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Miscellaneous - 105 WINTERGREEN DRIVE 4/30/2018 (3)
A Lot.& Street Map/Parcel CONSTRUCTION APPRgVAL Has plan review fee been paid YE,S NO Permit#ZZ Pian Approval_: < Date: M % Approved by: �. Designer ' �0 06 Plan Date: / / 9 Conditions: G� ,c,j -_ .. Water:.' u I..:_Town Well pp.y Well`.P Wait: = Driller: CONDITIONS: Is the installer licensed? YE N Type of Construction. - -NEW' IR New Construction. Certified Plot Pla R Me' .. - YES:.N0_ Y Floor Plan Review' YES NO r pproval.from f=orm"U YES Conditions'ofA NO - Issuance of DWC ,permit . -. - = NO DWC Per Paid? .a Dl/WC Permit.# - YES N Installer ' Ul r'1- t '134n Inspection: r.. - ES NO Excavatio_ n Inspection:- Needed: _ Passed BY - Construction Inspection: Needed:. - /As Built Plan Satisfactory::- atisfacto ry --� .. AYES: _ F • � a �•� YES., .+ - . - _ Approval of Backfill -:Dat A e: By Final Grading Approval: Date. v ` vr� By: --. Final Construction Approval: .Date: By: Certificate of Compliance: Approval:_ - -- - Date: Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rat Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form - Not for Voluntary Assessme its JUN _ g 2009 105 Winterareen Drive Property Address L�H�EALTH UK I n Hlvuvvc� t Melody Palmer DEPARTMENT Owner's Name North Andover Citylrown MA 01845 State Zip Code 5/14/09 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 1. Inspector: John Soucy Name of Inspector Soucy's Septic Service Company Name 78 N. Broadway Company Address Salem City/Town 603-898-9339 Telephone Number B. Certification NH State 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: ® Pass ❑ Conditionally Passes ❑ Fails ❑ eed Further Evaluation by the Local Approving Authority Signature 5/14/09 Date TKe system insp for shall sifomit a copy of this inspection report to the Approving Authority (Board of Health or DE ;)' 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 M Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM ,•�''y 105 Wintergreen Drive Property Address Melody Palmer Owner Owners Name information is required for North Andover MA 01845 5/14/09 every page. Cityfrown 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: 13) 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 or 17 t Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 105 Wintergreen Drive Property Address Melody Palmer Owner's Name North Andover MA 01845 5/14/09 City/Town State Zip Code B. Certification (cont.) B) System Conditionally Passes (cont.): Date of Inspection ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M �y 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. 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 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 Y2 day flow t5ins - 09/08 Title 5 Official Inspection Forth: 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 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. Cityrrown 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 • 09/08 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 M 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Insecti®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Wintergreen Drive Property Address Melody Palmer Owner's Name North Andover MA 01845 5/14/09 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? [if yes separate inspection required] Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: see attached Sump pump? Last date of occupancy: Commercialllindustrial 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 ■ Yes Z No ■ Yes Z No ■ Yes ►ZI No ❑ Yes ® No Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 09/08 Title 5 Oficial Inspection Forth: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. City/Town State Zip Code Da System Information (cont.) Last date of occupancy/use: current Date 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: owner 1500 gallons gage on truck inspection, maintenance Date of Inspection ❑ Yes ❑ No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Subsurface Sewage Disposal System Forme - Not for Voluntary Assessments 105 Wintergreen Drive Property Address Melody Palmer Owner's Name North Andover MA 01845 5/14/09 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 6/2000 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: F1 cast iron ® 40 PVC El other (explain): I 26 inches feet n/a Distance from private water supply well or suctionine. feet Comments (on condition of joints, venting, evidence of leakage, etc.): no leaks present Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No 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) 6'x 10.5' Dimensions: Sludge depth: ❑ Yes ❑ No t5ins ^ 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts "Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. City/Town State Zip Code Date of Inspection De System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 37" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" 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.): 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: Date t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systema Forma e Not for Voluntary Assessments M ,•�''r 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. CitylTown 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.): baffles o.k., no leakage of tank 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). is copy attached? ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Wintergreen Drive Property Address Melody Palmer. Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. City/Town State Zip Code Date of Inspection Dm System information (cont.) Distribution Box (if present must be opened) (locate on site plan): 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.): Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 N, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 15'x 60' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no signs of hydrolic failure 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 t5ins - 09/08 ❑ Yes ❑ No 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 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Wintergreen Drive Property Address Melody Palmer - Owner Owners Name information is ired for re North Andover MA 01845 5/14/09 w 4 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately z \ A3 ER \ \ 1500 SEPTIC 2 EXISTING FOUR BEDROOM HOUSE DISTRII ILL ELEV. 125.21 15'---� BOX O O Q� Itl I II �I 2C MIL POLY BAP 1'P Hr LIMIT OF SAN TP 91 9s II i I i PT #2 •1\, I ! tl 15' Ji 97.03 RGREENVE - 31940'24E r 7z. DISTANCES 0 ka' LOCUS MAP. SCALE: 1" = 2083' ff t TO TANK ' 9.0' 2 TO TANK 28.+' >\i�'id 1 TO D BOX. 18.0 _ •� 2 TO D BOX 31.0'�t' 1 TO A 12.9' , •to F 61.9' FOR 2 TOA 31 0' 2 TO F 87.9' O 1\ 1 Clk 1 TOC 23.0 1 TO D 65.0' J/J`j .r(0 i 10* 2 TO C 37.0' 2 TO D 90.5'�`i. t5ins • 09108 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme - Not for Voluntary Assessments M �•�''r 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Name information is required for North Andover MA 01845 5/14/09 every page. Cityfrown State Zip Code Date of Inspection Da System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7/12/99 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 09/08 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 105 Wintergreen Drive Property Address Melody Palmer Owner Owner's Mame information is required for forth Andover MA 01845 5/14/09 every page. City/Town State Zip Code Date of Inspection Eo Report Completeness Checklist ® 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 May CO 09 11:06a ?DPW 9786889573 P.1 Summary Record Card generated on W0120DS 10;58:11 AM by Use Evans Page 1 Town of North Andover Tax Map # 210-104.B-0198-0000.0 Parcelld'16522 105 PALMER, MELODY NCDRIVE PO BOX 307 TWIN MOUNTAIN, NH 03595 Ciass 101 Single Family Property Type 1 Residential Size Total 2.03 Acres FY 2009 UB Mailina Index Name/Address Type Loan Number Activelinact. From Until PALMER, MELODY C. Payor PO BOX 307 TWIN MOUNTAIN, NH 03595 UB Account Maint. Account No Cycle Occupant Name Activelinactive Bldg Id. 18047.0 - 105 WINTERGREEN DRIVE Last Billing Date 4/6/2009 3180076 03 Cycle 03 Active UB Services Maint. Account No. 3180076 Service Code Rate Charge MultipliedUsers MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 33.90 /1 UB Meter Maintenance Account No. 3180076 Brand Serial No Status YTD Cons 13242409 a Active METE METE Date Reading 3/17/2009 499 12/1512008 489 9/16/2008 486 6/10/2008 477 3/14/2008 463 12/17/2007 448 9/14/2007 430 6/20/2007 404 3/16/2007 372 12/13/2006 344 9/19/2006 320 6/20/2006 293 3/20/2006 264 1/312006 242 9/15/2005 215 Trouble Code:03 -9% 6/14/2005 188 3/25/2005 167 12/15/2004 138 9/17/2004 109 6/14/2004 53 4/23/2004 37 12/23/2003 0 Location Brand Type Size YTD Cons 00 METE METE w Water 0.63 0.63 36 Code Consumption Posted Date Variance a Actual 10 4/29/2009 226% a Actual 3 1/20/2009 -64% a Actual 9 10/10/2008 -42% a Actual 14 7!16/2008 -7% a Actual 15 4/11/2008 -11% a Actual 18 1/22/2008 -37% a Actual 26 10/12/2007 -9% a Actual 32 7/2012007 11% a Actual 28 4/16/2007 7% a Actual 24 1/19/2007 -5% a Actual 27 10120/2006 -6% a Actual 29 7110/2006 9% a Actual 22 4/17/2006 18% a Actual 27 1/17/2006 -15% a Actual 27 10/14/2005 12°% a Actual 21 7/15/2005 -11% a Actual 29 4/5/2005 -11% a Actual 29 1/14/2005 -45% a Actual 56 10/8/2004 92% a Actual 16 7/30/2004 1°% a Actual 37 5/17/2004 0% n New Meter 0 12/23/2003 0% TOWN OE NORTH AND 0VER SEWAGE DISP O.SAL SYSTENI I_ ,STALLA-TION CERTIFICATION The undersisned here ;v certify that the Sewage Disposal Systern i (Y) repaired. v located at ! p 5 AAA Ing Te - was ewas installed in conrermance with the No-th Andover Board of Hea ith a:proved plan, System Desi, -,n Pe;:rit .= dated with an approved desa m flow of c0ailons per day The mate:a:s used were in conformar.:L :with those specined on the approved- plan; the systzn7 was installed in accordance %,,,ith the previsions of ? 10 C,"YlR- 15.000, Title 5 and local r ei--.ilatiors, and the final grading agrees substantially %`7th the approved plant. Ail wort: is accurateiv represented or, the As -built which has been submitted to the Board e- Health. Bed inspection date: Ensineer Rcprest :ative Final inspect:en date -- E-ngireer Represe^tat'%-e instal:er: —: L.; C. Date ir, M Cesium, Engineer: Date' N_ ----- C. TANGARD AL n?' I - < .4 INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes A. Bottom of Bed 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation, etc. Comments: B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sew 1. Pipe diamet minimum 4" 2. Schedule 40 pi 3. Watertight joints 4. Inlet to tank cement 5. Slope minimum 0.01 o /8" per foot minimum 6. Pipe properly set on comp firm base 7. Pipe laid on continuous grade ' straight line 8. Cleanouts precede all change in ' ment and grade 9. Manholes at any 90° change 10. 10' minimum offset to water line Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum .1c % 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and ea tee 6. 3-20" manholes 7. Inlet tee minimum 12" under invert 8. Outlet tee minimum 14" under invert 9. Outlet line cemented 10. Air space 3" above tees 11. 2" - 3" drop from inlet to outlet 12. Pipe set 13. Compact base with 6" of 3/4" crushed stone under 14. Tank is watertight Comments: NO Initials Sz.. A- l L'P -fa t Yes NO E. Pump Chamber 1. If separate from tank, com act base with 6" of 1/4" stone underneath 2. Minimum 2" pipe to d -box i vity system 3. 20" access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d -box Comments: F. Distribution Box 1. D -box level _ t/ 2. Minimum 0. IT' (2") drop from inlet to outlet ✓ 3. Minimum 6" sump 4. Outlet pipes show equal distribution 5. Compact base with 6" of stone beneath box ,✓ 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Z Comments: G. Soil Absorption system 1. All stone double -washed -'/." -- 1 ''/z" - pea stone Bucket test done? 2. Minimum 2". of pea stone above distribution lines 3. Minimum 6" stone beneath pipe 4. Distribution lines capped or co ,q�to - 5. Grading meets 3:1 slope 6. Minimum of 9" of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not, then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree wi Ian. Z length 100') 3. Width of trenches agree with p - um 2% maximum - 4'. 4. Vent present if <50 feet or specifi 5. Distance between trenches minimum ' and maximum of 6' 6. Minimum distance between trenches 10 7. Pipe slope minimum 0.005 or 6" per 100' 8. Depth of trenches below outlet invert minimum Yes NO 9. Pipes set on stable base. Comments: 1. Leach Field I . Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6" per 100' 3. Separation between pipe 6' maximum 4. Pipes connected at end 5. Separation between adjacent fields 10' minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: J. Leaching Pits 1. Minimum inlet ' e 4" 2. Pits of concrete 3. Sidewall between 12" 48" wide 4. Access manholes on each P. 5. Pipes cemented with hydraulic ent Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9" soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond NEW ENGLAND ENGINEERING SERVICES INC October 12, 1999 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 105 Wintergreen Drive, North Andover, Septic system design Dear Sandra: Enclosed you will find five copies of a septic system design for the above referenced property. These plans are being submitted for approval. The following additional items are also being submitted. 1. Soil evaluator sheets. 2. Application form. 3. Check to cover the fee. 4. Form 9A Local Upgrade Request Form 5. Request to have the local variances and upgrade approvals considered at the next Board of Health meeting. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, c� Benjamin C. Osgood, Jr., EIT President P.S. Please note that our new address is 60 Beechwood Drive, North Andover. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 NEW ENGLAND ENGINEERING SERVICES INC October 12, 1999 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 105 Wintergreen Drive, North Andover septic system design Dear Sandra: Please accept this letter as a request to have the following local upgrade approvals and local variances considered for approval at the next Board of Health meeting. Local Upgrade Approvals: 1. Reduction in the offset distance between the bottom of the leach field and the water table from 5 feet required by Title 5 section 15.212(b) to 4 feet. 2. Reduction in the offset distance between the leach field and the foundation wall from the 20 feet required by Title 5 section 15.211(1) to 10 feet. Local Variance Required: 1 Reduction in the offset distance between the leach field and the wetlands from 100 feet required to 50 feet. 2 Allow the use of a 20 mill poly barrier in lieu of a concrete wall for slope reduction. If you have any questions or need additional information please do not hesitate to contact this office. I will attend your next Board of Health meeting to discuss this matter. Sincerely, Benja ' C. Osgood, Jr., EIT President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 Oct -15-99 08:19A Paul D. Turbide, PE/PLS 508-465-0313 P.03 October 15, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for 105 Wintergreen Drive Dear Sandra, I find that the design plans dated Sept 27, 1999 adequately address the regulations. Note that this upgrade design requires local variances for reduction in the offset distance between the bottom of the leach bed and the groundwater from 5' to 4', and reduction of offset from leach bed to foundation wall from 20' to 10'. If you have any questions or comments please feel free to contact me. Sincerely Carlton A. Brown, PE/PLS Wintergen105.doc PORT ENGINEERING Civil Engineers & Land Surveyors One Harris Street Newburypom MA 01950 (978)465-8594 0 w c 2 O Z © O .+ E a a ii w O J w �- J3:0 Z N to LU ro Z z o. Q N R1 = LA LA U a > v Qw n > 2 (A ce o O Q 0 LL OZ a ocv c O Q 4 N u � -C Ce Y a� Q ce ZC) co o c 0 3 u o J O c C: Q O N O f.. O � N N ro ro a� � N \ Q L z �, — t ro N °vER rte* C N O a ?;F, V1 CL N LL APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERIMIIT DATE:_q 0® CTj=NT L`iSTALLER'S LIC1'NSEr LOCATION: JU%i1 , 7k,' 4,v� c L -;t . LICEN SED DIST ST SIGNATURE: 7 CHECK ON ;. REPAIR: I A ONE 44 3-2S__ 1 2 Com/ NSW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only X75.00 Fe.. Attached? Yes No Foundation As -Built? Yes No Floor Plans? Yes No Approval �! Date: 1�6 dd INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at (dam [,y�� -w�, oelative to the application of s�xw r o dated )CC-) for plans by .U_ f:'I and dated 7 16V with revisions dated'^ I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to 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 two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against 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 BOH, 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. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company 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 in the Town of North Andover plus significant fines to all persons involved. 4. 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. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. 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 Li ed Septic Insta r OU Date: G Town of North Andover, Massachusetts Form N°.2 f,ORTN BOARD OF HEALTH O""all + \ 3? �` e. F w a 4L i " DESIGN APPROVAL FOR 7SJAC"u� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant f tA(z'A—X*U--L--�Test No. Site Location_ ) A/ �n Reference Plans and Specs ENGINEE TE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAI AN, BOARD OF HEALTH Site System Permit No. /16 Town of North Andover, Massachusetts Form No. 1 r1ORTH BOARD OF HEALTH 0 GjAkw==117-1 9 0/c -F 1A11° APPLICATION FOR SITE TESTING/INSPECTION �9SSACHUS���y ApplicantlY/,)'V- rvriinr- AUUKtJS TELEPHONE Site Location /z�j—!t)72 -- Engineer_-_oe':x) 066,6-A Jr.- ADDRESS TELEPHONE Test/Inspection Date and Time 71 -21,? -CHAIRMAN, BOARD OF HEALTH FeeTe✓ 94.E st No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. May -27-99 12:4SP North Andover Com. Dev. SOS 688 9642 P.01 SEPTIC PLAN SUBMITTAL FORM _ LOCATION: 1N 1F/t' tE1V 6i21 u C19 N. -!yam✓ O boi YZ �1E�V PLANS: YES $125.00/111an__ REVISED PLANS: YES - S 60.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE: /v /R DESIGN ENGINEER: ,/jYW �; �,q,,� o ,v-�'n��11�v�ctzUte c -s 1,vc DATE TO CONSULTANT: *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. I2 Page 1 of 5 9A - APPLICATION FOR LOCAL. UPGRADE APPROVAL f i Commonwealth of Massachusetts ,IU6; i2t� f u o wcA- , Massachusetts Application for Local Upgrade Approval Title 5, 31.0 CMR 15.000 DEP approved form required by 31.0 CMR 1.5.403(1.) To be submitted to Local Approving Authority/Board of Health- For the upgrade of a failed or non -conforming system with a design flow of <10,000 gpd, where full compliance, as defined in 310 -CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non -conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: VVI--- ?AUM r (Z rc Address: 1o5 �,�Vwn G-2�Gn� pCLiv� Phone #: Address of facility: d`, 1,V -1-CA 64ZiFF I .D2tuF 2 iub 2) Applicant (if different from above) Name:' �S Am e Address: Phone #: 3) Type of Facility: Residential Commercial School Institutional (SPCC1fY) ,C1 A9 C-1— r-�4M71,4 RD A4,e r 4) Type of Existing System: _privy . cesspool(s) other(describe) Page 2of5 conventional; system Type of soil absorption system (trenches, chambers, pits, etc.) 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system 6 6 O gpd Approved: !��_yes A=pprovaI date:$ G no Why: b) Design flow of proposed upgraded systempd Why y A.R. c) Design flow of facility 40 gpd 6) Proposed upgrade of existing system is: a) j_ Voluntary required by order, letter, etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: EA -r- li t c d'y ') -ng i we/y-9YsT�,1- c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) o20` 7n /a' x12044 kEi?�cK F) FL.D 17-0 1:'ovA.)0AV0N Percolation rate of 30-60 minutes per inch (state actual perc rate) Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) Reduction of required separation. between bottom of SAS & high groundwater (specify proposed reduction & perc rate) ' -/-v y ` 02 m:I /xrncA Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the code) , System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a . variance pursuant to 310 CMR 15.410-15.417. 7) 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 ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater Y feet As determined by: Evaluator's name: 4&qpf204 57Ay tZ Evaluator's Signature: Date of evaluation: 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. 'If the department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name bate notified Ad4ress f Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain Nvhy full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: 7 -HC C-'t-.cVkf7h%, DF 7HiF xis T�•✓l,- J�r��d�¢no .y �jlrlit 5 Etx� E2 TKA /X & w Q, l- t-lo"I Pt j 644 Me s Ys TE'M c,41v 6C AA&S t b e b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. COST ,s 412oMlb&770C' c) A shared system is not feasible. d) Connection to a sewer is not feasible. .5,A10 C- IPC F$ Na i CX/&7- i✓ —i-Hl/92 E/9 DF i-21WN 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? yes no 0 Page 5 of 5 11) Certification , "I, the facility owner, certify under penalty of law thaj 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 knowing violations." Facilify Owner's Sire Date &h! C4 M ✓` 6 Print Name -s6- 000 -JL �iS/`Fr Name of Preparer Date x'79 - 686 - / 768 Telephone No. & Address of Preparer NOTE: Title 53 310 CAIR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade.approval upon issuance by the Board of 13ealth and prior to commencement of construction. BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: (ol a`ac LOCATION OF SOIL TESTS: 105- 5- Lo t vA" rce-^ ve Assessor's map & parcel number: � o4 a — �9 g OWNER: Wy„ < /1 el&S,. Pc,1vwc- TEL. NO.: 178- &85— 7/2" ADDRESS: ENGINEER: A &A, lr a TEL. NO.: 686- i7C f's CERTIFIED SOIL EVALUATOR: be,, OsG Intended use of land: residential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: 2 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 $275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. 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 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. 14 tes, TI) j Ip ........ . .. . if tes, TI) j Ip ........ . .. . if Nol 2 e FORM 11 - SOIL EVALUATOR FORA'i Page 1 of 3 Date: Commonwealth of Massachusetts ^1o. , per . Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By: �e�lf� Date: , 9 Witnessed By: 17 ion Address W�� �'v ��// love. ,`�t �i32 Ii 4/�� Aaa«o. am Tcicplarc / • 4? -7-r' 4 ' r/-7 / New Construction ❑ Repair Liu Office Review Published Soil Survey Available: No ❑ Yes Year Published ........... Publication Scale Drainage Class �..-- Soil Limitations Surficial 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 ❑Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Soil Map Unit Current Water Resource Conditions (USGS): Month W&�AI-0— Range :Above Normal ❑Normal ❑Belcw Normal Other References Reviewed: kiDEF APPROVED F0101 - 12/07/95 Location Address or Lot No. FORM 1Y - SOIL EVALUATOR FORM Page 2 of 3 On-site ^ ew � ��� Deep Hole Nunnba, ' , _ Tlnno����^��� VVma�hnn��»�� ~ Location (identify onsite plan) Slope Land Use (96> Surface Stones veVeu,vo/ . _. Landform . __/~�WW Position on landscape (sketch on the baok) Chutonnma from: ' �4~� �_ Open VVo1mr 8ndy/�7"'^~ foo1 Drainage way/ - feet Possible VVm1 Area feet Property Una /l�"- feet Drinking Water Well . feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % At 'MINIMUM v,Z MvLtn"cuv=C"°.",""..°".~~""=="^.^'..~` parenmaterial (geologic) Depth to Groundwater: Standing Water iothe Hole: -- Weeping from Pit Face: Estimated Seasonal High Ground Water: FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.� On-site Review "2 Date: Time �Z '" Weather�/w �F Deep Hole Number .: Location {identify on site plan) ��:...:::...::::......:....:..:......::::...:..:.::........:..:�:::.:.:::::.:........:::.::.::,.....::.,::.:..::. .. ...::...: : Land Use Slope (%) Surface Stones -- Vegetation....::::.:.. ......:....:... ::..::.:...:.......:..:...............:.::.::,:.::..... Landform Position on landscape (sketch on the back) Distances from: Open Water Body/5�0 feet Drainage way �Jry feet Possible Wet Area feet Property Line .:/..��:.. feet Drinking Water Well ..,. 777 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) G,7� �w L sy 77 7CF0�� �= Z t �7L - tviii mum Vr L rlVICJ ncuvinCV /�� cv Gn, , nvr v.a�Vwr vans. n.un Parent Material {geologic) �C �` DepthtoBedrock:, Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM - 12107/95 DORM 11 - SOIL LVALUA"roll FORM Page 3 of 3 Location Address or Lot No.'i� G�//i�/lZ��X/ ��1� A14 Ai%4(� Determination -for Seasonal High Water Table Method Used: El Depth observed standing in observation hole , inches ❑ Depth weeping from side of .observation hole inches Depth to soil mottles 77 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 Date Z g9 DEP APPROVED FORM - 12/07/95 P-04130 of::'NFT F 4 Pf'i�ov CD COA)PlTl OAJ5 : DI SAFPRnVED R�4SoNS LnT 15 wq, Gi{ _s�PE�_� TewrJ D wEc..c_ stPrl c Sy S TEM PA -r6' q -Z6 -8b APi-zDU1106 Aurhol?ffy Has o'�1��. of-- GOwt(J I T ICWA S lra�oi��I w,r�Te� 1%4-\,-- W S`IA LLATlOAJ -'C r EiG/�U/JT(c►1�1 ►rpAj v/JrG 11-23-87 --1i�15s ❑ FAIL - PAX. 3 Z3 -�� r FINAL iVSPF�rionJ CG461,0A&4- _4PPROOEP 04TCu" ANWIA)G AUTHORvrx � DlSA.PPKOvEP Rcjso NS FwAL A PPIZVAL DArC 12-�u �Ilo occl-,(, �e�w►� `El�C : YS 'ENY i �D F3ox -rant Z'/2 5iK WOOFpN LOT 1¢ LOT 15 A= 86,3!55 t S.F. m � .5wpe REQU//eEUENT ..................... DES/GN E -L. El/.4T/ON 47-:7: ...... (TOP OF 5570O _ ........ . EX/5T/NCS' ELEI/�1T/ON .47............... ..... T .... 2EQU/2E0 F/L = ............. zFLE!/.4T/ON,5 ops/�'N Qs aU/(-T INV PIPE OL/T 0F/1OUSE /Zo• eo5 /22.50 INV PIPE INTO TgNi- /20.30 /ZZ, 25 INV P/PE OUT OF TANK /20-05 121.8¢ INV PIPE INTO D. BOX 1117,04- /20.89 /NV P/PE OUT OF D. BOX //9. Col /20.78 INV END OF PIPE " azo. 120.17 GV,4TEie EL EV4 Tiv1'v 114.50 .4 VER,46E STONE DEPT// QT PICOBE NOTE.' T/1/S PL,4N /s NOT ,4 N,4.P2,4NTY OF 711E SYSTEM BUT Q VE21F/C,47/ON Of TVE LOC,4TION OF 711E" EI'/STIiV/ ST�eUCTL/2E5. SY45TE'/!�I ,//DI�T1441VDO IEIA� FOR Ni BRIAN MELAN501V s C,4 L E / ,,_ DQ TE.- �./& /88 CA1,e15T1,4N,546N- EN61N6Z7, MN 11VC. //4 KENOZ,4 4 VE, A4YEelllL L, /Y114. r �EX15T/NG— SEPTIC �} 5Y'5 7-E'M j SFPT►G J"� TAN � L 1311 r FP�IfY� Wa rot LOT 14 ZOT 15 A= 86 , 355 t 5.F. SLOPS 2�QU//��it�1�lV T .................. DE5/ON ECEI/4T/ON ,47-: - ....... (TOP OF STO ) _ EX/5TIM 4 CEDI 1 -ION ,HJT ......... 2EQU/2FD F14 = Fl- ,F�/.4ROW, OE51�W ,45 30W- q INV PIPE OUT OFNOUSE /ZO•4o5 /22.b0 /NV P/PE INTO T4NK /20.30 /2Z.25 INV P/PE OUT OF TANK IZO • D5 /2/.84 INV. PIPE INTO D. BOX 119.84- /20.89 INV PIPE OUT OF D. BOX //9. &7 /20.78 INV END OF PIPE 11 ' `C" � �' 1 120-17 GVd TEfC EL Ei/,d TIO/v 114,50 .4 VER46E 5 TONE DEPTH 4T PIC08E NOTE . - T11/S PL ,4N /5 NOT 4 GV,41P/�.4NT Y OF T/IE 5Y57E1V BUT 4 IIE2/F/C,47/0N Of TILE LOCATION OF T//E EX/STIM .57-Pll 'T///?FS `SUB-SU.2F,4CE D/SPO,SA SYSTEM LtioRTNANDOVE/3 , MA. FOR BRIAN MELAN501V 5C,4L E.- DATE: �/lo /88 CA1e16T1.4N,546N- CN61N6F,IEI C, /W //4 A<ENOZ.4 .4 VE., &4VE1111- L, /Y1,4. \:I, OFFICES OF APPEALS I WILL )ING CONSERVA"[ ION HEALTH PLANNING OF 'tOR ih S Town of I''+TORT14 ANDOVER C"usI )1 V `151 () N OF PLANNING & COMMUNITY DEVELOPMENT KAREN 11.11. NEI -SON, DIRECTOR To Whom it May Concern, 120 Main Street North Andover, Massachusetts ()184 5 (61 7) 685-4775 April 15, 1988 re; fill easement Lot 14 Wintergreen The fill_ easrtn(>>,t. which is shown on lot 14 was intended to reserve room .for the breakout fill that is necessary for lot. 15's septic system. As can be seen on the plans for the two lots the leach area for lot 15 is much closer to the lot line than. the leach area for lot 14. The system on 1.4 is far enough from the boundary that its breakout f1l.l. fits entirely on lot 14. If the lots were tinder common ownership and developed at the same time there would be ilo need for an easement. The easement was to assure that let 15's fill could still be installed even if it was developed at a much later date than lot 14. The easement s11.01.1.1.d have beers recorded at the registry of deeds to make It bli:l.ing, but I understand that it wasn't. Wether or not the easement is actually valid, the conditions of the permits will be sa t i_s f_ .i -(,d as long as the final grading is carried out according to plans and Board of Health approval will be given as soon as it does. As it stands now, it is in botl-1 lots best interest to complete the filling so that the lots are ready to Landscape. If you have any questions, feel free to col)ta.ct this office. Sincerely, �- cc Brian Mel.rrnsonr).?- Mike fGr-af / )