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Home My WebLink AboutMiscellaneous - 1020 SALEM STREET 4/30/2018 (2)Ifflif o � O 0 0 A o O o m CD K Tcn 0 o m 0 rr roar -Ur�t4 Lot & Street Zor / 5Ae-e't Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: NO Permit# Plan Approval: Date: 11?7 Approved by:� Designer: 0 S GOA Plan Date: &11,1-k7 Conditions: Water Supply: wn Well Well Permit-_---___ Driller: Well Tests: Chemical Bacteria I Bacteria II Plumbing Sign -Off: Comments: Date Approved Date Approved Date Approved Wiring Sign -Off: Form "U" Approval- Approval to Issue: Date Issued �%G/Q By: Conditions: Final Approval: All Permits Paid? NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION Is the installer licensed? a • NO Type of Construction: SEPTIC SYSTEM INSTALLATION Is the installer licensed? NO Type of Construction: NE REPAIR New Construction: - Certified Plot Plan Review NO Floor Plan Review - �. NO Conditions of Approval from Form U YES NO Issuance of DWC permit: d� NO DWC Permit Paid? YES NO DWC Permit #�j�j j Installer 0Sg ,.- Begin Inspection: �-� NO Excavation Inspection: Needed: Construction Inspection: Needed: Plan Satisfactory: Approval of Backfill: Date:44� By: Final Grading Approval: Date: Final Construction Approval: Date: /I f /9 By: Certificate of Compliance: Approval: Date: pF NORTy qti ? oO� p � m * it FF1 LEI COPYSSA C H USS PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 8/7/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Additional Leaching area By: Robert Daigle Jr. At: 1020 Salem Street Map 104D Lot 32 North Andover, MA 01845 The Issuar f of this certificate shall not be construed as a guarantee that the system will function satisfactorily. �dskn Sawyer/ Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Commonwealth of Massachusetts City/Town of Certificate of Compliance GqM Form 3 SvOy Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab ISI 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 the local Board of Health to determine the form they use. This is to Certify that the following work on an On -Site Sewage Disposal System 12 Construction of anew system ❑ Repair or replacement of an existing system ❑ Repair or replacement of an existing system component Has been done in accordance with Title 5 and the Disposal System Construction Permit (DSCP): DSCP Number '+/j Facility Owner 1020 XAL.> K? S -T¢F-e Street Address or Lot # J✓®Q iw /a AlbDyE4 City/Town Designer Information: Na Signature Installer Information: _ It, Signature DSCP Date ly�14 State Name of Company -7-31-141 Date , � V 4r;, / 4 Name of Co any / /9 Dater I 0 / f? yg- Zip Code Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. Approving Authority Signature Date t5form3.doc• 06/03 Certificate of Compliance • Page 1 of 1 N OF IL - vt T!'FAANKUN No, 37045 o N 3y-2�•'�---- __ 549'x ' - - £�flsr FUM-A710N:: � 4 . `. LOT 1 1.00 Ac 175.00' N69'41'27"W SALEM STREET THIS PLAN IS THE RESULT OF A SURVEY PERFORMED ON 12/22/97 BASED ON THE INFORMATION SHOWN ON PLANS OF RECORD ESSEX NORTH REGISTRY OF DEEDS. AS—BUILT FOUNDATION LOCATION PLAN ASSESSOR'S MAP 104D LOT 32-1 NORTH ANDOVER, MASSACHUSETTS Scale: l "=60' — Dec.23,1997 Prepared for BELFORD CONSTRUCTION NEW ENGLAND ENGINEERING SERVICES, INC. 33 Walker Road—Suite 22—North Andover,MA. 01845 Tel -(508)686-1768 W Map -Block -Lot Commonwealth of Massachusetts 104.D0185 ----------------------- BOARD OF HEALTH Permit No BHP -2014-0673 North Andover ----------------------- FEE P.I. _ $250.00 ----------------------- �4barrw yry F.I. DISPOSAL WORKS CONSTRUCTION PERMIT Robert K. Daigle, --------- Permission is hereby granted ----------------------g— '-Jr ---'------------------------------------------------------------------- to (Construct) an Individual Sewage Disposal System. atNo 1020 SALEMSTREET ------------------------------------------------------------------- ----------------------------------------------- - ---- - -- - 2014 ----- as shown on the application for Disposal Works Construction Permit No. BHP -2014-067 Dated une F HEALTH Issued On: Jun -25-2014 --------------------------- ------------------------------ °f NORTi�� Application for Septic Disposal System g� ti�ao 'ah0 - �� •`°° °c TODAY'S DATE Xonstruction Permit —TOWN OF $ 250.00 — Full Repair ORTH ANDOVER, MA 01845 $125.00 - Component �SS�etiuS�t Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your [Repair or replace an existing system component — What? e r cursor - do not use the return A. Facility Information key. /G 9,6 Sa.le44 'Q Address or Lot # �I City/Town 2.- *TYPE O"EPTIC SYSTEM*: ❑ Pump Gravity (choose one) ***If pump system, attach copy of electrical permit to applica ion*** 2�1� ❑ Conventional System (pipe and stone system) �VN 25p z 4�g4d,� El Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certific tion tootaivt a' ri ttyere`� f y9tem. IC`N IND ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenan e A nt) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information - . fka_ G/u Name Address (if different from above) City/Town State Zip Code Telephone Number 3. Installer Informatio AvIt Arne Name of Company J A7/1C � City/Town State � � � � � � Zip Cod Telephone Number (Cell Phoneb/# iiffpoossible please) 4. Designer Inform tion Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 N°RTy, Application for Septic Disposal System AConstruction Permit -TOWN OF TH ANDOVER. MA 018 PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: ❑Residential Dwelling or ❑ B. Agreement The undersigned agrees to ensure the const on-site sewage disposal system in accord Environmental Code, as well as the Local North Andover, and not to place the sys been issue y thiMBoar-1-of e h. Name 0 )SI )I - TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component and maintenance of the afore -described the provisions of Title 5 of the e Disposal Regulations for the Town of Rion until a Certificate of Compliance has G /.n //I Date of Health Representtive) � Date Application Disapproyd for the following reasons: For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump Sys tem? If so, Attach copy of Electrical Permit Yes No 4. Foundation As -Built? (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) Relative to the application of Qlj p� (Installer's name) Dated � � �� o ay s ate For plans by e ., 0 (Engineer) And dated 14114 411 a rigina ate With revisions dated 1l /,1, 13 (Last revised date) 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 manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that reauesting an inspection. without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (ls� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept(@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the me of this obligation. Undersigned Licensed Septic Installer: (Name —Signed) North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 1020 Salem St INSTALLER: Robert Daigle DESIGNER: Ben Osgood PLAN DATE: 10/28/13, Rev BOH APPROVAL DATE ON INSPECTIONS MAP: 104D LOT: 32 11/12/13 PLAN: 11/19/13 TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: 7/11/14 (partial) DATE OF FINAL CONSTRUCTION INSPECTION: 7/25/14 (partial) DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ® Contractor reports any changes to design plan N/A Existing septic tank properly abandoned N/A Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan X Title 5 sand installed, if specified on plan N/A 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan N/A Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: 32'Wx23'L FINAL GRADE Loamed Seeded Cover per plan Comments: DOCUMENTS NEEDED LJ' Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer As -Built Plan BM = 140.38 H R = 9.40 HI = 149.78 SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Lateral 1 TOP 0.77/0.82 Lateral 1 INVERT 148.66 / 148.61 148.77 / 148.68 Lateral 2 TOP 0.86/1.00 Lateral 2 INVERT 148.57 / 148.43 148.75 / 148.66 *Elevations of laterals were about .10 -.20+/- lower than approved plan but elevations were based on existing elevations of the end of the each existing trench. Blackburn, Lisa From: Isaac Rowe <irowe@millriverconsulting.com> Sent: Thursday, July 31, 2014 4:14 PM To: Blackburn, Lisa; Sawyer, Susan Cc: 'Pam Lally'; 'Isaac Rowe' Subject: RE: Salem St. Final Construction Attachments: 1020 Salem St - Final inspection form.doc Susan/Lisa, Attached is the final inspection form for the above referenced property. The invert of the extended portions of the trenches were about 0.1- 0.2' lower than the approved plan. However, the installer was using the existing end elevations of the existing trenches. Please�let-rife 'know if you have any questions. Thanks, Isaac M. Rowe, R.S. Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 Fax: 978-282-1318 irowe(@millriverconsultina.com www.millriverconsulting.com From: Blackburn, Lisa[mailto:LBlackburn@townofnorthandover.coml Sent: Thursday, July 24, 2014 8:37 AM To: Dan Ottenheimer; Isaac Rowe; Pam Lally Subject: Salem St. Final Construction Good Morning, Please call Rob Daigle (978.423.6933) for final construction at 1020 Salem St. Thank you. Lisa Blackburn Health Department Town of North Andover 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone 978-688-9540 Fax 978-688-8476 Email Iblackburn@townofnorthandover.com Web www.TownofNorthAndover.com 1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessm 1020 Salem Street Property Address Anthony Warren Owner's Name North Andover City/Town MA 01845 State Zip Code RECEI'V'ED ents [10V* ob 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 10-30-2013 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor - do not Benjamin C. Osgood Jr. use the return key. Name of Inspector Pennoni Associates r� Compo Company Name 13 Branch Street Company Address North Andover MA 01845 City/Town State Zip Code 978-749-9929 870 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �2 ) 10-31-2013 ector' ignature Date The 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 1 1 3 . Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal* System Form - Not for Voluntary Assessments 1020 Salem Street Property Address Anthony Warren Owner's Name North Andover MA 01845 10-30-2013 CityrFown 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 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 1020 Salem Street Property Address Anthony Warren Owner's Name North Andover MA 01845 10-30-2013 Cityrrown 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 ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 o11 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1020 Salem Street Property Address Anthony Warren Owner's Name North Andover MA 01845 10-30-2013 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h 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 a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 10-30-2013 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- 1 0,000g pd. ❑ ® 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code C. Checklist 10-30-2013 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 Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): A c Number of bedrooms (actual): AAA DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts u u Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 1020 Salem Street Water meter readings, if available (last 2 years usage (gpd)): Detail: 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: ❑ Yes ® No current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 10-30-2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 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: ❑ Yes ® No current Date Gallons per day (gpd) ❑ 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 G W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1020 Salem Street D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 10-30-2013 Date of Inspection Pumped 11/23/11 per BOH records gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): l5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Property Address Anthony Warren Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 10-30-2013 Date of Inspection Pumped 11/23/11 per BOH records gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): l5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 10-30-2013 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: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from rivate waters I well ors ction line 2' feet N/A V upp y u feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe behind finished walls in basement. Pipe OK in tank. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1' 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) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 2 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 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Septic Tank (cont.) MA 01845 10-30-2013 State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness <1 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measure Stick 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 in good condition, liquid level normal, sch 40 PVC tees in good condition. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3/13 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official 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 1020 Salem Street MA 01845 State Zip Code 10-30-2013 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Property Address Anthony Warren Owner Owner's Name information is required for every North Andover page. City/Town MA 01845 State Zip Code 10-30-2013 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 1020 Salem Street Property Address Anthony Warren Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert a 10-30-2013 Date of Inspection 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.): Box in good condition. No evidence of leakage in or out, distribution equal. Depth below grade = 18" 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.): * 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 10-30-2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2- 2'deep x 3' wide x 60' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of leach trenches looks normal, no ponding, damp soil, or unusual vegetation. 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 • 3/13 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 1020 Salem Street D. System Information (cont.) nnA 01845 Zip Code 10-30-2013 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 Property Address Anthony Warren Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) nnA 01845 Zip Code 10-30-2013 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code t5ins • 3/13 10-30-2013 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 Z'r4>-PAAJ IA, IS• o 1b T4Nk, Zg.Lt To :0 -5-8.6 4b r) a�-z �® NK ti LeT- Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments b ^M 1020 Salem Street D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to hi h round water' A 10-30-2013 Date of Inspection W g feet Please indicate all methods used to determine the high ground water elevation: // // IN] Obtained from system design plans on record If checked date of desi n Ian reviewed 1997 ' g p 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: Soil evaluation for original system design performed by this inspector Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to hi h round water' A 10-30-2013 Date of Inspection W g feet Please indicate all methods used to determine the high ground water elevation: // // IN] Obtained from system design plans on record If checked date of desi n Ian reviewed 1997 ' g p 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: Soil evaluation for original system design performed by this inspector Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 i Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1020 Salem Street Property Address Anthony Warren Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist 10-30-2013 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 OF p10 R ULE Copy SSACHusE North Andover Health Department (ommunity Development Division November 12, 2013 Benjamin Osgood, P.E. Pennon Associates, Inc. 100 Burtt Road, Suite 120 Andover, MA 01810 Re: 1020 Salem Street (Map104% Lot 32) Dear Mr. Osgood: The proposed wastewater system design plan for the above site dated October 28, 2013 and received on November 6, 2013 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item. V 1 Please provide the soil testing date, name of the soil evaluator, Board of Health representative and the percolation test log on the design plan (3 10 CMR 15.220(4)). /2. Please provide a statement identifying whether the property is within or not within the L/ Lake Cochichwick watershed (NA 3.2). Please sign and date the elevation/location statement provided on the design plan (NA 3.2). >---"4. It is unclear whether the topographic information was completed by Pennoni Associates •/ Inc. or New England Engineering. Please clarify this on the design plan. 5. An inspection port is required in the soil absorption system (3 10 CMR 15.240(13)). 6. Under "System Elevations", there appears to be a typo as no Trench 2 End is depicted. If Trench 1 End 148.75 (Ex) is supposed to be Trench 2 End then there is not a 0.5% slope for Trench 2 from existing end (148.75) to proposed end (148.70). /7. The breakout elevation of 149.2 is not met on the southern and eastern side of the t/ proposed leach trenches. Please revise the proposed finish grades accordingly to meet the breakout requirement. �8. Please clearly indicate on the design plan the date of the as -built plan for the existing system. Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 9. Although not required, a statement should be added to the design plan to clearly indicate the purpose for the proposed addition to the existing leach trenches. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely, r` usan Y S er, REHS/RS Public Health Director cc: Anthony Warren Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Anthony Warren 1020 Salem Street North Andover, MA 01845 11/14/13 Susan Sawyer Public Health Director Town of North Andover 1600 Osgood Street Suite 2035 North Andover, MA 01845 RE: Application for Building Permit and wastewater system expansion at 1020 Salem Street (Map 104D, Lot 32) Dear Susan, We kindly request that the Health Department accept this letter of agreement in regards to the septic system expansion at 1020 Salem St. As you aware, we have submitted the septic system expansion plans for the above mentioned property, designed by Ben Osgood for approval by the Town of North Andover Health Department. Upon receipt of the approval letter, we kindly request that your department expedite approval for issuance of the building permit. The following are the reasons for our request: Due to the late date in the year we would likely not be able to start construction on the septic system without going past the town's cutoff for completion of the system. We are however able to start on the addition and would like to get the foundation in this fall before frost enters the ground so as to avoid spring site work and to be able to start framing directly their after. We are committed to starting the septic system in the spring and completing it as soon as feasible and before the addition is finished. The main purpose of adding the addition to our house is to provide a sun room for our family and not an added bedroom, as such the impact while technically adds a bedroom will not adversely affect the existing compliant system during construction. In order to keep to a strict schedule and complete construction expeditiously, we would like to move forward with construction as soon as possible. Currently, we are receiving bids on the septic system upgrade including excavation work for the addition and will be securing a contractor soon, but have not done so to date. Worst case we will complete the installation of the septic system no later than July 2014 and no later than the addition. Respectfully 07 0,;,� Anthony Warren OF NORTy qti LA ti 9SSACHUs�� North Andover Health Department (ommunity Development Division November 19, 2013 Anthony Warren 1020 Salem Street North Andover, MA 01845 Subsurface Sewage Disposal System Plan for 1020 Salem Street, North Andover, Massachusetts Map 104D Lot 32 Dear Mr. Warren, 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 Pennoni Assoc. Inc. dated October 28, 2013, last revised on November 12, 2013. The design has been approved for use in the construction of the expansion of an existing onsite 4 -bedroom septic system to a 5 -bedroom (max 11 -room) home. This plan is generally good for 3 years from the date of approval, however as a condition of this approval this system is agreed to be installed by no later than July 2014. The Health Director has accepted this agreement, as a condition of approval of the building permit application for an addition with a garage and a bedroom as depicted on plans provided by Russell Bousquet; signed and dated October 23, 2013. These plans are accepted as an 11 -room home. Prior to July 2014, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. Failure to do so will result in a request to be present at a Board of Health meeting to address the members directly, as to why this agreement has not been adhered to. This approval is also subject to the following conditions: 1. 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 Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 1020 Salem Street November 19, 2013 Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit (3 10 CMR 15.020(1)). 2. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. 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. Since ,� usan Y. Sawyer, Public Health Dir cc: Ben Osgood Jr. P.E., Pennoni Assoc. Inc. file Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 ." TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT IV 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 —Phone Susan Y. Sawyer, REHS/RS 978.688.8476— FAX Public Health Director E-MAIL: healthdeptna townofnorthandover.com WEBSITE: http://www.townofnorthandover.com SEPTIC PLAN SUBMITTAL FORM RECEIVED Date of Submission: �� V � 2013 Site Location: OZO T`�1"j 4 `� " ""6 TOWN OF NOR" H OWAIT�E t�F1'ARTM ANDOVER R Engineer: rsE t�l V CrC>>Z�b New Plans? Yes_�'/_$225/Plan Check # 1!5'n (includes 1St submission and one re- review only) _ tO� Revised Plans?Yes $75/Plan Check # Site Evaluation Forms Included? Yes No_v_ Local Upgrade Form Included? Yes No 1V Telephone #: C1' 7 " `YL Gs 01 '5 Fax #: E-mail: SNIT AorV' , WA(ZYZEN 0� NORRTI-I — PYZE'y , WM Homeowner Name :-%31�OI��' \,NifAR n OFFICE USE ONLY When the sission is complete (including check): 7 Date stamp plans and letter ➢ t// Complete and attach Receipt ➢ _Copy File; Forward to Consultant ➢ 1/ Enter on Log Sheet and Database IS) r�TA 5 a � T 1611�1--O - ": 7 - / n/97 OM14 DY: F:INE� fPONf UVAWN z J� r� I I I I I 1 1 I I I 1 I 1 I I I 1 1 I I I I I I I 1 I 1 I 1 1 1 I I I I I I 1 I rl I I II I I I I I I I I I I II II � I I II II II II II I I II II Orn I I it C I I Q I I I I I I I i I I I I I I 1 I I I I 1 I I I I I I 1 I I I � I t 1 I 1 I I I I I I I I I I I I I I I II I I I I I 1 I I I I I I I I I I I I I I I I II_---------- �-4 1 I ' 1 ---------- LJ i _ ['of W -I 3/ Ib"-ILpI1' ogre: I/ 311/ 91 -- MAP �L. 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ILC'Er: q - -�- \-- ---� ----\ . /I \k ; ZEE]. \� | | - ( � . $ f » '\ \/ \ ) Ns . 77 \ \ / , ( -------- -��---------.�: %%§ may .�---�---�----- %�_$� m H�r� / - »9LDEr OF GGERCi ES P 7 /A &»»BEAN %Cf. _ j ^ - _7/_5/@_72 { fQ2p HAO \R COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _1020 Salem Street _ —North Andover Owner's Name: _John Machonis _ Owner's Address: _1020 Salem Street_ _ North Andover, MA 01845_ Date of Inspection: 12/17/2004_ Name of Inspector: Neil J Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: ( 978 ) 475-4786 JAN 12 2005 TOWNOF NORTH' -R HEALTH DEFT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils q� Inspector's Signature: Date: _12/17/2004_ The 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. Notes and Comments: ****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. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _1020 Salem Street North Andover— Owner: _Machonis_ Date of Inspection: _12/17/2004_ Inspection Summary: Check AAC,D or E / ALWAYS complete all of Section D A. System Passes: X 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. Answer yes, no or not determined (Y,N,ND) in the 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. ND explain: 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 ND explain: 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _1020 Salem Street _ North Andover_ Owner: Machonis_ Date of Inspection: _12/17/2004_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _1020 Salem Street _ North Andover_ Owner: _Machonis_ Date of Inspection: _12/17%2004_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: _No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is'/z day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —No Any portion of a cesspool or privy is within a Zone 1 of a public well. No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] _No_ (Yes/No) 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 10,1000 gpd to 15,000 gpd. You must indicate either `yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. Page 5 of i I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _1020 Salem Street _ North Andover— Owner: _Machonis _ Date of Inspection: _12/17/2004_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? Yes_ , Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _Yes_ — Existing information. _Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _1020 Salem Street _ _ North Andover_ Owner: Machonis Date of Inspection: _12/17/2004 FLOW CONDITIONS RESIDENTIAL 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_ Number of current residents: _5 Does residence have a garbage grinder (yes or no): Yes Is laundry on a separate sewage system (yes or no): _ No Laundry system inspected (yes or no): _ Seasonal use: (yes or no): _No Water meter readings: Yes_ Sump pump (yes or no): _No Last date of occupancy: - Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped this year, owner_ Was system pumped as part of the inspection (yes or no): _No` If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool ` Overflow cesspool _ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) �_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): _ Approximate age of all components, date installed (if known) and source of information: _ 6 years old, 5/9/1998, As built plan_ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1020 Salem Street _ North Andover— Owner: _Machonis_ Date of Inspection: _12/17/2004_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _24"_ Materials of construction: _ cast iron _X_40 PVC ,other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _ Unable to see piping leaving foundation, finished basement. 3" PVC in house, no leaks visible._ SEPTIC TANKS: X Depth below grade: _12"_ Material of construction: X concrete ` metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: _10' x 5' x 4' Sludge depth: —2" _ Distance from top of sludge to bottom of outlet tee or baffle: _28"_ Scum thickness: _2" _ Distance from top of scum to top of outlet tee or baffle: _8" _ Distance from bottom of scum to bottom of outlet tee or baffle: 18" _ How were dimensions determined: _Tape Measure_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.)_ Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage._ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1020 Salem Street North Andover— Owner: _Machonis_ Date of Inspection: _12117/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass __polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X Depth of liquid level above outlet invert: _0 _ 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.):_ D -box level & distribution equal. No evidence of leakage. Light solid carryover. D -Bog cover broken. Replaced cover. PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): _ Alarm in working order (yes or no): _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _ Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1020 Salem Street _ North Andover _ Owner: __ Machonis Date of Inspection: _124W/2004_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _X leaching trenches, number, length: 2 trenches 60' long_ leaching fields, number, dimensions: overflow cesspool, number: innovativelalternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _ Soil ok. Vegetation ok. No sign of ponding to surface._ 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 sludge layer: _ Depth of scum layer: _ Dimensions of cesspool: Materials of construction: . Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _ PRIVY: (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.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1020 Salem Street_ _ North Andover— Owner: _Machonis _ Date of Inspection: _12/172004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Driveway A House Water Meter B A to Tank = 28'6" A to D -Boz = 51'8" B to Tank =15'8" B to D -Boz = 25'11" Septic Tank 60' D- .4 Boz Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _1020 Salem Street North Andover_ Owner: _Machouis_ Date of Inspection: _12/17/2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4' _ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _8/9/1997_ 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: _ as per design plan, no water 4' below trenches_ 11C m m T4 N 1-1 Ch 1tv Nri mull m LL T m D N t� 61J C` I fD =- fD .4 4, 1 n T I � � Q " I www ask= s-4 g `k'4.fiNi»9� D N t� 61J C` I fD =- fD .4 4, 1 n T I � � " I www s-4 SN �= I WWww C"0 !4Y y i W Lo (7 W eJ pm.�ay Vi i ' 3Y MB � •� l-: �! J 'w� }� T Summary Record Card generated on 1/3/2005 2:10:12 PM by Lisa Warren Page 1 Town of North Andover Tax Map # 210-104.D-0185-0000.0 1020 SALEM STREET MACHONIS, JOHN & KELLY 1020 SALEM STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Size Total 1 Acres FY 2005 UB Mailing Index Name/Address Type Loan Number MACHONIS, JOHN & KELLY Payor 1020 SALEM STREET NORTH ANDOVER, MA 01845 UB Account Maint. Property Type Active/Inact. From Account No Cycle Occupant Name Active/Inactive Bldg Id. 3649.0 - 1020 SALEM ST Last Billing Date 10/8/2004 3160376 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE^ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 381.31 /1 UB Meter Maintenance . Serial No Status Location Brand Type Size 43993597 a Active ENC F.L. ? w Water 0.63 0.63 Date Reading Code Consumption Posted Date 12/8/2004 1739 a Actual 26 Trouble Code:03 9/15/2004 1713 a Actual 94 10/8/2004 Trouble Code:03 6/9/2004 1619 a Actual 21 7/30/2004 Trouble Code:09 5/10/2004 1598 a Actual 218 5/17/2004 12/11/2003 1380 n New Meter 0 12/11/2003 1 Residential Until YTD Cons 0 Variance -68% 37% -52% 0% Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 1020 Salem Street, North Andover Owner: Machonis Date of Inspection: 12/17/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil . Bateson Bateson Enterprises, Inc. a 6 Z E CC, LL rn C p.pa'Yk2Sto . - °0 3 Q L Lr 0 a � OC L i o N 14 a> U c � N L rc C O C c — Uw O < r3 U D E Co °) C r N r a Z Vl C rJ N w v C d -i Q = O a� `^ -j U _ O U O a N N O w a `n L F 3 .� N U.N O O C 0o m C O Z a) oor � - '3 _ U L1`+-- L Y O N O U L N L N u CLU Q N O 0 N — U1 O d U N N N C U1 U C v N C C C O CN C p.pa'Yk2Sto . - FROM : R.C. TANGARD PHONE N0. : 617 334 0115 144Y [y '98 15:12 P.w2 f TOWN OF NORTH ANiDovM SEWAGE DISPOSAL, SYSTEM INSTALLA•1' ON (=TIF1CATION The uaderdped hereby certify that the Sewage DiWoW•Systcru (X x) constructed; (. ) repaired; by Emniamin c. 0s loCatedat Lot 1 Sa,1-m Streat Asse 'ra M .10 Lot 32 was int-Alled tn, r_onfore=or N . Audovw 13ba d' of Health approved p1ma, S ymm DcdpPUMjt# 980 _,, datcd 1 3 ptdwperdoy. u /9 7 - X- w'* s appoved dcsigu flooof 440 "dweriu (Mf0rma= with tb*5e gXdfied on the qpj� PIM tbo "=V=%g6&diu aoaordaaaewith the pmvisicms of 310 CMZ 15.000, I'Ifle 5 and 1001 MP19donA ad the -Mid ,grad}ugr Rum =bst=tially with -the appMvtd Plea. All,wo& is -acculmely raxwenteacn, the As -built which hast bcen submit to the Board ofHaaitil. Zinstallaa': 7.,�c. #: 126-8 Dflre- •,. . 5.12.g,91�_ I)Cdp weer. Dam: Ril`HAQb TANGARO / a�F FcisrfQ6a`�4. Town of North Andover, Massachusetts BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time F CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. 3?'�• 0 N � 9 • s 4 t BOARD OF HEALTH 146 MAIN STREET TEL. 688-9 540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: &)ZO LOCATIOK OF tOIL TESTS: 2-d71--/ Assessor's map & parcel number: Mgn /®y ip 1107-'-30 OWNER: Pesci PC TEL. NO.: 6� 01-117:V ADDRESS: /dew �.nJ%u,!% � "tJinP�lis ENGINEER: 5��,«, �-,�, TEL. NO.: G PCS-- 176 Q, CERTIFIED. SOIL EVALUATOR: (2 Intended use of land: residential subdivision,ingle m�home,commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of $75.00 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. 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. 0 DORM .11 - SOIL EVALUATOR FORM Page I of No Commonwealth of Massachusetts i�)ewa Massachusetts Cn %J . .. ry 9.. 1 ?1!1.. A i.nnnnYMni"t fnOn-vimr.. Date: ?1/, .'- 11 ` DEF APPROVED FORM-.12l07I95 aVhl 4.=... fQ j 2 Date: q `t lig � ( Performed By. .... ) ,h , ; SQ Witnessed By. - �- f! � 1 pwncr's Ni �- /� p b / � `On ZI J fT �d *�� 7 , num Z I - location Address or 1 Lot N SSC! 2 5' i nn' ntli v Ort, N1(f! Addresi, and �r � J, TeleDhore) - a•T s j t/L ✓% N'.�' N a r �.� ao eW Construction { Repair ❑ Office Review F7 Yes Published Soil Survey Available: No . 19 ��8� Unit 1 Soil Map , ... ,..... Year Published t.q 81 Publication Scale: S o ,..,. ,.. Classx"P� ... cc�si✓e� l.Limitations _ . Drainage Surficial Geologic Report Available: No Yes ❑ : `_ 'ar Published Publication Scale Geb ogic Material. (Map Unit) 1.a dform Flood Insurance Rate Map: Anr,yJe 504 year flood boundary No Yes , irlhin 500 year -flood boundary No ❑Yes ❑ t ithin 100 year flood boundary No [Yes , t' eland Area: _..... Wetland inventory Map (map unit) National Wt lands,Conservancy Program Map (map unit) current Water Resource Conditions (USGS): Month . Range :Above Normal ❑;Normal 0Be1cw Normal ._ Oter References Reviewed: ` DEF APPROVED FORM-.12l07I95 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. LJ Jdlev" On-site Review _o Time: �, ° 30 Weather Deep Hole Number 7�:..::. Date:....... :.:.:.... Location (identify on site plan) o Land Use .:...Fb..f Gs �::: Slope (%) /0 Surface Stones f � Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body . ;� ,ZOO feet Drainage way 7/10' feet Possible Wet Area '../o.o: feet Property Line 55�. feet Drinking Water Well 5:ivo. feet Other ^...:: DEEP OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravei F:5L ioytz � �- 20" i3 f i. 10�R r✓tass i v e� 'r r -i P L 2D g0ie e>2 .F. -Sl- ;?5 _ f^ruble e NlGt.SS+tee W`�78n Cr -11 102 lIDS t? sTrart�c� 5y TO 1S Ne- Lvei D VtaV, re C S i y/�QQJ► &ra ,r M'ANCr(�n1u'3C z,N� ��(� J=51... j0 R. Sl( Parent Material (geologic)i7f-42jack g[--Qy6L DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: _ Hg„ - Estimated Seasonal High Ground Water: -- iiDEP APPROVED FORM - 12/07/95 FORM 11 - 5.011: EVALUATOR FORM .Page 3 of 3 Location Address or Lot No. �.o'� ( Baa l ems'` SA%, 00 2 Determination ,dor Seasonal High Water Table Method Used: ❑ Depth. ,observed standing in observation hole, inches 0 Depth weeping from side of observation hole....,:,. inches Depth to soil mottles .::.., inches Ground water adjustment feet Index Well Number Reading Date Index well level . Adjustment factor .::. Adjusted ground water level Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material: exist in all areas observed ;throughout the area proposed for the soil absorption system?,s 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 of Environmental Protection and that the above analysis was performed by me consistent with the.required training, expertise and.experience described in 310 CMR 1.5.017; Signature C' Date lo FORM 11 - SOIL EVALUATOR FORMM Page I of 3 ijc+. o r+^in... C......:G. f.Dc cX 1!L at Performed By j ...... Witnessed By: rs pwne ' Name, F'c R 51 F�c,leu f" Le at,on Address m :.Address, aM *iAil �lbLo,ulev�nSTelephone A ew Construction ® Repair C Office Review Survey Available: No... ❑ Yes Published Soil S, , .FC i , I x(0080 Soil Ma Unit � .• . ' Year Published i� .., .... Publication Scale Drainage. Class L-xe0.>' *J<1 �^�'� Soil Limitations S/o .P.� ........ Surficial Geologic Report Available No. 0 Yes Year Published Publication Scale Geologic.Material (Map Unit) Landform Flood Insurance Rate Map: Above 500 year flood boundary No Yes n F - I DEP APPROVED FORM • 12107195 FORM II - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. j_oi 1 5ale,m ��• A), 6N.60vC�2 On-site Review T? ►t? 1 7 Time:. .► 3 d Weather Deep Hole Number Z Date:..�1..�.:16.... � Location (identify on site plan) ........ .. . Land Use :::::..:1'.r -es f'..._ ::... Slope f %) .. Surface Stones , Vegetation :-Ak xe,0.. Landform .:.:.: _ _::...... . Position on landscape (sketch on the back) Distances from: Open Water Body > 204 feet Drainage way 7160 feet Possible Wet Area >11 U,0 .: feet Property Line w`20.'. feet I Drinking Water Well S.: 1:0 v_::, feet Other Depth from Soil Horizon Surface (Inches) 0-1/ fir /I -W 13,-13a I' y0"--7,5" I cb, DEEP OBSERVATION HOLE LOG Soil Texture Soil Color Soil Other (USDA) (Munsell) Mottling (Structure, Stones, Bounders, Consistency, Grav ryi (�S<s f v C A B L i S• L. ai 38" gap mAss�ve , �►2t13�E BL r1'tFFsSiv� fri AE C` Parent Material (geologic) &,.-, 1ac a.1 d0} "'J'_DepthtoBedrock: -7 Jr„ Depth to Groundwater: Standing Water in the Hole:—, O N 15 Weeping from Pit Face: /V`0 _ Estimated Seasonal High Ground Water: iiDEP APPROVED FORMM - 12/07/95 FORM 1I - SOIL LVALUATOR FORUM Page 3 of 3 Location Address or Let No, —L.+- 1 A), ft Jo.jee _ # Z TrsT fir' Determination for Seasonal Ifigh Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole inches Depth to: soil. mottles .,:.3 inches ❑ Ground water adjustment :..... ..... ..:..: feet Index Well Number "Reading Date Index well level . Adjustment factor Adjusted ground water level Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? N a. If not, what is the depth of naturally occurring pervious, material? 3� Certification I certify that on s/% /99�C(date) i Piave passed the soil evaluator examination approved by the Department`of Environmental Protection and that the above analysis was performed byme consistentertise and experience ,with the. required training, exp described in 310 �CMR,15.017 Signature rn Date l0 3 Q DEP APPROVED FORM 12/07195 J FORM 11 - SOYL EVALUATOR FORM Page 2of3 Location Address or Lot No. Lai' Sa �e►-r� S� /V(-}� O o�?E R On-site Review Deep Hole Number TSP 3 Date:_ las IllTime:: 1,1 ��34 Weather 6Jet)I- �ooJ.. Location (identify on site plan) �- a 110 Surface Stones Land Use ,:::.....�a:�es.::.: Slope (/o) Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body .> ZaID feet Drainage way ?/C -D feet Possible Wet Area > .. lc -c> Ifeet Property Line feet I Drinking Water Well ?::.t,:P-Q . feet Other ... DEEP OBSERVATION HOLE LOG` Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % GraveD ?o r es7� � i 4+4 Q -.9 - Co nnMO.✓ ROO i r' n4Rssr✓E 30,. 132- F S. L. �oyc> CGM�,0k" 2Jo i5 ssiVE7 fi;Zt�tgz� C T4 lo11R� 2,„5�� oa,P f.v P�ACc� Fri p6tF 5� r` i %� �� STONcS CraMMO Al Ah - o, ptS r Parent Material (geologic) IPM.1Ac, C�ui-�✓ Depthtof3edrock: Depth to Groundwater: Standing Water in the Hole: /VOAJJ Weeping from Pit Face: /1/6NE Estimated Seasonal High Ground Water: ly f3 -- iillEP APPROVED FORM - 12/07/95 FORM. I1 - SOIL LVALUATOR FOPUNI Page 3 of 3 Location Address or Lot No. N . (-) w90 v� � Determin don for Seasonal High Water Table Method Used: Depth observed standing:in observation hole.. inches' Depth weeping from side of observation hole ... inches Depth to soil mottles YP' inches ❑ Ground water adjustment .... feet Index Well Number Reading Date Index well level Adjustment factor Adjusted ground water level . ......... . Depth of Naturally Occurring Pervious Material Does at least four feet 'of naturally occurring pervious material exist in all areas observed: throughout the area proposed for the soil absorption system? ;�3r_,g " If not, what is the depth of naturally occurring pervious material? Certification I' certify that on -all (date) l have passed the. soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date O DEP APPROVED FORM • 12107/95 FORM 11 - SOIL, I;YA.I,UA'1'01Z FORK Page 1 of 3 Date: ,-1 2s q7 No, , Commonwealth of Massachusetts Al,��o,,v�- , Massachusetts Soil Suitabli Assessment or On-site Sewa a Dis osal en) a►M^ .� CQ oocQ,._ Date: 'l Zs an Performed By: : Witnessed By: .....I Location Address Or �.p� l ` } .}— au L (Z (y 1• f JS Owner's Namc Addtest,.and �)b�-� �!/�tR/I Zt �1tZ I P`b(-i �2f Lo � � /U¢ri'In Rn�v 1'ekphone I 'Tru S fee 3, 7 a,sie� 5/' N- RN/�auP.,2 ew Construction Repair Office Review Yes published Soil Survey Available: No:E 1't 1 gOoS.. Soil Map Unit �q 8I ...:..... Publication Scale Year Published `� (1�jjSo►1 Limitations Fxereb�►v ,Drainage Class .... �, Surf cial Geologic'Report Available: No `Yes Year Published Publication Scale ..• Geologic Material (Map Unit) ........... Landform ... . Flood Insurance Rate Map. Above 500 year flood boundary No Yes Within 500 year flood boundary No ]Yes El Within 100 year flood boundary.No []Yes ❑ Wetland Area: National Wetland Inventory:Map (map unit) ��(av� Wetlands ConservancyProgram. Map, (map unit)......... ................ Current Water Resource Conditions (USGS): Month, Range :Above Normal : QNormal . ❑Belc�ri Normal _ Other References Reviewed' FORM 11 - SOrL EVALUATOR FORM Page 2of3 Location Address or Lot No. 1. -OT t 5A LENt ' ST, , /,19Nao\)L P - On -site Review a? Time: I ;L '.00 Weather ©v tc16 Deep Hole Number Date:...7I:r) i coo y-, Location (identify on site plan) . . / Land Use :....-FO:R/o) EST. Slope ( lO.. Gd Surface Stones 0 Vegetation .:/►n tx. n :: .:.,.50d0�::..: Landform Position on landscape (sketch on the back) - Distances from: Open Water Body 7 2-c?` feet Drainage way > feet I Possible Wet Area >../ d o. feet Property Line (P feet Drinking Water Well x.i.o.o.- feet Other .. DEEP OBSERVATION HOLE LOG` Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % GraveJ D-S1� S.L., 10� — t05 r ,r naR,OV3 mea f=wE mo—i's {Yl IgSS l �E� • 1- v OS 6 - 151 36�� IS L. S, ►0� 2 y _ifLRT� ftE fl g,qa 05 o -F fSc dl e CG 1J,15C J �1\NOS ! •' G"'.- -C- itn a-ss� � c •rte ,S rN (TLE G-2Ara� Epp rfZ�r4 6LC � moos c-: . 3�� la�.r CZ t✓'.6-S a log fz - 2.5 e ;Z !D % G�wvcc co.» pr+cT g �,s�s/8 ,„rtSS�vL frziRB�E IVIIIVIIVIVIvI Vf- Parent Material (geologic) I�it� glRciac� �� ( w,��QS h DepthtoBedrock: Death to Groundwater: Standing Water in the Hole: NC? i✓JF Weeping from Pit Face: IVO A✓ t _ Estimated Seasonal High Ground Water: S DEP APPROVED FORM - 12/07/95 :Method Used: 0 Depth observed standing in observation hole'.. inches Depth weeping from side of observation hole :: inches ®- Depth to soil mottles inches O.Ground water.adjustment feet Index Well Number ............. .. Reading Date Index well level Adjustment .factor ::...,.:. , Adjusted ground water level..... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? -:�-c-x If not; what is the depth of naturally occurring pervious material? Certification I certify that ori' rr/I 19 (dated I have' passed the soil evaluator examination. approved by the Department of Environmental Protection and that the above -analysis was performed by me consistent with.the required training, expertise and experience described.in 310 CMR 15.017.. $ign&tu.reJ. Date !o Q DEP APPROVED FORM - 12102195 FORM 11 - SOIL EVALUATOR FORNNI Pagel -:Of 3 No. T�.r Commonwealth of Massachusetts Massachusetts .'I r •1_I- 1.: Date.: 71,;yr Q'7 ovrX �'`" Date: Performed By: ..... �..... ... . ... ............ Witnessed By: Na PqC. �` C 2esx TwS Nam, + Lociuon Add"" a %.DI 1 m Owner's , naacss. ,ne A1be i- P Manzi T�z; I L �Ibrr% —We TcicPhont JnJST FES I 7a �stea s� N. f},voa� t of ew Construction Repair ❑ Office Review 'Published Soil Survey Available: No ❑ Yes t; ig0000 Soil Map Unit Year Published 1q01Publication Scale SIL.. s ` - Drainage Class Lr ",e) .5��• it Limitations SuIrficial Geologic Report Available: No © Yes ❑ Year Published Publication Scale - . Geologic Material (Map Unit) ...................................................... Landform Flood Insurance Rate Map: Above 500 year flood boundary No ❑ Yes Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No El Yes ❑ Wetland Area: nn ............ ........... . National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map map unit) ....... ... . ................... Current Water Resource Conditions (USGS): Month - Range :Above Normal ❑Normal ❑Belc'v Normal ".-Other References .Reviewed: DEF APPROVED FORM • 12107195. FORM 11 - SOTL EVALUATOR FORINT Page 2of3 Location Address or Lot No. I Salew-k 5.1 A), IgJo,,e2. On-site Review t�ii�� Date: -11; ±d t? Time: ) 2 Deep Hole Number 13U Weather O�e�-casT ! - COO!— Location (identify on site plan) Land Use ... f o9 r7 t Sl o e (%) / l Surface Stones . Vegetation Landform Position on landscape (sketch on the back) -. Distances from: Open Water Body > z -"O feet Drainage way 7feet Possible Wet Ar6a 7 1 co feet Property Line y0'.. fegt Drinking Water Well ? tQ-D feet Other DEEP OBSERVATION HOLE LOG* Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) )J w ad (�2 TVI IIYII VIV TVI VI i- V��v •��•+•••-� ------- - --- I /1 Parent Material (geologic) ?,0 1 q,; d 001 GIS DepthtoBedrock: Z Depth to Groundwater: Standing Water in the Hole: N O N L Weeping from Pit Face: r1 U k? C Estimated Seasonal High Ground Water: /( f 0- ' /V-4' iiDEP APPROVED FORM - 12/07/95 FORM 11 - SOIL LVALUATOR FORM Page 3 of 3. Location Address or Lot No. LO+ % '-s" C, -. Sfre,ef' A/. 6 ^sou el - Determination for Seasonal High Water Table Method Used: �a�e2-cc�jle NoT' cQ�ie!`►r�ne. res +- No(-C"o 0 ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole inches ❑ Depth to soil mottles .. inches Ground water adjustment .... ..............feet Index Well Number ...... Reading Date .._. _ Index well level. Adjustment factor ................ Adjusted ground water level _......... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on (date) I. have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature DEP APPROVED FOR'+! - 12/07195 Date .4 � Qw- n :-'�r If _4 If _4 74 1 m DATE: 9-9— <7 7 LOCATION: d Scc�— ENGINEER: &,,cj BOH WITNESS: PERCOLATION BOTTOM DEPTH OF 4 y s TIME OF SOAK:. (At least 15 minutes long) TIME AT 12" TIME AT 9" TIME AT 6" l f At' M OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: TIME AT 12" TIME AT 9" TIME AT 6" (At least 15 minutes) DATE: �T —�F ---, 7 i LOCATION: / V d —y ENGINEER: U BOH WIT L' 0 NESS. Aje- PERCOLATION TEST # 4F 3 BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: i 457 A M (At least 15 minutes long) TIME AT 12" / %°/ �. J+ �� 3 � ,_AA TIME AT 9" ! �p S TIME AT 6" OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: TIME AT 12" TIME AT 9" TIME AT 6" (At least 15 minutes) DATE: 10; LOCATION: c ENGINEER: BOH WITNESS: 5 7�;;( #f / PERCOLATION TEST # loll BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: O t',. —7 A (At least 15 minutes long) TIME AT 12" � •`/ �. , 3 rvvl TIME AT 9" TIME AT 6" OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: TIME AT 12" TIME AT 9" TIME AT 6" (At least 15 minutes)