upgrade Approval - A reduction in the offset distance between the leach bed and a wetland from 50 feet to 32 feet 2) A Local bylaw variance approval - A reduction to the offset between the leach bed and a wetland from 100 feet to 32 feet The 4 -bedroom design has been approved for use in the construction of a replacement onsite septic system. This general approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance must be endorsed by the installer, designer. and the Town of North Andover. The time period for which this plan is valid is reduced to two years from the date of a septic system inspection that did not meet the acceptable criteria in the state regulations. . This approval is subject to the following conditions: 1. A signed maintenance agreement must be submitted prior to the issuance of a Certificate of Compliance will be issued by the Health Department 2. The attached DEP Form 9b must be submitted to the appropriate Regional Office of the Department of Environmental Protection at One Winter Street, Boston MA by the property owner. 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 (310 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 N 10C 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 witli any of the aforementioned requirements. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincerel , us Y. S� H /RSA Pub is Health Director cc: Engineering and Surveying Services Date: Customer: Mailing Address: Site: Operation and Maintenance Service Contract for Pressure Distribution Soil Absorption System This form is a suggested format. You and your service provider may choose a different type of form. Service Co.: Service Address: Service Phone: This Company agrees to provide service and maintenance for the Pressure Distribution Disposal Field at the above referenced address. The following maintenance and service schedule is proposed for the next (2) two years of operation commencing upon the date of Certificate of Compliance, receipt of the signed contract and the annual cost in full. Scheduled Annual Service Cost: 4 visits per year at $ per visit = $ (Note: all covers and access ports must be to grade to allow for maintenance.) Check sludge and scum depth and clean the effluent filter in the 1500 -gallon septic tank. Check panel and alarm system. Check ejector pump and float switches in the Pump Chamber. Check distal pressure and compare with design plan. Clean and flush laterals as necessary. Notify client verbally of any problems encountered. Notify North Andover Board of Health and owner within 24 hours of a system failure or alarm event with corrective action taken. Unscheduled Service Unscheduled emergency service calls will be billed at the following hourly rate: ➢ Monday through Friday from 7 a.m. — 5 p.m. = $ per hour ➢ Monday through Friday from 5 p.m. — 7 a.m. = $ per hour ➢ Saturday and Sunday with a minimum 2 hr charge = $ In accordance with the Title V Regulations, quarterly inspection reports will be submitted to the local Board of Health. Acceptance by Owner: Signature Acceptance by Inspector: Signature C:\My Documents\Septic\O&P Service Contract for Pressure Distribution SAS.docCreated on 9/10/2004 2:01 PM 0 Commonwealth of Massachusetts City/Town of Local Upgrade Approval Form 96 �M Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q a DEP has provided this form for use by local Boards of Health if they choose to do so. The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. The system owner shall provide a copy of the Local Upgrade Approval to the appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before commencement of construction. A. Facility Information 1. Facility Name and Address Rrian Arsnow Name 100 Raleigh Tavern lane Street Address North Andover City/Town 2. Owner Name and Address (if different from above): Name Citylrown4 Zip Code 3. Type of Facility (check all that apply): X Residential ❑ Institutional MA 01845 State Zip Code Street Address State Telephone Number ❑ Commercial ❑ School 440 4. uesign rlow per siu t�ivim -i o./ -u -j- gpd 5. System Designer: Ben OsgoodName ® PE E] RS 60 Beechwood Drive North Andover 01845 Address Citylrown State, ZIP B. Approval 1. Local Upgrade Approval is granted for: ® Reduction in setback(s) — specify: Reduction in offset distance between the leach bed and the wetlands from 50 feet to 32 feet ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. % reduction 100 Raleigh Tavern Lane 9b • rev. 5/02 Local Upgrade Approval* Page 1 of 1 0 Commonwealth of Massachusetts City/Town of Local Upgrade Approval Form 9B y �M B. Approval (continued) ❑ Reduction in separation between the SAS and high groundwater: Separation reduction Percolation rate Depth to groundwater ❑ Relocation of water supply well (explain): ft. min./inch ft. List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: North Andover Health Department Approving Authority Susan Sawyer, Health Dir. 9/23/04 Print or Type Name and Title Si ature Date 100 Raleigh Tavern Lane 9b • rev. 5/02 Local Upgrade Approval, Page 2 of 2 0 -\ COMMONWEALTH OF MASSACHUSETTS 1 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF EtiVIRONMENTAL PROTECTION ONE WINTER STREET, BOS �'C Ag�g17- 92-5500 MITT ROMNEY OCT 0 7 2004 Governor ELLEN ROY HERZFELDER KERRY HEALEY Secretary. TOWN DEPARTM ANDOVER Lieutenant Governor EDWARD P. KUNCE Acting Commissioner MODIFIED CERTIFICATION FOR GENERAL USE Pursuant to Title 5, 310 CMR 15:000 Name and Address of Applicant: Infiltrator Systems, Inc. P.O. Box 768 6 Business Park Road Old Saybrook, CT 06475 Trade name of technology and model: High Capacity Chamber, Standard Chamber, Infiltrator 3050 (Storm Tech SC -740) and Equalizer 24 and 36 (hereinafter the "System"). Transmittal Number: W023699 Date of Issuance: February 21, 2003 Date of Expiration: February 21, 2008 Authority for Issuance Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000, the Department of Environmental Protection hereby issues this Certification to: Infiltrator Systems, Inc., P.O. Box 768, 6 Business Park Road, Old Saybrook, CT 06475 (hereinafter "the Company"), for. General Use of the System described herein. Sale and use of the System are conditioned on and subject to compliance by the Company and the System owner with the terms and conditions set forth below. Any noncompliance with the terms or conditions of this Certification constitutes a violation of 310 CMR 15.000. Glenn Haas, Director Date Division of Watershed Management Department of Environmental Protection This information is available in alternate format. Call Aprel McCabe, ADA Coordinator at 1-617-556-1171. TAD Service - 1-800-298-2207. DEP on the World Wide Web: http://WwW.mass.gov/dep n ZJ Printed on Recycled Paper 0 Infiltrator Modified Certification for General Use Page 2 of 8 I. Purpose 1. The purpose of this Certification is to allow use of the System in Massachusetts, 'w on a General Use basis. 2. With the necessary permits and approvals required by 310 CMR 15.000, this Certification authorizes the use of the System in Massachusetts. 3. The System may be installed on all facilities where a system in compliance with 310 CMR 15.000 exists on site or could be built and. for which a site evaluation in compliance with 310 CMR 15.000 has been approved by the local approving authority, or by DEP if DEP approval is required by 310 CMR 15.000. 11 Design Standards 1. The models listed below are covered under this Certification. Model Dimensions W x L x H Inches Invert Height Inches Equalizer 24 15 x 100 x 11 6 Equalizer 36 22 x 100 x 13.5 6 Standard Chamber 34 x 75 x 12 6.5 Infiltrator 3050 or StonnTech SC -740 51 x 85.4 x 30 24 High Capacity Chamber 34 x 75 x 16 11 2. The System is an open -bottom leaching unit molded from polyolefin resin. It can be installed without aggregate or distribution pipe as an absorption trench in accordance with the requirements in 310 CMR 15.251. 3. The use of acy as specified in 310 CMR 15.247 is not necessary with the System when installed as a trench, bed or field. 4. The minimum separation between any two trenches, shall be as specified in 310 CMR 15.251. 5. For new construction, the applicant can size the System in a trench configuration without aggregate, using the effective leaching areas presented in the following table. No System shall be designed and constructed with a soil absorption system area of less than 400 square feet. Infiltrator Modified Certification for General Use Page 3 of 3 2 Effective leaching area is equal to 1.67 times the bottom width plus two x invert. Effective leaching area is equal to 1.0 times the bottom width plus two x invert. 6. Systems shall be sized in accordance'. with the following table for new construction in DEP designated nitrogen limited areas as defined in 310 CMR 15.214 and 15.215. The effective leaching area, as shown in the following table, shall be used for any System . installed in a Department designated Nitrogen Sensitive Area or for any System that is installed for new construction where a private drinking water supply well is proposed to serve the facility, as defined in 310 CMR 15.214 (2) and for which a variance to the minimum setback distance of 100 feet has been granted. Effective Effective Model Leachings Leaching Area Area 2.3 SF/LF SF/LF Equalizer 24 3.75 NA Equalizer 36 . 4.73 NA Standard Chamber 6.53 NA Infiltrator 3,050 or NA 8.2 StormTech SC -740 High Capacity Chamber 7.79 NA Effective leaching area is equal to 1.67 times the bottom width plus two x invert. Effective leaching area is equal to 1.0 times the bottom width plus two x invert. 6. Systems shall be sized in accordance'. with the following table for new construction in DEP designated nitrogen limited areas as defined in 310 CMR 15.214 and 15.215. The effective leaching area, as shown in the following table, shall be used for any System . installed in a Department designated Nitrogen Sensitive Area or for any System that is installed for new construction where a private drinking water supply well is proposed to serve the facility, as defined in 310 CMR 15.214 (2) and for which a variance to the minimum setback distance of 100 feet has been granted. 1. Effective leaching area is equal to 1.0 times the bottom width plus two x invert. 7. Systems installed on remedial sites shall be allowed to utilize the effective leaching areas presented in item 5 above or additional reductions in soil absorption leaching area approved by the approving authority in accordance with 310 CMR 15.284. In no instance shall the reduction in the soil absorption system required in 310 CMR 15.242 exceed the maximum reduction allowed for alternative systems approved in accordance with 310 CMR 15.284. The effective leaching areas presented in item 6 above shall be used for remedial sites located in Effective Model Leachingl Area SF/LF Equalizer 24 2.3 Equalizer 36 2.8 Standard Chamber 4.0 Infiltrator 3050 and 8.2 Storm Tech SC -740 High Capacity Chamber 4.5 1. Effective leaching area is equal to 1.0 times the bottom width plus two x invert. 7. Systems installed on remedial sites shall be allowed to utilize the effective leaching areas presented in item 5 above or additional reductions in soil absorption leaching area approved by the approving authority in accordance with 310 CMR 15.284. In no instance shall the reduction in the soil absorption system required in 310 CMR 15.242 exceed the maximum reduction allowed for alternative systems approved in accordance with 310 CMR 15.284. The effective leaching areas presented in item 6 above shall be used for remedial sites located in K i\ Infiltrator Modified Certification for General Use Page 4 of 8 Department designated Zone H or IWPA when the facility is to be brought into full compliance in accordance with 310 CMR 15.404. 8. In accordance with 310 CMR 15.240 (6) absorption trenches should be used whenever possible. When the System is installed for new construction without aggregate in a bed or field configuration, as defined in 310 CMR 15.252, the System shall be designed using the effective leaching area for the bottom width presented in the following table. C hambers shall be spaced a minimum of six inches apart' (edge -to -edge) when used in a bed configuration. No system shall be designed and constructed with a leaching area of less than 400 square feet. The effective 1 eaching a rea s hall o my b e e qual t o t he bottom width for any System installed in a Department designated Nitrogen Sensitive Area or for any System that is installed for new construction where a private drinking water supply well is proposed to serve the facility, as defined in 310 CMR 15.214 (2) and for which a variance to the minimum setback distance of 100 feet has been granted. II 1. Effective Leaching area is equal to 1.67 times bottom width only. 2. Effective leaching area for Infiltrator 3050 or StormTech SC -740 is equal to 1.0 times the bottom width 9. The System, when installed in a bed or field configuration without aggregate on remedial sites, shall utilize the effective leaching areas presented in item 8 above or additional reductions in soil absorption system area approved by the approving authority in accordance with 310 CMR 15.284. In no instance shall the reduction in the soil absorption system area required in 310 CMR 15.242 exceed the maximum reduction allowed for alternative systems approved in accordance with 310 CMR 15.284. 10. The System, when installed as specified in 310 CMR 15.253: Pits, Galleries, or Chambers, shall have an aggregate base and/or be surrounded by aggregate and shall be sized as specified in 310 CMR 15.253 (1) (a) and (b). Effective depth can be increased up to two feet with the corresponding addition of up to 14 inches of base aggregate. Bottom width can be increased by two to eight-SF/LF with the corresponding addition of one to four feet of aggregate per side. Effective Leachings Model Area SF/LF Equalizer 24 2.08 Equalizer 36 3.05 Standard Chamber 4.72 Infiltrator 3050 or 4.25 StormTech SC -740 High Capacity Chamber 4.72 1. Effective Leaching area is equal to 1.67 times bottom width only. 2. Effective leaching area for Infiltrator 3050 or StormTech SC -740 is equal to 1.0 times the bottom width 9. The System, when installed in a bed or field configuration without aggregate on remedial sites, shall utilize the effective leaching areas presented in item 8 above or additional reductions in soil absorption system area approved by the approving authority in accordance with 310 CMR 15.284. In no instance shall the reduction in the soil absorption system area required in 310 CMR 15.242 exceed the maximum reduction allowed for alternative systems approved in accordance with 310 CMR 15.284. 10. The System, when installed as specified in 310 CMR 15.253: Pits, Galleries, or Chambers, shall have an aggregate base and/or be surrounded by aggregate and shall be sized as specified in 310 CMR 15.253 (1) (a) and (b). Effective depth can be increased up to two feet with the corresponding addition of up to 14 inches of base aggregate. Bottom width can be increased by two to eight-SF/LF with the corresponding addition of one to four feet of aggregate per side. Infiltrator ``Iodified Certification for General Use Pa -e5 of 8 11. The requirement that Chambers installed in trench configuration as specified in 310 CMR.15.253(6) be provided with inlets at intervals not to exceed 20 feet is not applicable to the System. III. General Conditions 1. The provisions of 310 CMR 15.000 are applicable to the use of the System, except those that specifically have been. varied by the terms of this Certification. 2. The facility served by the System, and the System itself, shall be open to inspection and sampling by the Department and the local approving authority at all reasonable times. 3. In accordance with applicable law, the Department and the local approving authority may require the owner of the System to cease use of the System and/or, to take any other action as it deems necessary to protect public health, safety, welfare or the environment. 4. The Department has not determined that the performance of the System will provide a level of protection to the environment that is at least equivalent to that of a sewer. Accordingly, no new System shall be constructed, and no System shall be upgraded or expanded, if it is feasible to connect the facility to a sanitary sewer, unless allowed pursuant to 310 CMR 15.004. 5. Design, installation and use of the System shall be in strict conformance with the Company's DEP approved plans and specifications and 310 CMR 15.000, subject. to this Certification. IV. Conditions Applicable to the System Owner 1. The System is approved for the treatment and disposal of sanitary sewage only. Any wastes that are non -sanitary sewage generated or used at the facility served by the System shall not be introduced into the on-site sewage disposal system and shall be lawfully disposed of. 2. For new construction, the owner initially shall size a soil absorption system in accordance with 310 CMR 15.242 to demonstrate that a conventional Title 5 soil adsorption system using aggregate, including a reserve area, can be installed on the site. The owner may than size the soil absorption system for the System. The total area required for the aggregate system, which may include the area designated for the System, and a reserve area shall be preserved and the owner shall ensure that no p ermanent structures or other structures are constructed on that area and that the area is not disturbed in any manner that will render it unusable for future installation of a conventional Title 5 soil absorption system. o Infiltrator Modified Certification for General Use Page 6 of 8 3. The owner of the System shall at all times properly operate and maintain the on- site sewage disposal system. 4. The owner shall furnish the Department any information that the Department requests regarding the operation and performance of the System, within 21 days of the date of receipt of that request. 5. No owner shall authorize or allow the installation of the System other than by a person trained by the Company to install the System. V. Conditions Applicable to the Company 1. By January 31st of each year, the Company shall submit to the Department a report, signed by a corporate officer, general partner, or Company owner that contains information on the System for the previous calendar year. The report shall state known failures, malfunctions, and corrective actions taken for the System as well as the date and address of each event. 2. The Company shall notify the Department's Director of Watershed Permitting at. least 30 days in advance of any proposed transfer of ownership of the technology for which this Certification is issued. Said notification shall include the name and address of the proposed new owner and a written agreement between the existing and proposed new owner containing a specific date for transfer of ownership, responsibility, coverage and liability between them. All provisions of this Certification applicable to the Company shall be applicable to successors and assigns of the Company, unless the Department determines otherwise. 3. The Company shall furnish the Department any information that the Department requests regarding the System, within 21 days of the date of receipt of that request. 4. Prior to any sale of the System, the Company shall provide the purchaser with a copy of this Certification. In any contract for distribution or sale of the .System, the Company shall require the distributor or seller to provide the purchaser of the System, prior to any sale of the System, with a copy of this Certification. 5. If the Company wishes to continue this Certification after its expiration date, .the Company shall apply for and obtain a renewal of this Certification. The Company shall submit a renewal application at least 180 days before the expiration. date of this Certification, unless written permission for a later date has been granted by the Department. 6. The Company shall prepare an installation manual specifically detailing procedures for installation of its System. The Company shall institute and maintain a training program in the proper installation of its System in accordance with the manual a nd provide a training course at least annually for prospective o Infiltrator Modified Certification for General Use Page 7 of 8 installers. The Company shall certify that installers have passed the Company's training qualifications, maintain a list of certified installers, submit a copy to the Department, and update the list annually. Updated lists shall be forwarded to the Department. 7. The Company shall not sell the System to installers unless they are trained to install these Systems by the Company. VI. Conditions Applicable to Installers of the System 1. Each Installer shall install the System in accordance with Company training on the installation of the System and the conditions of this Certification. 2. No Installer shall install the System unless the Installer has been trained by the Company on installation of the System. VII. Reporting 1. All submittals of notices and documents to the Department required by this Certification shall be submitted to: Director Watershed Permitting Program Department of Environmental Protection One Winter Street - .6th floor Boston, Massachusetts 02108. VIII. Rights of the Department 1. The Department may suspend, modify or revoke this Certification for cause, including, but not limited to, non-compliance with the terms of this Certification, non-payment of an annual compliance assurance fee, for obtaining the Certification by misrepresentation or failure 'to disclose fully all relevant facts or any change in or discovery of conditions that would constitute grounds for discontinuance o f t he C ertification, o r a s n ecessary f or t he p rotection o f p ublic health, safety, welfare or the environment, and as authorized by applicable.law. The Department reserves its rights to take any enforcement action authorized by law with respect to this Certification, the System, the owner, or operator of the System and the Company. IX. Expiration Date 1. Notwithstanding the expiration date of this Certification, any System installed prior to the expiration date of this Certification, and approved, installed and maintained in compliance with this Certification (as it may be modified) and 310 Infiltrator Modified Certification for General Use Page 8 of 8 CMR 15.000, may remain in use unless the Department, the local approving. .authority, or, a court requires the System to be modified or removed, or requires discharges to the System to cease. W 023699 Infil. Reduced Size -Jan. 2003SHC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 MITT ROMNEY ELLEN ROY HERZFELDER GOveTI10T Secretary KERRY EEALEY Lieutenant Governor EDWARD P. KUNCE Acting Commissioner February 21, 2003 Carl W. Thompson, P.E. . Technical Director Infiltrator Systems, Inc. 6 Business Park Road Old Saybrook, CT 06475 Re: Application for WP61b Certification for General for Alternative System Trade Name of Technology and Model: Infiltrator Systems Transmittal No.: W023699 Dear Mr. Thompson: The Department has completed its review of your application for Certification for General Use for the above referenced technology. We are pleased to issue the enclosed Modified Certification for General Use for Infiltrator Systems. Should you have any questions regarding this Certification, or should you wish to meet with us to discuss any questions or concerns you, may have, please do not hesitate to contact Steven H. Corr at 617-292-5920. Sincerely, O _ Glenn Haas, Director Division. of Watershed Management Enclosure This information is available in alternate format. Call Aprel McCabe, ADA Coordinator at 1-617-556-1171. TDD Service - 1-800-298-2207. DEP on the World Wide Web: httpJ/www.mass.gov/dep J Printed on Recycled Paper t JANE SWIFT Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 jiECEIVED OCT 0 7 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT CERTIFICATION FOR GENERAL USE Pursuant to Title 5, 310 CMR 15.000 Name and Address of Applicant: Bio-Microbics, Inc. 8271 Melrose Drive Lenexa, KS 66214 BOB DURAND Secretary LAUREN A. LISS Commissioner Trade name of technology and model: MicroFAST Treatment System Models MicroFAST 0. 5, 0.75, 0.9, 1.5, 3.0, 4.5 and 9.0; HighStrengthFAST Treatment System Models HighStrengthFAST 1.0, 1.5, 3.0, 4.5 and 9.0 and NitriFAST Treatment System Models NitriFAST 0.5, 0.75, 1.0, 1.5, 3.0, 4.5 and 9.0 (hereinafter the "System"). A Schematic Drawing illustrating each FAST System is attached and is part of this Certification. Transmittal Number: W 012530 Date of Issuance: August 13, 2001 Expiration date: August 13, 2006 Authority for Issuance Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000, the Department of Environmental Protection hereby issues this Certification for General Use to: Bio-Microbics, Inc., 8450 Cole Parkway, Shawnee, KS 66227 (hereinafter "the Company"), certifying the System described herein for General Use in the Commonwealth of Massachusetts. Sale and use of the System are conditioned on and subject to compliance by the Company and the System owner with the terms and conditions set forth below. Any noncompliance with the terms or conditions of this Certification constitutes a violation of 310 CMR 15.000. Glenn Haas, Acting Assistant Commissioner Date Bureau of Resource Protection Department of Environmental of Environmental Protection This information is available in alternate format by calling our ADA Coordinator at (617) 574-61372. DEP on the Worid Wide Web: http:/ANvwv.sWe.ma.us/dep 0 Printed on Recycled Paper 0 0 Bio-Microbics Certification for General Use MicroFAST, HighStrengthFAST and NitriFAST I. Purpose 1. The purpose of this Certification is to allow the use of the System in Massachusetts on a General use basis. 2. With the necessary permits and approvals required by 310 CMR 15.000, this Certification authorizes the installation and use of the System in Massachusetts. The System may be installed on all facilities where a system in compliance with 310 CMR 15.000 exists on site or could be built and for which a site evaluations in compliance with 310 CMR 15.000 has been approved by the local approving authority or by DEP if DEP approval is required by 310 CMR 15.000. 4. The System is approved for use at facilities with a maximum design flow less than 10,000 gallons per day (GPD). H. Design Standards The FAST treatment system (Fixed Activated Sludge Treatment), Models MicroFAST 0. 5, 0.75, 0.9 and 1. 5, HighStrengthFAST 1.0 and 1.5 and NitriFAST 0.5, 0.75, 0.9 and 1.5 consist of a single tank having a primary settling zone and an aerobic biological zone. Solids are trapped in the primary settling zone where they settle. In the aerobic zone, the bacteria colony attaches itself to the surface of a submerged media bed and feeds on the sewage as it circulates. Models MicroFAST, HighStrengthFAST and NitriFAST 3.0, 4.5, and 9.0 consist of a standard Title 5 septic tank for settling solids and a second tank with the submerged media for aerobic treatment. 2. Models MicroFAST 0. 5, 0.75 and 0. 9, HighStrengthFAST 1.0 and NitriFAST 0. 5, 0.75 and 0.9 shall be installed in the second compartment of a two-compartment septic tank with a total liquid capacity of at least 1,500 gallons. Models MicroFAST, HighStrengthFAST and NitriFAST 1.5 shall be installed in the second compartment of a 3000 gallon tank. The two-compartment septic tank shall be installed between the building sewer and a standard Title 5 Soil Absorption System (SAS) constructed in accordance with 310 CMR 15.100 -15.279, subject to the provisions of this Approval. Models MicroFAST, HighStrengthFAST and NitriFAST 3.0, 4.5 and 9.0 shall be installed between a septic tank designed in accordance with 310 CMR 15.223 and the SAS. III. General Conditions The provisions of 310 CMR 15.000 are applicable to the use of this System, except those that specifically have been varied by the terms of this Certification. Page 2 of 6 O Bio-Microbics Certification for General Use MicroFAST, HighStrengthFAST and NitriFAST 2. Any required operation and maintenance, monitoring and testing shall be performed in accordance with a Department approved plan. Any required sample analysis shall be conducted by an independent U.S. EPA or DEP approved testing laboratory. It shall be a violation of this Certification to falsify any data collected pursuant to an approved testing plan, to omit any required data or to fail to submit any report required by such plan. 3. The facility served by the System, and the System itself, shall be open to inspection and sampling by the Department and the local approving authority at all reasonable times. 4. In accordance with applicable law, the Department or the local approving authority may require the owner of the System to cease operation of the System and/or to take any other action as it deems necessary to protect public health, safety, welfare or the environment. 5. The Department has not determined that the performance of the System will provide a level of protection to public health and safety and the environment that is at least equivalent to that of a sewer. Accordingly, no System shall be upgraded or expanded, if it is feasible to connect the facility to a sanitary sewer, unless as allowed pursuant to 310 CMR 15.004. 6. Design and installation and use of the System shall be in strict conformance with the Company's DEP approved plans and specifications and 310 CMR 15.000, subject to this Certification. IV. Conditions Applicable to the System Owner The System is certified in connection with the discharge of sanitary wastewater only. Any non -sanitary wastewater generated or used at the facility served by the System shall not be introduced into the System and shall be lawfully disposed of. 2. Operation and Maintenance agreement: Throughout its life, the System shall be under an operation and maintenance (O&M) agreement. No O&M agreement shall be for less than one year. ii. No System shall be used until an O&M agreement is submitted to the local approving authority which: Provides for the contracting of a person or firm competent in providing services consistent with the System's specifications and the operation and maintenance requirements specified by the designer and any specified by the Department; Page 3 of 6 • O Bio-Microbics Certification for General Use MicroFAST, HighStrengthFAST and NitriFAST Contains procedures for notification to the Department and to the local board of health within five days of a System failure, malfunction or alarm event and for corrective measures to be taken immediately; Provides the name of an operator, which must be a Massachusetts certified operator as required by 257 CMR 2.00 of an appropriate grade that will operate and monitor the System. The operator must operate and maintain the System at least every six months and anytime there is an alarm event. 3. The owner shall notify the Department and the local approving authority, in writing, within seven days of a change in the operator. 4. The owner of the System shall at all times have the System properly operated and maintained in accordance with the Company's and the designer's operation and maintenance requirements and this Certification. 5. The owner of the System shall provide a copy of this Certification, prior to the signing of a purchase and sale agreement for the facility served by the System or any portion thereof, to the proposed new owner. 6. The owner shall furnish the Department any information that the Department requests regarding the System, within 21 days of the date of receipt of that request. 7. By September 30'h of each year, the System owner shall submit to the Department and the local approving authority an O&M checklist and a technology checklist, completed by the System operator for each inspection performed during the previous 12 months. Copies of the checklists are attached to this Certification. V. Conditions Applicable to the Company By January 31 st of each year, the Company shall submit to the Department, a report, signed by a corporate officer, general partner, or Company owner that contains information on the System for the previous calendar year. The report shall state: the number of units of the System sold for use in Massachusetts during the previous year; the address of each installed System, the owner's name and address, the type of use (e.g. residential, commercial, school, institutional) and the design flow; and for all systems installed since the first issuance of Certification for General Use, all known failures, malfunctions, and corrective actions taken and the address of each such event. 2. The Company shall notify the Director of the Watershed Permitting Program at least thirty (30) days in advance of the proposed transfer of ownership of the Page 4 of 6 - 0 Bio-Microbics Certification for General Use MicroFAST, HighStrengthFAST and NitriFAST technology for which this Certification is issued. Said notification shall include the name and address of the proposed owner containing a specific date of transfer of ownership, responsibility, coverage and liability between them. All provisions of this Certification applicable to the Company shall be applicable to successors and assigns of the Company, unless the Department determines otherwise. 3. The Company shall furnish the Department any information that the Department requests regarding the System, within 21 days of the date of receipt of that request. 4. Prior to its sale of the System, the Company shall provide the purchaser with a copy of this Certification. In any contract for distribution or sale of the System, the Company shall require the distributor or seller to provide the purchaser of the System, prior to any sale of the System, with a copy of this Certification. If the Company wishes to continue this Certification after its expiration date, the Company shall apply for and obtain a renewal of this Certification. The Company shall submit a renewal application at least 180 days before the expiration date of this Certification, unless written permission for a later date has been granted in writing by the Department. 6. At the time of the sale of the System, the Company shall provide the purchaser of the System with an installation manual. VI. Reporting All notices and documents required to be submitted to the Department by this Certification shall be submitted to: Director Watershed Permitting Program Department of Environmental Protection One Winter Street - 6th floor Boston, Massachusetts 02108 VII. Rights of the Department 1. The Department may suspend, modify or revoke this Certification for cause, including, but not limited to, noncompliance with the terms of this Certification, non-payment of any annual compliance assurance fee, for obtaining the Certification by misrepresentation or failure to disclose fully all relevant facts or any change in or discovery of conditions that would constitute grounds for discontinuance of the Certification, or as necessary for the protection of public health, safety, welfare, or the environment, and as authorized by applicable law. The Department reserves its rights to take any enforcement action authorized by Page 5 of 6 Bio-Microbics Certification for General Use MicroFAST Hi hStren hFAST and NitriFAST g lrt law with respect to this Certification and/or the System against the owner, or operator of the System, and/or the Company. VIII. Expiration date Notwithstanding the expiration date of this Certification, any System sold and installed prior to the expiration date of this Certification, and approved, installed and maintained in compliance with this Certification (as it may be modified) and 310 CMR 15.000, may remain in use unless the Department, the local approval authority, or a court requires the System to be modified or removed, or requires discharges to the System to cease. W012530 FAST Bio-Microbics Cert. for Gen. Use Page 6 of 6 A,L�wz�v 4Z-�� June 18, 2015 1 North Andover Board of Health 1600 Osgood Street North Andover, MA 01845 Attention: Health Agent 44 Commercial Street Raynham, MA 02767 Tei: (508) 880-0233 Fax: (508) 880-7232 Reference: FAST® Wastewater Treatment System - Serial Number: 24277 Attached please find the Field Inspection & Service Report with field test results for services performed on 4/25/15 at the property of David Wondolowski located at 100 Raleigh Taveni Lane, North Andover, MA, Please call if you have any questions or require additional information. Sincerely, Wastewater Treatment Services, Inc. Service Department Enclosures Copy to: David Wondolowski Massachusetts DEP I N -C 0 A P O A A T E 0 8450.Cole Parkway, Shawnee, KS 66227, Phone 913-422-0707, Fax 913-422-0808 e-mail:onsiteO)biomicrobics.com, www.biomicrobics.com, 800-753-FAST(3278) FIELD INSPECTION & SERVICE REPORT For Bio-Microbics Single Home F,4Sr System WAIN INSTi�LLATION AUTHORIZED SERVICE PROVIDEA - Installation Address: 100 Raleigh Tavern Lane North Andover, MA 01845 Name: wastewater Treatment Services, Inc. Owner Name: David WondoloHski Mail Address: 100 Raleigh Tavern Lane North Andover, MA 01845 Mail Address: 44 Commercial Street Raynhani, MA 02767 Phone: 617-821-1617 Fax: e-mail: Pholte: (508) 880.0233 Fax: (508) 880-7232 e-mail: Model No. Serial No. v Date of Installation Date of last pump out MicroFAST.5 24277 11/11/2004 _ 9/23/2013 EQUIPMENT.; _ Yj S NO MAiNT1 NA1`ICR PERFORME DAND GOM 9y -TS " Electrical Pancl(s) Visual Alarm Operating v x Audio Alarm Operating (if present) x Blower(s) Air Inlet Filter Clean x �~ Blower Hood Vents Clear x Excessive Noise ^ x Excessive Vibration — - x 'IYeatment unit(s) w Unusual Odor _ x Pumpout Required _ x Primary Settling Zone 12" Aerobic Treatment Zone 0" EFFi UE�T,(OAtiO»alj _ LIMIT ': RESULT Estimated Daily Flow 440 gpd pH (Standard Units) 6.89 v Color Clear Temperature Odor "-�---v- —Earthy Comments:, Michael Foisy 4/25/15 P 01 Town of North Andover Office of the Health Department Community Development and Services Division 400 OSGOOD STREET North Andover, Massachusetts 01845 Susan Y. Sawyer, REHS/ RS Public Health Director 978.688.9540 - Phone 978.688.9542 - Fax CERTIF'ICA7E Off' COJKILLIA9WE As of: November 15, 2004 This is to cert that the individual su6surface disposafsystem repaired (X) — �F'uCCSystem 6y John Soucy at 100 Raleigh Tavern Gane North Andover, W,4 01845 has been instafled in accordance with the provisions of Title v of the State Sanitary Code and with the North Andover Board of ifeafth regulations. The Issuance of this certifl*cate shall not 6e construed as a guarantee that the system will function satisfactorify. Sus�YT. Sawyer it 6fic ifeafth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 O TOWN -OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; i r repaired; SD.I cy located at _ 11; 11) ja At AI &Y i~4rAi ; LAA".— was_ installed in conformance with the North Andover Board of Health approved plan, System Design Permit* plan dated - itP with a design flow of gallons per day. The materials. used were in conformance with those specified or< the approved plan, the system was installed in accordance with. the provisions of 310 CIw1R.15.000, TRIP, 5 and local regulations,. and the final grading agreos ,substantially with the. approved plan. All work is. accurately represented on the As built which has been submitted to the Board of Health.. Bed inspection date: Final inspection s , �40.45 i► PMr Engineer Representative Engineer Representative Iac.#: Date: Commonwealth of Massachusetts r Map -Block -Lot 107.A- 0109 - Board of Health Permit No North Andover BHP -2004-0701 .•tea. ,y, •.ti. ,, P.I. FEE $250.00 — Disposal Works Construction Permit Permission is hereby granted Jolu1 Soucy to (Repair) an Individual Sewage Disposal System. at No 100 RALEIGH TAVERN LANE - --. I - -- ------ --- ----- ------------------------- as shown on theapplication for Disposal Works Construction Permit No. BHP -2004-070 m Dated October 14 2004 ----- Issued On: Oct -14-2004 -�- -------- a. u ----_- ------ Board of Health 4u ru ....... a................... got..0 ................... ....... na..• ......................y...r.�....................................................... •r¢.Jirli■u..o■p..a...•uauu..•n• •. 1i• r u -.a:• O TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT - n 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 ''4S "^�•�''`�� SACNU50 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.9542 — FAX healthde t catownofnorthandover.com. www.townofnorthandover. coni APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:4tq--1'-1-©9 LOCATION: [06 dr a -`�4U,cw LICENSED INSTALLER NAME: 19 u c x PLEASE PYINT SIGNATURE: TELEPHONE# LfS'3-G_ 7 CHECK ONEV FULL SYSTEM REPAIR: ($250) COMPONENT REPAIR (indicate what parts): ($125) * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As -Built Plan. $250.00 or $125 Fee Attached? Yes V No Project Manager Obligation From Attached? Yes No Foundation As -Built? Yes No /(/Floor Plans? Yes No Approval of Health Agent Date: ZJ INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at lel ��V\ h -,f relative to the application ofe Jr1g,_ (C -2,6 -dated 10 for plans by ,S� and dated with revisions dated I understand the following obligations for management of this project: 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 manger, 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 Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With 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. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application .for installation. I further understand that work 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 tc nsed Septic Installer Date: 10-144-0 Disposalorks Construction Permit # Commonwealth(of Massachusetts City/Town of Local Upgrade Approval Form 9B DEP has provided this form for use by local Boards of Health if they choose to do so. InVodaft When MW out forms on the computer, use only the tab key to move your cursor - do not use the return key. ®tul The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. The system owner shall provide a copy of the Local Upgrade Approval to the appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before commencement of construction. A. Facility Information 1. Facility Name and Address Brian Arsnow Nam 100 Raleigh Tavern lane Sheet Address North Andover city/Town 2. Owner Name and Address (if different from above): Nam City/Town Zip Code 3. Type of Facility (check all that apply): MA State Street Address State Telephone Number 01845 Zip Code X Residential ❑ Institutional ❑ Commercial ❑ School 4. Design flow per 310 CMR 15.203:. 440 gpd 5. System Designer. BeneOsgood ® PE ❑ RS 60 Beechwood Drive North Andover 01845 Address City/Town State, ZIP B. Approval 1. Local Upgrade Approval is granted for. ® Reduction in setback(s) — specify: Reduction in offset distance between the leach bed and the wetlands from 50 feet to 32 feet ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. % reduction 100 Raleigh Tavern Lane 9b • rev. 5/02 Local Upgrade Approval* Page 1 of 1 Commonwealth of Massachusetts City/Town of Local Upgrade Approval Form 9B B. Approval (continued) ❑ Reduction in separation between the SAS and high groundwater. Separation reduction Percolation rate ft. Min./inch Depth to groundwater R ❑ Relocation of water supply well (explain): List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: North Andover Health Department Approving Authority Susan Sawyer, Health Dir.9/23/04 Print or Type Name and Title ' natureagn� Date 100 Raleigh Tavern Lane 9b • rev. 5102 Local Upgrade Approval* Page 2 of 2 BOARD OF HEALTI NORTH ANDOVER, MASS. 01845 978-688-9540 APPLICATION FOR SOIL TESTS DATE: MAP & PARCEL: A -- 1 L 9 LOCATION OF SOIL TESTS: L ftF r OWNER:1 t.l %�t2SiV (��} TEL. NO.: -9 -1 b C s 8 2W 1 ADDRESS: ENGINEER: ' 3 Fr Klk- A t K� C 3 iZ . Int , TEL. NO.: C1 `1 Fi — C>'P, (0 - 17 & CERTIFIED SOIL EVALUATOR: Intended use of land: Residential Subdivision Is This: Repair testing X_ Undeveloped lot testing In the Lake Cochichewick Watershed? Yes Single Family Home Commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: Upgrade for addition No 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Betbw This Line 9 N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: RECEIVED JUL 2 8 2004 TOW, i,!. -:-,(HANDOVER HEATH DEPARTMENT ' .3alS J Z A col 883491 E. Donald McKenzie, Jr. and Nancy McKenzie of North Andover, Essex County, Massachusetts in consideration of Two Hundred Seventy Thousand One Hundred and no/100 ($270,.100.00) Dollars grant to Brian. G. Ar.snow and Lucy Leake Arsnow husband and wife as Tenants by the Entirety of 100 Raleigh Tavern Lane with quitclaim cebcttattts mwU"Ag North Andover., MA The land, with the. buildings thereon, in North Andover, Essex. County, Massachusetts, being shown as Lot 15 on a plan of land entitled "Definitive Plan, '.Ral.eigh Tave'r.n Estates', North Andover, Massachusetts, Owner, Old North Andover Realty Trust, Engineer, Hayes Engineering, Inc., dated May 15, 1968", and recorded in the Essex North District Registry of Deeds as Plan No. 5913, said lot .being more particularly botinded and described as follows: SOUTHERLY and SOUTHWESTERLY: by Raleigh Tavern Lane (North) as appears on said plan in two courses, 165.46 and 173.19 feet; NORTHWESTERLY: by Lot .#14 as appears on said plan, 21.4.09 feet; , NORTHEASTERLY: by Lot #1.6 (remaining land) as shown on said plan, 100.67 feet;.and EASTERLY: by Lot #16, as appears •on said plan, 235.00 feet. Containing 44,824 square feet of land, more or less. Being the same premises conveyed tous by decd of Walter R. McDonough and Madeleine D. McDonough dated October 30, 1981 and recorded with said Deeds in Book 1543, Page 3. Executed as a sealed instrument this rt ,day of7 Ju e 1992 J � m a E. Don enzie, r . v x o S '.--- H `-MM M - F `.o;; Nancy: cKenzie :W Cyo F,W - 2L�he 4lomontucalth of �nssachusetts tn ss. June ��l 19 92 Essex, Then personally appeared the above named. E. Donald McKenzie, Jr. and Nancy McKenzie and acknowledged the foregoing instrument to be thei free a �dlm 0Before e. n rewey, , r F. Nwr s- Public 7l2t,7FX7q^fJ1i:P762F My commission expires - .June ' 12 , 1998 e � \ d10 +� l � s by V,r • � °� s64 o S , ;Ivl� 4. �P' 0 PC o at �y. ,0 0 c NN a h 11 � � sstz�2i a 0 �\ o ho � 0 rlb0 �L i 60 -ZEN co �l N b N �� -zo r � g �• � � � oz• .r �-�- ` � b �Lj � Ery t4 µ� 0 h r� r �9z �sZ-6o -2 �• � • 1. , r _G N ti nr , (� Page 1 of 1 Dellechiaie, Pamela From: Dan Ottenheimer [info@millriverconsulting.com] Sent: Tuesday, August 17, 2004 1:59 PM To: Susan Sawyer; amcbrearty@millriverconsulting.com; 'Pamela Dellechiaie' Subject: Raleigh Tavern soils Sue and Pam, Attached please. find the soil and perk test results for 99 100 1 'igh Tavern Lane. Dan ::Mill iv r consulting Daniel Ottenheimer, President Mill River Consulting Septic System Management Services ,2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www.millriverconsulting.co info millriverconsulting.com 8/30/2004 t 0 1 r P, I vg�� i c4 ,. K .... -ate �:-. _. - __ � - _ _•... s