HomeMy WebLinkAboutMiscellaneous - 109 SULLIVAN STREET 4/30/2018 (3) / 109 Sullivan Street
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS , SYSTEM LOCATION
1-7� (example: left frontjof house)
S w( f i V w✓ � c
DATE OF PUMPING: "7 IrTla ' QUANTITY PIMPED
GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)Syll-MU
v a uM PUMPLil BY:
�l
COMMENTS: e2P kc I
,� ��✓'
5 7l
CONTENTS TRANSFERRED TO:
D �
---- --- /
i
Lot & Street Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: YES NO Permit#
Plan Approval: Date: Approved by:
Designer: Plan Date:
Conditions:
Water Supplyown Well
Well Permit: Driller:
Well Tests: Chemical Date Ap oved
Bacteria I Date Approv
Bacteria 11 Date Approved
Plumbing Sign-Off: Wiring Sign-off:
Comments:
Form "U" Approval: Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid? YES 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
CONDITIONS:
Is the installer licensed? ES 0
Type of Construction: NEW CRELAIR
New Construction: Certified Plot Plan Review YES NO
Floor Plan Review YES NO
Conditions of Approval from Form U YES NO
Issuance of DWC permit: NO
DWC Permit Paid? ES NO -
DWC Permit# Installer:
Begin Inspection: YES NO
Excavation Inspection:
Needed:
Passed: Zz By:
r
Construction Inspection:
Needed:
As Built Plan Satisfactory:
YES:
Approval of Backfill: Date: By: l
Final Grading Approval: Date: By: �
Final Construction Approval: Date: By:
Certificate of Compliance: Approval: Date:
Town of North Andover NORTH
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr Telephone(978)688-9540
Public Health Director Fax(978)688-9542
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
X0/02
This is to certify that
the distribution box and connection pipe
constructed (X) or repaired ()
by
Angelo Petrosino
at
109 Sullivan Road
has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the
North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will function
satisfactorily.
&1;7
Brian J. LaGrasse
Board of Health Inspector
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
T'bvv_."_ oft�:ofi_ TH�1t QGC
BOARD OF HFACM
APR
\ 9 2002
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System Kconstructed,
( ) repaired;
by_ ao/a -1k0.2o
locatedat /0'9 '2 111;A'n I a,Z erz
was installed in conformance with-the North Andover Board of Health approved plan,
System Design Permit# , plan dated , with a design flow
of gallons per day. The materials used were in conformance with those specified
on the approved plan; the system was installed in accordance with the provisions of 310
CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with
the approved plan. All work is accurately represented on the As-built which has been.
submitted to the Board of Health.
Bed inspection date: ��„ �.�✓�b
Engineer Representative
Final inspection date: vvl&
Engineer Representative
Installer: �` �u Lic.#: Date:
Engineer: Date: 31A.3,/10 Z
Jun-07-00 03:32P Paul D. Turbide, PE/PLS 978`-465-0313 P.03
June 7, 2000
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 109 Sullivan Road
Dear Sandra,
Enclosed find the"Checklist for North Andover Septic System Plans" for the above-
mentioned site. The following is a list of all the`Problem' areas and deficiencies Port
Engineering has found.
3
❑ The high point of the existing grade over the proposed leaching bed has elevation
100.5'. ESHW was observed to be down 36 inches. Thus the elevation of ESHW is
97.5'. The bottom of leaching bed should be 3 feet above ESHW(is the local
upgrade approval is allowed)or elevation 100.5'. The design plans show an
elevation of bottom of leaching bed of 99.7'. Thus the leaching bed must raised by
0.8 feet.
v Wetlands disclaimer must be added. NA 8.02S
o The design plans do not specify whether a garbage disposal can be installed. If it is
included then there must two septic tanks in series(3 10 CMR 223(1)(c))and the
system must be 50'/o bigger(310 CMR 240(4))
o A swale is required on the,;outh side of the leaching bed because the toe of the
slope is closer than 5 feet from the property line.
❑ The retaining wall must be poured concrete(or a waiver must be requested and
approved). NA 9.02
❑ A riser must be installed over the septic tank(as well as over the pump chamber)
310 CMR 228(2)
❑ A 6-inch stone bed must be placed under the dbox. 310 CMR 221(2)
a A baffle must be installed in the dbox. 310 CMR 232(3)(a)
a The piping is designed to be SDR35. North Andover requires Sch 40 PVC. NA
10.01
❑ The distribution lines must be connected with solid pipe. NA 15.01
o Buoyancy calculations must be submitted. 310 CMR 221(8)
POI)w ❑ A manual operating switch must be included in the pump system. NA 12.01
ItI ❑ A check valve and bleeder hole is required in the pump system. NA 12.01
ENGINEERINGIf you have any questions or comments please feel free to contact me.
Civil Engineers& Sincerely
Land Surveyors �iCCJ/
One.Harris SCreel Carlton A. Brown,PE/PLS
Newburyport,ata Sullivan109.doc
01950
(978)465-8594
SEPTIC PLAN SUBMITTAL FORM
LOCATION: 0 9 5.��� ✓��
NEW PLANS: YES $125.00/Plan
REVISED PLANS: r'� YES $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES (:IiO)-
DATE:
C'OIV W �, •`\ I S.1 PSG. Te .. 1
DESIGN ENGINEER:
DATE TO CONSULTANT: 3
*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.
STANTON W. BIGELOW, M.S., P.E., P.L.S.
Professional Civil/Environmental Engineer and Land Surveyor
Commercial Title Surveys Building Inspections and Certifications
Title 5 Inspector DEP-Licensed Soil Evaluator
Site Development Permitting and Construction Management
An Associate of Harbor Engineering Associates P.C.
----------------
6 Winthrop Avenue
Beverly, Massachusetts 01915
Te1.lfAX: -(978) 922-2629
E-mail: jlwilh@mediaone.net
November 8, 2000
Board of Health Office
c/o Community Development & Services
27�C sTlee Street
North Andover, MA 01845
Attention: Sandra Starr, R.S., C.H.O., Director
-RE: Revised Design Plans for Replacement System, 109 Sullivan Road
Dear Ms. Starr:
Enclosed please find three (3) sets of totally revised design plans and specifications for the above-
referenced replacement sewage disposal system, which I have prepared on behalf of James McInerney,
present owner/occupant of the referenced property. These drawings are to replace those dated April 22,
2000, for which your office provided review comments back to me dated July 7, 2000 (which comments I
have addressed in full with this re-submittal).
Also enclosed please find a bank check in the amount of $60.00, to cover the cost of your re-submittal
review fee for this project.
My client is very anxious to sell the property as soon as the new system can be installed, and has asked
that your review be as expeditious as possible. Due to health problems, I was unable to complete these
plans and provide them to your office before now, but I am confident that my status will now allow me to
complete this and other similar projects.
If you have any further comments and/or questions, please feel free to call or e-mail me at the above
number and e-mail address. I look forward to your favorable action relative to the enclosed plans.
Very truly yours, 11
Stanton W. Bigelow, M.S., P.E. cc: James McInerney
Consulting Civil/Environmental Engineer William Smith & Sons
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I yq�t
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at U0 h relative to the application
of. - _&,,Cnb dated ��G^ I for plans by \-rhA L� B�< and
dated lgo with revisions dated \.S',2 40 6
I understand 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,
j 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
p below. I understand that requesting an inspection, without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a$50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first.s Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be
on site.
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 at 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 Licensed Septic Installer
Date: 6 - 2911" — F.
Disposal Works Construction Permit#
foo!,,"i of
BOAR6 OF
BOARD OF HEALTH
NORTH ANDOVER, MA 01845 ,JUN 2 6 2001
978-688-9540
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: &�z r CURRENT INSTALLER'S LICENSE# —
LOCATION: 6)
LICENSED INSTALLER:
SIGNATURE: jn �� ti TELEPHONE# 3 a
CHECK ONE:
REPAIR: JC NEW CONSTRUCTION: -
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$160.00 Fee Attached? Yes No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval Date:
Town of North Andover F NORTH
O tt�eo ,e by
Office of the Health Department
F y n
Community Development and Services Division * i
oq ..
William J.Scott,Division Director �---
27 Charles Street �9Ssac►+us��cg
North Andover Massachusetts 01845
Sandra Starr � 'telephone(978)688-9540
Health Director Fax(978)688-9542
December 11, 2000
Stanton Bigelow
6 Winthrop Avenue
Beverly, MA 01915
Re: 109 Sullivan Road
Dear Stanton:
This is to notify you that the plans for the repair of
109 Sullivan Road have been
approved.
If you have any questions, please do not hesitate to call the Board of Health Office at
978-688-9540.
Sincerely,
ZVI
Sandra Starr, R.S., C.H.O.
Health Director
SS/smc
cc: J. McInerney
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
Nov-20-00 04:42P Paul D. Turbide, PE/PLS 978-465-0313 P.02
i
November 20, 2000
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 109 Sullivan (Lot 12)Revision
Dear Sandra,
I find that the design plan dated August 8,2000 adequately addresses the concerns
outlined in your letter of review dated July 7,2000.
If you have any questions or comments please feel free to contact us.
Fflr PortEngineerin Associates,Inc
aul D. T u r b i e, E LS
PODT
r
ENGINEERING, �-
c
Civil Engineers&
Land Surveyors
One Harris Street
Newburyport,Wk
01950
(978)465-8594
\\server\p\nabh\2884\Sullivan Road 109 .doc
Nov-20-00 04:42P Paul D. Turbide, PE/PLS 978-465-0313 P.02
i
November 20, 2000
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 109 Sullivan(Lot 12)Revision
Dear Sandra,
I find that the design plan dated August 8,2000 adequately addresses the concerns
outlined in your letter of review dated July 7,2000.
If you have any questions or comments please feel free to contact us.
For Port Engineerin Associates, Inc
`Paul D. Turbi e, E PLS
PODTENGI�EE�ING
iti
Civil Engineers&
Land Surveyors
One Harris Street
Newburyport,MA
01950
(978)465-8594
\\server\p\nabh\2884\Sul1ivan Road 109 .doc
Nov-20-00 04:42P Paul D. Turbide, PE/PLS 978-465-0313 P.01
Facsimile Cover Sheet
To: SANDRA STARR
Company: NORTH ANDOVER BOH
Phone: 978-688-9540
Fax: 978-688-9542
From: Paul D. Turbide, P.E.IP.L.S., President
Company: Port Engineering Associates, Inc.
Phone: (978) 465-8594
Fax: (978) 463-0313
Date November 20, 2000
Pages Including This
Cover Page: 2
Comments:
Sandy,
I have attached our review of the SDS repair at 109 Sullivan Road(I,a }t 12 .
Thanks,
Paul D.Turbide,P.E./P.L.S.
PODT
iti
ENGINEERING
Civil Engineers&
Land Surveyors
One Harris Street
NewburyporL.MA
01950
(978)465-8594
140RFH Town Of North Andover .
oF,t�ao:°'9y0
�� `�+ ° �` Community Development & Services William J. Scott
O A
27 Charles Street Director
$ _ a (978) 688-9531
North Andover, Massachusetts 01845
�✓ °wwreo a°a 45
�SSACHUSE�
Fax 978-688-9542
July 7, 2000
Board of Stanton W. Bigelow
Appeals 6 Winthrop Ave.
(978) 688-9541 Beverly, MA 01915
Building Re: 109 Sullivan Road,N. Andover
Department
(978) 688-9545 Dear Mr. Bigelow:
Conservation This is to inform you that the proposed design for the repair of the septic system
Department at the above-referenced site has some technical deficiencies that must be addressed
(978) 688-9530 before the plan can be approved. They are as follows:
1. The groundwater elevation has not been adjusted to the highest existing grade,
Health resulting in a separation to groundwater of less than 3 feet as requested in the
Department Local Upgrade Approval application.
(978)688-9540
2. Missing wetlands disclaimer. (NA 8.02s)
3. Note required that there can be no garbage disposal and if one is present it must
Public Health be removed.
Nurse 4. Swale on south side of property because toe of slope closer than 5' missing.
(978) 688-9543 P p Y p g•
5. Retaining wall must be poured concrete. (NA 9.02)
6. Risers over septic tank and pump chamber missing. (310 CMR 15.228(2))
Planning 7. D-box missing 6 inch stone base underneath. (31.0 CMR 15.221(2))
Department
(978) 688-9535 8. Baffle in d-box missing. (3 10 CMR 15.232(3)(a))
9. All pipe required to be Sch 40 PVC. (NA 10.01)
10. Distribution lines not connected with solid pipe. (NA 15.01)
11. Buoyancy calculations missing. (3 10 CMR 15.221(8))
12. Manual operating switch missing. (NA 12.01)
13. Check valve and bleeder hole missing. (NA 12.01)
Please be aware that all review re-submittals require a$60.00 fee. Please call
the office at 978-688-9540 if you have any questions.
Sincerely,
Sandra Starr,R.S., C.H.O.
Health Director
I
Cc: J. McInerney
File
Address !07 5w-.Ever 5-t. Title of File Page of
Date File Open:, Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes
action Document/ document/
Num. Action Department
Board of Appeals - Board of Health - Planning Board - Conservation Commission - Building Department � J
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE I OF 5
Commonwealth of Massachusetts
Noa. AVJDo1/SjZ , Massachusetts
Application for Local Up air de Approval
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
o - -
To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or
nonconforming 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 nonconforming system with a design flow
of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full
compliance, as defined in 310 CMR 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 36,ME-5 Yc,1wce,4-Y
Address 1<D3 5-3t-L-i v D 14c-i- o 1 4 S
Phone # 91 8) (.SI- 94-3i
Address of facility i o9
2) Applicant (if different from above) I
Name Se.r.t a As, A6o✓E
Address
Phone #
3) Type of facility
X residential commercial _ school
_
institutional-
(Specify)
nstitutional(Specify) 'ic.,tr;,;f F;,sC"61ae � <` :a
;11a.1741'I
MAY 12 6
DEP APPROVED FORM-12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 2 OF 5
4) Type of existing system
_privy cesspool(s)--x conventional system
Other (describe)
Type of soil absorption system(trenches;chambers, pits,etc.)
P rr
5) Design flow based on 310 CMR 15.203
a) Design flow of existing:system
Approved? yes approval date - .y�V_t ow r-S
no why?
b) Design flow of proposed upgraded system 44o gpd
c) Design-flow of facility 44o gpd
6) Proposed upgrade of existing system is -
a) X Voluntary
Required by order, letter, etc. (attach copy)
Required following inspection required by 310 CMR 15.301 (provide date
inspection form was submitted to the approving authority) (date)
b) Describe the proposed upgrade to the system
AF34t-AWN EXlSilrtG
_s-%z_4 _ 1-1S LA_ 2^ cm.4 .T.tA&4P 6p IG T4,11G
�4�7oo-C.i��t.o.fl �O.IMP Ck-k4mc e%L (75G G,%,!=. . O.S-41P PJMP 40P
5%J A" - roCsc rLE.MM-Q SzoaE Tn ESD . A
j
c) Which of the following are applicable to the proposed upgrade?
Reduction of setback(s) (list setbacks to be reduced with proposed setback distances)
Percolation rate of 30-60 minutes per inch (state actual perc rate)
DEP APPROVED FORM-12/07/95 t
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL.
PAGE 3 OF 5
Up to 25% reduction in subsurface disposal area design requirements (state required
& proposed size)
Relocation of water supply well (identify well, describe relocation)
X Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & perc rate) 41 TO
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 310 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)(i)(1). The evaluator must be.a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
3.25 feet
As determined by:
Evaluator's name
Evaluator's signature
Date of evaluation A.►�� T 9, �99,�
=DEP APPROVED FORM-12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 4 OF 5
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 or well is affected by certified mail 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.
List of affected Abutters:
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
9) Explain why 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:
S,rs -IM
FeAc u .ts ( Ex%sn►r. D Q.�✓� .1�,� � � o.+
W-
b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
IJo �L7�RJgi J✓F Svs As �kPPRoJoj 6-t D.r--
. SYSt'Fs-1 OPC-Qi4t7.t�, �J'4.I7'04G'cS -Co E.1✓ ZoNMir�r. •
DEP APPROVED FORM-12/07/95
FORM 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL
PAGE 5 OF 5
C) a shared system is not feasible:
)-J >J*r,,P pp SYT�a�1 lr W-e Gr,) L42GE lcT StZ6s
Pto"I s rr S W4a,1* 5--rwa-t 'n+ c �Jov�.� 8` CocT - eFftC-rt✓,-
d) connection to a sewer is not feasible:
iJc Sc-� AJG,I��g �, I.J 'TKt$ A�cA
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? X yes no
11) Certification
"I, the facility owner, certify under penalty of.law that this document and all
attachments, to the best of my knowledge and belief, are true, accurate, and .
complete. I am aware that there may be significant consequences for submitting
false information, including, but not limited to, penalties or fine and/or
imprisonment for knowing violations."
�e 13
Fa ty owner's signature Date
JAMS MC, I I Y
Pr' Name
STa,.}tb� w 3t G E Love F M -4)z
2
Name of preparer Date
(913) <)Za- 7-6L9
W t..Ma P.oP AJC. 3:-JCt-c.-� M A cAy15
Telephone # & address of preparer
NOTE: Title 5, 310 CMR 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 Health and prior
to commencement of construction.
DEF APPROVED FORM-12/07/95
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
No. Date:
Commonwealth of Massachusetts
Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By:
........ ............................ Date:
W 1 Q ................
imessed By: .......... .............................................. ...... ..................
99
L=ion Address 0-mr's N", \JA-M & 14 e�TQ e12-J iny
L0(* Address.and 10 Cy 5L/(—C—j VA4-W
Tel.Phorx I
New construction ❑ Repair
Office Review
Published Soil Survey Available: No Yes
Year Published 11.61- Publication Scale Soil Mar) Unit
Drainage Class \A/e L--- DZA'015�jroil Limitations ........ .......
Surizicial Geologic Report Available: No 11 Yes
Year Published
Publication Scale
GeologicMaterial (Map Unit) Tl.tl ...................................................................................................................................
Landform ...........G..
Flood Insurance Rate Map:
Above 500 year flood boundary No LV Yes F
Within 500 year flood boundary No 7 Yes El
Within 100 year flood boundary No OYes ❑
Wetland Area:
National Wetland Inventory Map (map unit) ................................................................................................................
Wetlands Conservancy Program Map (map unit) ...................................................................................................
Current Water Resource Conditions (USGS): Month
Range :Above Normal ONormal 013elowNormal
Other References Reviewed:
HAY -26
-jo :'DEP APPROVED FORM-12/07/95
FORM 11 - SOIL EVALUATOR FORM
Page 2of3
Location Address or Lot No. I 0 Sumac-tvwr+.l
On-site Review
Tom'
i w
Deep Hole Number Date:.:.8-::9:"..9q Time::. Weather
Location (identify on site plan) ...:
Land Use DENrl A.L- Slope M 3 -..5 Surface Stones
Vegetation -..... . ..:.
Landform G.t?o,y.�,L.A ... M O.r2lZ ►►>Ltt,...:..
Position on landscape (sketch on the back)
Distances from:
Open Water Body, 1 00 feet Drainage way. 156 Beet
Possible Wet Area > 1 0 0 feet Property Line :ZD..... feet
Drinking Water Well .? feet Other .....:..
DEEP OBSERVATION HOLE LOG* I
I
Depth from Soil Horizon Soil Te-cure Soil Color Soil Other
Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, %
Gravel)
p L, 0; Oe- �
q�tCLI
J
3(1" ter,,2-
&b.,
&b,, c V
,315 2.sY
l 1517, C�o 5q-,LftS I
g C-2- els z.s A.
UM OF 2 HOLES RE001RED
I
A
Parent Material (geologic) I C& CO--tTA-e.-r p✓ - — DepthtoBedrock: P c>SS t 15L51
Depth to Groundwater: Standing Water in the Hole: N o+1 g-- Weeping from Pit Face: (V a t`Ct-
Estimated Seasonal High Ground Water:
Z'
pY -°DEP APPROVED FORM-12/07/95
j I
- I �
-: - FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. 109
On-site Review
a
Deep Hole Number Z.. Date::::: .,�.q.-`t�1 Time:.!.(.', 50 A--r-4 Weather
Location (identify on site plan)
Land Use ��s(:n �'rl rj-(— Slope (%) 25 ..o Surface Stones
Vegetation :.. ._F ,A7 G-...
Landform
. .. .. .::..
...... .......:.:......: .::.......... ... .
Position on landscape (sketch on the back)
Distances from:
Open Water Body > 106 feet Drainage way 4-01 feet
Possible Wet Area > 10 O feet Property Line 2•0 feet
Drinking Water Well 2 feet Other _.
DEEP OBSERVATION HOLE LOG*
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface (Inches) (USDA) (Munsell) Mottling I (Structure, Stones, Boulders, Consistency, °o
Gravel)
Z — 0 L 10
Q
3G" 13�, -f�s� toYtz4/� rn , d5
IoYrz`t'A
84� CL I sir (/3 sY to/Z
�Z
MINIMUM OF 2 HOLES REQUIRED AT EVFRY PROPOSED DISPOSAL AWET
Parent Material (geologic) IL& COr.17-A{.7' GVM—V— T"Icl— Depthtoaedrock: PyS5, 54—Y �4
Depth to Groundwater: Standing Water in the Hole: }�e,� Weeping from Pit Face: e F
Estimated Seasonal High Ground Water:
s
i DEP APPROVED FORM-12/07/95
x
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. p9 6vc_c._,v4-i! 75T-�-��-
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole.................. inches
❑ Depth weeping from side of observation hole ....... .. .. inches
� rr
Depth to soil mottles y inches❑ �Ground water' to adjustment ...... ........ feet
Index Well Number ............... Reading Date .................. Index well level
Adjustment factor _................ Adjusted ground water level .................._...............................
Deoth 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? SES
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on 9 3 (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 8 - Z6- 99
I
DEP APPROVED FORM-12/07/95
FORM 12 - PERCOLATION TEST
Location Address or Lot No. 1 oy SJt---,✓AJ 5re-Z-G-r
COMMONWEALTH OF MASSACHUSETTS
Massachusetts
Percolation Test* *,I
Date: .. �.► ►.l g 9 Time:
Observation Hole #2
Depth of Perc -7 Z_"
Start Pre-soak 9 ; 35
End Pre-soak SP
Time at 12"
Sp: 5.a
Time at 9" ,
Time at 6"
Time (9"-6")
Rate Min./Inch
* Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed [all", Site Failed ❑
...............................................................................................................................................................
Performed By:
Witnessed By:
Comments: .....:..:.:.:.................................:...:..............................................:...................
......................,...........:..:..:..........::,..,.:.:...,... ...................................
DEP APPROVED FORM-12/07/95
FORM 12 - PERCOLATION TEST
Location Address or Lot No. 109 S--$LL1✓&0 AJrxVec
COMMONWEALTH OF MASSACHUSETTS
IJ,n2,n-+ A"v>�z✓e�� , Massachusetts
Percolation Test* 2
Date: Time:
Observation Hole #
Depth of Perc 52" -
Start
2" `Start Pre-soak
End Pre-soak 1 l 3
Time at 12"
Time at 9" S y
Time at 6" 1 Z.. 19
Time (9"-6")
27 ►���.
Rate Min./inch 9 M�.����1c�a
* Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
I
Site Passed Rr� Site Failed ❑
...............................................................................................................................................................
Performed By: ,,•,, ��)
Witnessed By:
Comments: ...................,.......... . w......
1 DEP APPROVED FORM-12/07/95
RC1j�" i
GRAIN SIZE DISTRIBUTION TEST
JUL 2 2001 REPORT
C S C
C C \ I c
a w o
100 m ^ N ' � \ n v� � �
90
80
70
w
Z 60
F_ 50
w
U
W 40
0-
30 30
-A—A
20
10
0
200 100 10.0 1 .0 0 . 1 0 .01 0 .001
GRAIN SIZE - mm
7 3" 79 GRAVEL 7 SAND 7 SILT % CLAY USCS LL PI
• 0 . 0 0 .8 98 . 2 1 .0 SP
SIEVE PERCENT FINER SIEVE PERCENT FINER Location:
inches number
size • size • 0 WILMINGTON ,WASHED SAND
0,373 100,0 4 99 ,2
10 83.4
20 57 .9 Description :
40 30 .6 •F-M-C SAND
50 18 .8
100 3.9
GRAIN SIZE 200 0.9
030 0-901
UTS
OF UTA SACH SETT , INC.
RE D10 0.214 IE Remarks:
COEFF I CI-E-NTSB'y #200 WASH SIEVE
Cc 0 . 91 -
C� 4. 2
UTS OF MASSACHUSETTS, INC_ Project No. -
5 Richardson Lane Project : Q.C. FOR HEFFRON
toneham, MA 02180 Sample No . 8361C
i
J I
7-77
wo*
GRAIN SIZE DISTRIBUTION TEST REPORT
JUL 1 2 2001
N V m N
100 'O r' 24I M n -4. ne b". as MA
90
80
70
tr
Li
Z 60
z 50
w
U
w 40
30
20
10
0 Lt :111 K.....',
200 100 10.0 1 .0 0. 1 0.01 0 .001
GRAIN SIZE - mm
+3" % GRAVEL SAND % SILT % CLAY USCS LL PI
• 1.0 100 .0 0 .0
S i EvE PERCENT FINER-- SIEVE PERCENT FINER Location :
inchesnumber
51zc • •WILMINGTON ,WASHED STONE
100.0
1 . 78.8
12,6 Description!
0.75 0.6 01 1/2"DOUBLE WASH .STONE
GRAIN SIZE
60 33 .8
DD 30 U OF MASSACHUSETTE3, INC.
D10 24. 7 R IEW Remarks t
COEFFICIENTS
Cc 0 .98
Cu 1 . 4
UTS OF MASSACHUSETTS, INC. Project No; :
5 Richardson Lane Project - Q.C. FOR HEFFRON
Stoneham, MA 02180 Sample No . 8361D
1
e
Town of North Andover, Massachusetts Form No.3
HORTII BOARD OF HEALTH
Ot tt�ao 1ti
e
00
F A
DISPOSAL WORKS CONSTRUCTION PERMIT
�9SS4
CHUSEt
Applicant "
NAME ADDRESS _/ TELEPHONE
Site Location
Permission is hereby granted to Construct ( ) or Repair ( t an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No. /�•��
CHAIRMAN, BOARD OF HEALTH
Fee. ` D.W.C. No. to ,3
: Town of North Andover, Massachusetts n Form No.2
NOR?h BOARD OF HEALTH
F w
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
• Applicant Test No.
Site Location
Reference Plans and Specs. L�
NGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
Fee Site System Permit No. //oZ k
Town of North Andover, Massachusetts Form No. 1
NORTH A BOARD OF HEALTH
19
T
*
10 —,�ew,-I . APPLICATION FOR SITE TESTING/INSPECTION
ATED
�9SSACHUSE��y
Applicant
NA ADDRESS TELEPHONE
Site Location 6CJ GL
t
Engineer &-a�l
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time U�• ��
CHAIRMAN,BOARD OF HEALTH
Fee 7J Test No.
S.S. Permit No.&aD.W.C. No.Lj: C.C. Date Plbg. Permit No.
Town of North Andover, Massachusetts Form No. 1
NORTH BOARD OF HEALTH
OF�t,.Eo ,bq�O
19-
0
9 -
3� 5e 6 pL
' °R APPLICATION FOR SITE TESTING/INSPECTION
TED
�9SSACINU5���y
Applicant
NAME' ADDRESS -� TELEPHONE
L
Site Location
Engineer �—
NAME ADDRESS TELEPHONE
Test/I nspection Date and Time "*.'•'� -i rl' ' .
CHAIRMAN,BOARD OF HEALTH
Fee � Test No. I
S.S. Permit No. D.W.C. No. . = C.C. Date Plbg. Permit No.
INSPECTION CHECKLIST FOR SEPTIC SYSTEMS
Yes NO Initials
A. Bottom of Bed T�6/A
1. Excavation to proper depth l�
2. With trenches,sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation,etc.
Comments:
B. Retaining Wall 713/16/
1. Wall height and width as specified
2. Waterproofed
3. Wall minimum 10'to leaching facility t/
4. Wall meets specifications of plan e�
Comments:
C. Building Sewer .
1. Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Watertight joints
4. Inlet to tank cemented
5. Slope minimum 0.01 or 1/8"per foot minimum
6. Pipe properly set on compact firm base
7. Pipe laid on continuous grade in straight line
8. Cleanouts precede all change in alignment 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
3. Gas baffle present on outlet t/
4. Manhole to grade
5. Manholes over center and each 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, fi
13. Compact base with 6"of/<"crushed stone under tank
14. Tank is watertight
Comments:
Yes NO
E. Pump Chamber
1. If separate from tank,compact base with 6"of'/4"stone underneath 1/
2. Minimum 2"pipe to d-box if gravity system c/
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 Y
12. Pump delivers liquid to d-box
Comments:
F. Distribution Box
1. D-box level X
2. Minimum 0.I T'(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
Comments:
G. Soil Absorption system
1. All stone double-washed-'/d'- 1 '/2"
-pea stone
Bucket test done? c�
2. Minimum 2"of pea stone above distribution lines (/
3. Minimum 6"stone beneath pipe
4. Distribution lines capped or connected together �-
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 with plan. (Max. length 100')
3. Width of trenches agree with plan Minimum 2';maximum-4'.
4. Vent present if<50 feet or specified
5. Distance between trenches minimum 4'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 of 6".
i
Yes NO
9. Pipes set on stable base.
Comments:
I. Leach Field
1. 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 pipe 4"
2. Pits of concrete
3. Sidewall between 12"and 48"wide
4. Access manholes on each pit
5. Pipes cemented with hydraulic cement
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 LA
5. No areas over system that may pond
I
I
i
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
TO\A/nl OF N0(ZT4 40004SK
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade (/C) Abandon ( ) - X Complete System [-]Individual Components
I
log 5-3ld-I\j4rj ZC:az> es McI-jeQt.P+�
Location Owner's Name
1.07 5 109 Syt-.LtQD,, N1o214 A•Joc%/CP_
Map/Parcel# Address
Q. 45 1
Lot# Telephone#
ST7k's. 1'[c�.l W e,t ,000v/I
Installer's Name Designer's Name
(o �(�•m-c2oo �$�/ea�� BE\/6;jZL-'r MA 0191
Address Address
2 rp29
Telephone# Telephone#
Type of Building: DvA/ELL t&_YV Lot Size 4�*, 9'12- Sq.feet
Dwelling—No.of Bedrooms 4 Garbage Grinder (—) 04r,r At�cc�.as-gyp
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min. required) 44c) gpd Calculated design flow 440 gpd Design flow provided 440 gpd
Plan: Date Ape-it. 22 2eeYo Number of sheets 3 Revision Date
Title"PRePo Eos s eye Ar 'b!) A+o��
Description of Soils) C 3 fc�t-(eou exlr. ro,.r�fi I yC (�1 842
Soil Evaluator Form No. 11 Name of Soil Evaluator ;1JA rfi-j rm� S,Date of Evaluation $ 9
DESCRIPTION OF REPAIRS OR ALTERATIONS AG Jgo.j E-clsr►..Tc, 5--es-mm l,�s�u 2- Gflr•to�21�.1-vlt
5e*mc M r���5c� Gs.� p,>�C,4&.-ao«(15c GAj_) O 5 44P PJMP A"J.0 aocs 5 F E�r,Pettn STn
(.L-e.c���a ��,=moo•
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
C
Signed Qi Date S �3/O6-11D
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
------------------------------------------------------------------------
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
tJo2�-H AODadER BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) CR Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded X),Abandoned( )
by: -)A,-165 nl c 1 tJeg,�
at 1.3 20&.0
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
--------------------------------------------------------------------------
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
WOP-314 441)1 e-ft BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (X) Abandone an individual sews
( ) g
disposal system at A,e.l 9-D An as described
in the application for Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
�.,AY 2
i
FORM 1255 (REV 5/96) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
ro\a/ISI OF Worz-n4 Awooyse
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade OC) Abandon ( ) - X Complete System ❑Individual Components
loo) 5JLL1\/A,1 Qcgo JA^�ESMcI"Je?-t.1CY
Location Owner's Name
15 109 SOL.t`I V,0S,�J RID,, I\loiz k A--jooyrze_
Map/Parcel# ` Address
12 9431
Lot# Telephone#
'STIy.•S'roa! W, FaIG6lc.••/I
Installer's Name Designer's Name Q 191
AddressAddress
�91�) 922- ZG29
Telephone# Telephone#
Type of Building: D\Jk/ELL I�JCs Lot Size 4(o, 97Z Sq.feet
Dwelling—No.of Bedrooms 4 Garbage Grinder (—) 0-or ALLow,/ED
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min. required) 440 gpd Calculated design flow 44•o gpd Design flow provided 44,0 gpd
Plan: Date Apart. 22 2eeo Number of sheets 3 Revision Date
Tit1e�IPRr�Po3C-o ��P��c,� +r 5G-•w.4aE btsPo A�- Cyst AT tD9 12oee 1-i ►JC)wnd /�toZR,t
Description of Soil(s) C 3 lo�- o° e xA-e. 5,rC-%.1—(f1 ., ,, • C I94.) 1A M s Act,
Soil Evaluator Form No. 1 Name of Soil Evaluator P1Atrs-j >=a,e R, Date of Evaluation 9 I
DESCRIPTION OF REPAIRS OR ALTERATIONS .A>3-wix--no Exj5mjG 5-es� los-mt-t Z- G��tc�,�T►.�att I�
se"C-M&,jIf (�5�-Gn�.I/PJ�eP C,te,. �n�caz`I7So_GA�� 0,5 Af PO"e X00 Aoa '>-'F.. Er`F✓ett-n S-m-Jt
�
Ls*cuuio Irtst-a-
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not too place the system in operation until a Certificate of Compliance has been issued by the Board of Health.'
Signed �. 1rg� /�� C� II vim- ry-' Date
Inspections
1 ++t
.1
I
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
-----------------------------------------------------------
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
tJoe-r" Ai1no4E2 BOARD OF HEALTH
CERTIFICATE Ok COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded()C),Abandoned( )
by: )A"e,5 m c 1 tJe;( ,JC-y
at ✓e -A 7-a I'D
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector Date
The issuance of.this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
,
-.�..��.i.-..s--- ---s-...,'..,.a--.3-« �:.�-...
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
N,32,44 A-locVr--2 BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade Abandon ( ) an individual sewage
disposal system at 109'S-J�-Lt J AnI 9-o&o as described
in the application for Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON
V
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cU
lu
<i
I
� i 0
Ll I
ILI LJ
Lu i
-. � I11 �._ -1 z u- I- I- I-- - ►-- -� I - I-- I--
I�j U -� �- (Y I- uJ Lu Lu uJ j UJ �� U-I 111 Lu
<L O z O uI O z � w z
f� u_i O i- z I- I- I-
J
SEPTIC PLAN SUBMITTAL FORM
LOCATION: S..s L.t. ►y h CLo 4,P
NEW PLANS: =YES $125.00/Plan
REVISED PLANS: YES $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES NO
DATE: S • Z co
DESIGN ENGINEER:
DATE TO CONSULTANT: fid/
*If you want your plans expedited, please submit three plans and included-a-
stamped
a stamped envelope with the correct amount of postage to mail plans to Port
Engineering. MAY 2 6
When the submission is all in place, route to the Health Secretary.
V
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fl)
11)
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Ir
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LIJ
Cl _ `•- 4 (�) t O
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� iii � <r� v) <- �• u, cu O C >- �\I �)) ir)
IJJ <C 2 Or t'
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Lt-) Lt-) W IJ 1 LIJ 11J L1J
tU J O Z z z j - LI j -- --
IJ_1 (ID U_ cnI—
STANTON W. BIGELOW, M.S., P.E.-
6 Wmmop AVENUE
BEVERLY,MASSACHUSETTS 01915
(978)922-2629 E-MAIL: Jiwiih@mediaone.net
-----------------
P80FESSIONAL CIVK/ENVIRONMDFfgI ENS
ThLE 5 DESIGNANSPECTION SERVICES
WATERWAYS AND WETLANDS FUM1TTING
HARBOR ENGINEERING ASSOC., P.C.
BOARD OF HEALTH TEL. 688-9540
NORTH ANDOVER, [MASS. 01845
APPLICATION FOR SOIL TESTS
DATE:
_LOCATION OF SOIL TESTS: {0C) 5,3L. ,;VaIIJ
Assessor's map & parcel number: 10-7-6 ,dfcci 12-
OWNER: Ja�-ae7S TEL. NO.: C 9l1 - 94 i
ADDRESS: 1.09 ZoO,,
ENGINEER: S--A-Ymj -2e.e. TEL. NO.: 9,U_
CERTIFIED SOIL EVALUATOR: r-is-e-nj Z.S.
Intended use of land: residential subdivision, single family home, commercial
Repair testing Undeveloped lot testing
,
N. A. Conservation Commission Approval: �Z
hIaA
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 V-1 shall be submitted to
the Board of Health showing the location of all tests (including aborted
7. Within 60 days of testing soil evaluation forms shall be submitted. "AaovRf..
+'=ALT H
a
�
A ' ►���P i�; 1 t3
/ f
,.SCS
�.r
6X lo.7 BOARD OF HEALTH TEL. 688-9540
NORTH ANDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
DATE:
LOCATION OF SOIL TESTS: IV) s,3Lc.,Va,1► (Zcaaka
Assessor's map & parcel number: lo-7Z Parcel 12-
OWNER:
zOWNER: JN,,Ac 5 M e 1 o g-gwe r TEL. NO.:—(9-1 9-1 X) G 1-1 - 94 31
ADDRESS: lr>g S.1LL), Aa.! Z00\0
ENGINEER: n.� ..l . iG'� +a �.�. TEL. NO.: C9-1t) 92Z- Zc In
CERTIFIED SOIL EVALUATOR: Mrae-roj `►•1.
Intended use of land: residential subdivision, single family home, commercial
Repair testing Undeveloped lot testing
N. A. Conservation Commission Approval:
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. Tc"" '�?F ANDo1✓E[i/
HEALTH
7
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STANTON W. BIGELOW, M.S., P.E., P.L.S.
Professional Civil/Environmental Engineer and Land Surveyor
Commercial Title Surveys Building Inspections and Certifications
Title 5 Inspector DEP-Licensed Soil Evaluator
Site Development Permitting and Construction Management
An Associate of Harbor Engineering Associates P.C.
----------------
6 Winthrop Avenue
Beverly, Massachusetts 01915
Tel./FAX: (978) 922-2629
E-mail: jlwilh@mediaone.net
July 5, 1999
Board of Health Office
27 Charles Street
North Andover, MA 01845
RE: Application for Soil Tests
Dear Board of Health Office:
I would like to schedule soil tests on behalf of my client, James McInerney of 109 Sullivan Road
(Assessors' Map 10713, Parcel 12), who has experienced a septic system failure at his property. I am going
to be returning from a two-week vacation on July 20, 1999, after which time I could be available to conduct
soil tests. We would be able to perform soil evaluation on any day of the week except Fridays, when my
Certified Soil Evaluator, Martin Fair, R.S., has prior commitments. Mr. Fair and I would be on-site together
for the evaluation phase of deep test logging, and I would remain to perform percolation test(s) and
topographic survey work.
I have enclosed:
1) Plot Plan of site showing approximate area of existing system and proposed test pit site.
2) Copy of my signed agreement with Mr. McInerney, which serves as proof of his permission
to perform tests.
3) Completed "Application for Soil Tests"form.
4) Check in amount of$75.00.
Please feel free to.call my answering machine while I'm on vacation and leave a date and time for the
appointment. Thank you very much for your cooperation.
Very truly yours,
Z�,j .\
Stanton W. Bigelow, M.S., P.E. cc: Jaime McInerney
Consulting CiviVEnvironmental Engineer
a
J
i STANTON W. BIGELOW, M.S., P.E., P.L.S.
Professional Civil/Environmental Engineer and Land Surveyor
Commercial Title Surveys Building Inspections and Certifications
Title 5 Inspector DEP-Licensed Soil Evaluator
Site Development Permitting and Construction Management
An Associate of Harbor Engineering Associates P.C.
----------------
III�
6 Winthrop Avenue
Beverly,Massachusetts 01915
Tel./FAX: (978) 922-2629
E-mail: jlwilh@mediaone.net
June 24, 1999
James McInerney Client Phone: (978) 687-9431
109 Sullivan Road Loc.: 2 Miles N.on Rte. 114 in N.Andover,on Left
North Andover, MA 01845 is Sullivan Road, Follow to No. 109 on Rt.
Re: Agreement for Engineering Design Services, Septic System Replacement
at 109 Sullivan Road, North Andover
Dear Mr. McInerney:
As I stated to you on the telephone last night, I would propose to design your septic system replacement
in accordance with the following:
1. Soil Evaluation and Topographic Survey, Preparation of Design Plans and Permit Application for
submittal to North Andover Board of Health. -Total Fee of$1,750.00 with Retainer of$350.00 paid upon
your acceptance of this Agreement, and balance of $1,400.00 due upon delivery of completed Design
Plans and Permit Application. Backhoe services during.soil evaluation at client's expense. Board of
Health fees for soil evaluation and design plan review (total of$350.00) to be paid by Engineer.
1 2. As-Built Survey and Drawing of completed system installation with Engineer's Certification of System
Il Conformance with Title 5 (required by Title 5 at completion of construction). - Total Fee of $350.00 due
I, upon delivery of completed As-Built Drawing and Engineer's Certification.
3. If you desire to obtain construction funding through Massachusetts Housing Finance Agency/Danvers
Savings Bank Title 5 Homeowner's Loan Program, a Title 5 Inspection of the existing system will be
required as part of the application process. To have Title 5 Inspection completed, and assistance in
I completing the Loan Application, you would have to initial beside this paragraph and provide an additional
$250.00 fee, paid upon your receipt of my completed Title 5 Inspection Report. Septic tank pumping
III during Title 5 Inspection at client's expense. Additional plan sets to be invoiced to client at cost.
4. If additional services are required during course of this project, such as assistance in filing of Notice of
Intent to Conservation Commission, they will be provided on an as-needed basis, and time will be billed at
ii a rate of$50.00 per hour. Emphasis will be on"coaching" client through permitting process.
Very truly yours,
!' Stanton W. Bigelow, M.S., P.E.
Consulting Civil Engineer
Agreement by Client: Date: Retainer Paid:
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ELEX NO:4u,,
ADDRESS REPLY TO:
Form of Notice of Casualty Loss to Building 00
Under Mass. Gen. Laws,Ch. 139, Sec. 313
To: Building Commissioner or Board of Health d O
Inspector of Buildings Board of Select
addresses
Re: Insured: ¢
Property address:���
Policy No. / e�o
Loss of r zg/ 19_
File or Claim No. 5
Claim has been made involving loss, damage or destruction of the above captioned property, which
may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable.
If any notice under Mass Gen. Laws, Ch. 139 Sec. 313 is appropriate please direct it to the attention
of the writer and include a reference to the captioned insured, location, policy number, date of loss
and claim or file number.
Title:
On this date, I caused copies of this notice to be sent to the persons named above at the addresses
indicated above by first class mail.
Signature and dat ���/
MASSACHUSETTS CONNECTICUT NEW HAMPSHIRE VERMONT MAINE RHODE ISLAND ®EaeA�� y
Boston Lawrence Bridgeport Gorham Burlington Augusta Providence
Barnstable Pittsfield New London Keene Montpelier Lewiston
Brockton Salem No. Haven Laconia White River Jct. S. Portland NEW YORK
CLAIMS SERVICE OF �IMAXV6211a t 3 a'15mm
NEW ENGLAND,INC. Fall River Springfield Waterbury Manchester Utica
Fitchburg Worcester W. Hartford Portsmouth
FORM U
C/ TOWN OF NORTH ANDOVER
LOT RELEASE FOIA
SUBDIVISION
ASSESSORS MAP D
SUBDIVISION LOT(S)
PER1MA NT ADD ESS (ASSIGNED BY L
REET % �(fI1VCr
�To t
/ t
'� ICANT
' .
VdA' TE .OF APPLICATION �9 r
TOWN USE BELOW THIS i
PLANNING BOARD
DATE APPROVED
TOWN PLANNER DATE REJECTED
CONSERVATION .COMMISSION
DATE APPROVED t7 A A
CONSERVATION AD' I t )e.,) DATE REJECTED
u
BOARD OF HEALTH
DA'T'E APPROVED 7AIj�
HEALTH ANITARIAN DA'Z'E REJECTED
DEPARTMENT OF PUBLIC WORKSCF/�G�
DRIVEWAY PERMIT "
SEWER/WATER CONNECTIONS
FIRE DEPT.
RECEIVED BY BUILDING INSPECTION
P
DATE
a
k
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits r'
for the subject: lot. This form shall not •releive the applicant from the
compliance of :any applicable Town requirement or Bylaw,. K'Y
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FORM U
CJ TOWN OF NORTH ANDOVER
LOT RELEASE FORM
SUBDIVISION
ASSESSORS MAP
SUBDIVISION LOT(S)
PERMANENT ADD •ESS (ASSIGNED BY D.P.W.)
TREET
v ;F
ICANT PHONE
VDATE .OF APPLICATION 0 —
TOWN USE BELOW THIS LINE
PLANNING BOARD
DATE APPROVED
TOWN PLANNER
DATE REJECTED
CONSERVATION COMMISSION
DATE APPROVED 0-7 Lq /q1
CONSERVATION AD' I L DATE REJECTED
r
BOARD OF HEALTH
DA'T'E APPROVED �� J
HEAL'T'H SANITARIAN DATE REJEC'T'ED
DEPARTMENT OF PUBLIC WORKS
` DRIVEWAY PERMIT
SEWER/WATER CONNECTIONS
FIRE DEPT.
r
J;
RECEIVED BY BUILDING INSPECTION
<p.
DATE
,F.
y.
This form shall be signed by the agents of the Planning and Health Boards,
the Conservation Commission prior to the issuance of any building permits
for the subject: lot. This form shall not ,releive the applicant from the
compliance of :any applicable Town requirement or Bylaw-,.
a.
5