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Miscellaneous - 114 PENNI LANE 4/30/2018
114 PENNI LANE 210/107.D-0066-0000.0 � � ___�__ _ ____ .�..._-_ ._ _ / � Lot & Street _��FVA)l �/�/ZJ� Map/Parcel ld7I,14��' CONSTRUCTION APPROVAL Has plan review fee been paid: <YES NO Permit# 10(31 Plan Approval: Date: �6 a Approved by: Designer: ,--B. 05600b'd e Plan Date: 16 LW96011 Conditions: Water Supply: 4. Town. -. _-- _ Well :. Well Permit: �v Driller: Well Tests: Chemical Date Approve - Bacteria I Date-Approved_'`. Bacteria II Date Approved Plumbing.Sip-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: ' .►,. .,parr, - . - '-i`' ,, ;' ___SEPTIC SYSTEM INSTALLATION .-'-Is the installer licensed? NO _Type of Construction:. NEW PAIR ---- — _.__,_ ?� ''NeWConstruction:__�Certified Plot Plan Review YES N FroorPlan ReviewYES NO Conditions of Approval.from Form U YES NO w . Issuance ofDWC pernut - NO ��ernzitPaid? - - yES NO, :. - DC•Fermit# �. - - - - -�b Tfet� -So � ectioII� - z g Re Iiisg — . r :ExcavatioitTiispection �_ Veeded= _.. _. _. - ---Passed - - —. MY� Consttructioa Inspection: R - , . Needed: LApproval of Backfill- Date:_// / By a-- Final Grading Approval: Dater ` q By: _ Final Construction Approval` Date:' By: -- Certificate of Compliance. :. Approval: Date: Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record RECEIVED System Owner & address: Paul Collella JUN 13 2008 114 Penny Lane North Andover, MA TOWN OFINORTH ANDOVER DEPARTMENT Location of system: Front Date of Pumping: June 5, 2008 Type of system: Septic Tank I Gallons Pumped: 1500 Gallons System pumped by: Service Pumping& Drain Co., Inc. S Hallberg Park North Reading, MA License #: BHP 2007 0728, 0725, 0727,0722, 0724, 0726 Contents transferred to: Greater Lawrence Sanitary District DateJaune5, 2Q08 Pum inTechn°�ci an ASD _ p 9..: �Asa, This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes I TOWN OF NQRT r�NDOVER ` SYSTEM PUMPI. 0 RECORD UA CF l f SYSTEM OWNER& ADDRESS YSTEM LOCATION ]t) mow' l �} /Dzr'pnl RF.C SEP DA"TE UF PUMFIN(}; g-1- � � C;1:SSPW1.: NU YES SOPtic Tank: NU ..__.__.._...__. __ YES NATURE OF SERVICE: ROU"I'1NE EME.R0ENCY I -a I OBSERVATIONS: GOOD CONDITION FULL `ro COVER HEAVY GPF-ASE BAFFLES IN PLACL,, ROOTS LEACIIEI,:D RUNBACK EXCESSIVE SOLIDS - FLOODED SOLID CARRY0VER__ 01WER EXPLAIN � Synttm Pwnpcd by — _... . . ._O�. COMMENTS. i CON I'EN'i'S FKANSFERKED TO f I i i TOWN OF NORTH ANDOVER n SYSTEM PUMPING RECORD S1 STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) //- � AL/0 e 0,1)qdlw� r/lalnf U:a'I E OF PUMPING; QUANTITY PUMPED / rev CALLONS C 1 00L: NO YES SEPTIC TANK: NO YES V TINE �EYMERGEN NATURE OF SERVICE: ROU C UBSERVAT10NS: GOOD CONDITION FULL TO COVER HEAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER O�HFR (EXPLAIN) i >1 M PUMPED BY: C. UMNIENTS: UN"I ENTI ; TRANSFERREDTO: TOWN OF NORTH ANDOVER NORTH q APPLICATION FOR PLAN EXAMINATION ° ,",go ' ti- 3? 4t , a oL o Date Received10 + Pen-nit NO: A_ f 790�AAT/O�PP.�'�y i 9SSACHUS� t Date Issued: C IMPORTANT: Applicant must com lete all items on this page LOCATION f" t= _ Print 1 i. i PROPERTY OWNER C� Print NtAP NO.: ' PARCEL: ZONING DISTRICT: ' TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IhIPROVEMENT PROPOSED USE Residential Non-Residential New Building One family r ddition Two or more family Industrial Alteration No. of units: u Assesso BldgCommercial Repair, replacement Demolition Others: Moving(relocation) C Other Foundation only DESCRIPTION OF WORK TO BE PREFORMED 4-1 dentification Please Type r Print Clearly) yeti t' 4 Phone: / OW'-ER: Name: 1Q ( a Address: I ...Z- Phone:9MZ, � - � � CONTRACTOR Name:��'�! Address: i�G G ivy 4 Supervisor's Construction License: l UG��U75� Exp. Date: L ! � / I Home Improvement License: Exp. Date:nn 4* ARCHITECT'ENGINFER i/key- Name: Phone: kddress: ,2 � 77�- �T. 'sr- Reg. No. FEE SCHEDULE:BULDI:VG PER;ti/I T. 512.00 PER 51000.00 OF THE TOTAL ESTIMATED COST BASED 0,VS/25.00 PER S.F. Total Project Cost x12.00 =FEE: Check No.: Receipt No.: TYPE OF SEWERAGE DISPOSAL 1-1 Swimming Pools n Tanning;Massage/Body Art Public Sewer — I J _ Tobacco Sales Food Packaging/Sales Well Permanent Dumpster on Site Private(septic tank,etc. _ Electric Meter location to project NOTE: Persons contracting with unregistered contraciors do of have access to t e guar my f m Tnature of A lenti0wne < lure of contracto t-t� Std b ,. Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ n' []Water Shed Special Permit ❑ Site Plan Special Permit Other .COMMENTS DATE APPROVED N TE REJECTED a CONSERVATIO COMMENTS UQ(fi(A V, 4 AQ mr- AL,-/00 DATE REJECTED DATE APPROVE EALTH COMMENTS 2� t Zoning Board of Appeals: Variance, Petition No: Zoning Decision./receipt submitted yes _ Planning Board Decision: _ _Comments Conscrvatlon Decision: Comments 'Nater& Sewer connection/Sip_nature& Date Drivewav Permit Temp Dumpster on site yesro_ Fire Department sijnature/date __ cn m ID R) m Deco l 4 517-415 Rao Mo �.�`/ a6- l2tx�a, NI) i y Av co OD co l. . A re � � � �' ro fLSEPITICSTSTEM E A D.F. CLARK, INC. LE V PROFESSIONALS INC. RECEIVED AUG 2 4 2005 TOWN Or NORTH ANDOVER HEALTH DEPARTMENT August 16, 2005 Mr. Fred Sharifi 114 Penni Lane North Andover, MA 01845 RE: Subsurface Sewage Disposal System Inspection 114 Penni Lane, North Andover MA Dear Fred: Please find enclosed the Subsurface Sewage Disposal System Inspection Reports for the above referenced property. As noted on Part A of the reports,the systems Pass the inspection criteria. These inspections are good for the next two (2)years; you may extend the life of the inspection to three (3) years by having the septic tank pumped annually (before anniversary date of inspection). Thank you for allowing us to be of service to you on this project. Please contact us if you have any questions regarding this matter. Sincerely, D.F. Clark, Inc. Matthew A. Boucher Inspector Enclosure cc: North Andover Board of Health D.F. Clark, Inc. file PO Box 265 24A Mitchell Road 1ps%v1ich, X,lA 01938 978-356-5638 Fax 978-356-5500 Toll Free SSS-DF-CLARK TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSL SYSTEM FORM PART A CERTIFICATION Property Address: 114 Penni Lane North Andover,MA 01845 Owner's Name: Fred Sharift Owner's Address: I i4 Penni La-ie North Andover,MA 01845 Date of Inspection: August 12,2005 Name of Inspector:(please print) Matthew A.Boucher Company Name: D.F.Clark,Inc. Mailing Address: P.O. Box 265,Ipswich,MA 01938 Telephone Number: (978)356-5638 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approval Authority 1 Fails Inspector's Signature: 11`'` I jwuLa Date: iz &4 wS� ©� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/00 page 1 Page OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or hie,static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Nater Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the SAS,cesspool or privy is below the high ground water elevation X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or`�io"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered"yes"in Section"D"above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 Check if the following have been done: You must indicate es or `no7,as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined? (If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X 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? X _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No X _ Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): No ; [if yes,separate inspection required] Laundry system inspected(yes or no): No Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 7/2/03—7/26/05— 159,750 gallons=212 gpd Sump Pump(yes or no): Yes Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter reading,if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: System was last pumped in the early Fall of 2004 according to the owner Was system pumped as part of inspection(yes or no): No If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Certificate of Compliance dated January 27, 1999 accordiniz to Board of Health file. Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 BUILDING SEWER(locate on site plan) Depth below grade: 10" Material of construction: cast iron X 40 PVC other(explain): Distance from private water supply well or suction line: 34' Comments:(on condition of joints,venting,evidence of leakage,etc.): Building sewer pipe and joints are in good condition with no evidence of leakage. SEPTIC TANK: Yes (locate on site plan) Depth below grade: 4" Material of construction: X concrete_metal fiberglasspolyethylene _other(explain) If tank is metal list age_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 5' W x 10' L x 48"D Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: Taped measure&sludge judge Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Inlet and outlet tees are in place. Water level at outlet invert. Septic tank is in good condition with no evidence of leakage GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments:(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Penni Lane North Andover MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete__metal fiberglass_polyethylene_.other(explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): it DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) (Depth below grade= 15") 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.): Distribution is equal No evidence of solids carryover or leaks(in or out).D-box is in good condition. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no):___ Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc): 8 Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number: _leaching chambers,number: _leaching galleries,number: _leaching trenches,number,length: X leaching fields,number,dimensions: 1 leach field—30' W x 30'L _overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): SAS was inspected with a video inspection camera and found no signs of hydraulic failure or ponding. Soil is dry and sandy. SAS is in good condition.No evidence of solids carryover. CESSPOOLS: No (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Sem A B QWater A— 1 = 14'2" #1-Septic tank(center cover) B- 1 =50'5" A—2=20'9" #2—D-box B—2=56'5" Driveway Woods Woods Penni Lane 10 Y Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water 3.4 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record—If checked,date of design plan reviewed: Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: _Checked local excavators,installers—(attach documentation) _Accessed USGS database-explain: You must describe how you established the high ground water elevation: SAS is 28"below grade under front lawn.Test holes performed by Richard C.Tangard on 7/28/1998 found in TP#1 (area of SAS)mottling 0)58",TP#2(area of SAS)mottling(a,40",TP#3 (in rear of house)mottling45".There is a sump pump in basement.Elevation at bottom of SAS to bottom of sump is>4.0'. 11 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 1/27/99 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by John Soucy at 114 Penni Lane 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 as described in the Design Approval Site System Permit #1031 dated 10/20/98 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector I I TOWN OF NORTH ANDOVER SEWAGEbISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( )constructed; (x repaired; by . John Soucy located at 114 Penni Lane, -North Andover was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# ,dated ,with an approved design flow of gallons per day:--The materials used w nformance with those specified on the approved plan;the system was installed-in a provisions of 310 CMR 15.000,Title;5 and local regulations,and the final g' rrees's . tially with the approved plan. All work is accurately represented on the A :builtsubmitted to the Board of Health. C. _ TANG, /N G Installer: Date: Design Engineer: Date: q Bed Inspection Date J /3 EngiuCer Repre ative Final Inspection Date ng' eer Repre ative TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed, ( repaired, b located at was installed in conformance with the North Andover Board of Health approved plan, System Design Permit #/031, dated ty'' , with an approved design flow of Q 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: Engineer Representative Final inspection te: Engineer Represent iv, Installer: Lic.#: Date: / Design Engi er: Date: All AS-BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP& PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION& DEMENSIONS OF SYSTEM; INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA 1� LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM I TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WAN 150' OF SYSTEM LOCATION OF ATE AS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX STAMP & SIGNATURE (/ IM[PERVIOUS AREAS -DRIVEWAYS, ETC. NORTH ARROW FINAL CONTOURS LOCATION& ELEVATION OF BENCHMARK USED �/ LOCUS PLAN Town of North Andover r NORTIy OFFICE OF ° '" 1ti0 COMMUNITY DEVELOPMENT AND SERVICES ° . x 27 Charles Street :�9 ; WILLIAM J. SCOTT North Andover, Massachusetts 01845 S. '.. SACmUS01��� Director (978)688-9531 o Fax(978)688-9542 October 26, 1998 Mr. Ben Osgood, Jr. New England Engineering 33 Walker Road, Suite 23 North Andover, MA 01845 Re: 114 Penni Lane Dear Ben: The Board of Health, at their regularly scheduled meeting on October 22, 1998 voted unanimously to grant the following variances to the property stated above. 1) reduction in groundwater from 4 feet to 3 feet 2) distance to wetlands from 100 feet to 74 feet If you have any questions, please do not hesitate to call the Health Office at the number below. Sincerely, QAM Sandra Starr, R.S. Health Administrator cc: Joseph DiBlasi, 114 Penni Lane File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NEW ENGLAND ENGINEERING SERVICES INC October 22, 1998 (1(' 1 - Sandra Starr, Administrator North Andover Board of health 27 Charles Street North Andover, MA 01845 RE:114 Penni Lane septic design Dear Sandra: Enclosed are three copies of\a revised plan for the above referenced septic system design. The only change made to this plan is the location of the wetlands line. Mike Howard asked for soil borings to prove the location of the line and when that was done the line moved closer to the system. The variance to the local bylaw for distance to a wetlands is now 74 feet. I will be at your meeting tonight to discuss this matter. Sincerely, Benjamin C. Osgood, Jr., EIT President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 Oct-07-98 08: 12A Paul D. Tuvbide, PE/PLS 508-465-0313 P.02 October 7, t998 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 27 Charles Street North Andover,MA 01845 RE: Title V review for 114 Penni Lane 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. whin 1g aci it_v e Groundwater separation is less than the required 4'a variance and local upgrade approval has been requested. If the variance is granted then the plans need not be resubmitted. If you have any questions or continents please feel free to contact us. Sincmly aul D.Turbrde,PE/PLS Pon I ENGINEERING Civil Engineers& Land Surveyors One Harris Street Newburyport,MA 01950 (978)465-8594 Town of North Andover HORTN , OFFICE OF �? •eti c COMMUNITY DEVELOPMENT AND SERVICES ° 30 School Street x WILLIAM 7. SCOTT North Andover, Massachusetts 01845 Director OUTSIDE CONSULTANT ESCROW AGREEMENT NORTH ANDOVER BOARD OF HEALTH, kA 1 Agreement is made this olbetken the Town of North Andover and of for Soil Tests, lan Aeview KNOW ALL men by these present that the Applicant hereby provides the Town of North Andover with a check in the sum of $ " , to be deposited in an escrow account for the Town of North Andover and has deposited in an interest- bearing account as designated by the Town Treasurer to be expended by the North Andover Board of Health to insure payment to any outside consultant ( s) for Soil Tests, Plan Review for the above referenced project . This agreement shall remain in full force and effect until the specified project has reached completion , pard of Health Chairman Applicant or Agen �dl Date Date. 53-7058/2113 2791 F 887807675 NEW-ENGLAND,ENGINEERING~SERVICES, INC.- 2! 33 WALKER RD., STE. 23- PH. 978-686-1768 _ DATE NORTH ANDOVER, MA 01845 PAY TO THE /v 9 �'-..' .. ORDER OF I Eta W DOLLARS 8 IPSWICH SAVINGS BANK IPSWICH,MASSACHUSEITS'M938 _ NP 688-9535 MEMO , [46 MAIN STREET 42113 ?OSa ?1: 88 ?80 ?6 ? S11- 2 r9 1 °'°`^ i NEW ENGLAND ENGINEERING SERVICES INC September 25, 1998 28 Sandra Starr, Administrator North Andover Board of health 27 Charles Street North Andover, MA 01845 Re: 114 Penni Lane Dear Sandra: Enclosed are 3 copies of a septic system design for the above referenced property. Copies of the soil evaluator sheets and request for local upgrade approval sheets are also enclosed. Please have Susan Ford sign the request for local upgrade sheet as the representative of the local approving authority. This design requires a local upgrade approval for a reduction in the offset to the water table from 4 feet to 3 feet, and a local variance for a reduction in the offset distance from the leach area to the edge of the wetlands from 100 feet to 85 feet. This office requests that these requests be taken up by the Board of health at the next meeting. If you have any questions regarding the design please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr., EIT President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 SEP.23. 1998 11:08AM P 1 FROM R.C. TANGARD PHONE NO. : 781 334 0115 4 , FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 No. pate: Commonwealth of Massachusetts Massachusetts oa ut ahy Asses ent,forOn-site Sgwag e, Disposal Performed By., !�- . .. ....... . late: ._... .._ /..........• '��. Witnessed By: �,.. ,. .................................................................................................. ..... ........... , .... .. TedCrds..I NewConstruction ❑ Repaid Office Review Published Soil Survey Available: No ❑ Yes Q d year Published /� ...... .. . Publication Scale � ..��..�. . Soil Map Unit C ........... Drainage Ciass � ��••. :.• Soil Limitations r iD ...... ���T .....•,••..`..•._._.._._..... Surficiai Geologic Report Available: No K Yes ❑ Year Published . .......:.... Publication Scale �._.....�... GeologicMaterial (Map Unit) .. ............................................................................................................. ..... I............................. Landform. ...................................................................................................................................................................._................ ...... ............. Flood Insurance Rate Map: Above 500 year flood boundary No Oyes ❑ Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No [Dyes ❑ Wetland Area: National Wetland Inventory Map (map unit) ........................................................................................ _.:.,_._......... Wetlands Conservancy Program Map(map unit) ............................................................ .................................... Current Water Resource Conditions(USGS): Month zallza- Range :Above Normal t11 Normal ❑Belc w Normal ❑ Other References Reviewed: ----------------- ti f ---------------------------- FROM R.C. TANGARD SEP.23. 1998 11:10AM P 4 PHONE N0. : 781 334 0115 FORM 11 - SOIL ENALU.A,TOR FORM f Page 2 of 3 Location Address or Lot iqo. anzEUe review Deep Hgle Number ,.. Date: 7 / e / •S � Time:. �d Weather location Udentlfy on siteplan) :T Land Use l`�'..rG`"li w.........:....:... L $tope (%) Surface Stones :,.. , Vegetation , S �- - Landform ... •�J� „�srf _... . . ..... ....... ... Position on landscape (sketch on the back) .. .' - :............::. . .....:.. :... )stances from: .. . Open Water Body feet Drainage way :. feet Possible Wet Area feet Property Line feel Drinking Water Well ..., . . feet Other .. DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Texture Soil Color Surface(Inches) (USDA) Soil Other (Munsell) Mottling (St(u0ture,Stones,Boulders, Consistency, % Gravel) IY //Z '�o V :9 mum Parent Material(geologic) Depth to Groundwater: Standing Water in the Hole: DePU*t°Bedr°Gk. 'r' /e!;; WBeping from Pit Face: /3 Estimated Seasonal High Ground Water: _ VEP APPROVED FORM-1:/07195 " FROM R.C. TANGARD PHONE NO. 781- 334 0115 FORM 11 - SOIL EVALUATOR wni Page 2 of 3 Location Address or Lot No. //"7e On-site Review Deep Hole Number .:.�.. Date: /� Time: `Q, . .:. .. ,�. Weather//Z— �® Location (identify on site plan) Land Use lL ! Slope (%) �7, Surface Stones Vegetation . � Landform .55Z ��� . :... . .. :. .�.::....,. ...........:...... ,.rte Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way .. . . .:. feet Possible Wet Area feet property Line ... ,, feet Drinking Water Well ... . . feet Other . DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon.. Soil.Texture Sol Color Soil Other Surface(Inaheol (USDA) tMunsall) Mottling IStructure,Stones, Boulders,Consistency, Gravel) Z_ ox/o s Gyle 110A1C _ Parent Material(gaelogic) T�d� DeptMoBedrock: Dayth to Groundwater: Standing Water in the Holo: <�� Woeping from Pit Face: Estimated Seasonal High Ground Watar: '`�' _ �_ ,.,• ,�_ I DEP APPROVED FORM-12/07195 SEP-23. 1998 11:09AM P 3 FROM R.C. TANGARD PHONE NO. : 781 334 0115 FORM I I . SOII. ,;VALUATOR FORM Page 2 of 3 Location Address or Lot No, �n-site review Deep Hole Number „� .k Date:..?/ i � ; Time:../...�0 Weather Location (identify on site plan) Land Use . ... � ,���- •c17�1. � nope MS. �Urface Stones......,...�....w....... _.., ,......w:...�.w......� ....... ... . .:... Vegetation 'rte" Landform ...��..�._..,,,., .. ..�... . . �- .:v...... ,........ .4.. .._ .. ... .. ...: .. Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way ,, feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE LOG' Depth from Sell Horizon Soil Texture Soil Color Soil Surface(inches) (USDA) (Munsell) Mottling (Structure,Stones,BoOthulders, Consistency, % Gravel) 04112 (LLD¢3SAMEA Parent Material(geologic) L , j ��---��==��==-�_ Dapthiot3edrvck: � oenth to Groundwaton Standing Water in the Hole: Weeping from Pit Face: Esftatsd S06onal High Ground Water. i UCP ApPRUW-b FORM•12/07/95 rkUl•I k.1. IHNIaHRli HHUNL NU. : ftJ1 ,5,54 0115 ORM A X ^ S011, L VALUATOR FORM Pagc 3 of 3 Location Address or Lot No. / -��r/ ��/�� XIQ, betertnir�at�'orz for Seasonal �ig�Water Tabre Method Used: ❑ Depth observed standing in observation hole................. inches ❑ Depth weeping from side of observation hole................. inches ® Depth to soil mottles inches ❑ Ground water adjustment ................ feet Index Well Number Reading Date ................. Index well level Adjustment factor ................... Adjusted ground water level .................. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? -3 If not, what is the depth of naturally occurring pervious material? Certification I certify that on /�S' (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. /i Signature ate DEP APPROVED FORM•12/07/05 ,y Pagel of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(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: ..T osG0• (),- Address: ):Address: It 4 pe-, ; �ahc, N, �4 .��✓C2 Phone#: 918- r ae- (,pk y Address of facility: 2) Applicant (if different from above) Name:' 3-4MJ Address: Phone #: 3) Type of Facility: Q�Residential Commercial School Institutional (Specify) y Bc�ro�., f-lo.�•� • f�rLA Page 2 of 5 4) Type of Existing System: __privycesspools) _conventional system other(describe) Type of soil absorption system(trenches, chambers, pits,etc.) er,,k �1 5) Design Flow Based on 310 CMR 15.203: a) Design.flow of existing system gpd Approved: _yes Approval date: no Why: b) Design flow of proposed upgraded system yyo gpd Why y 4,,Q c) Design flow of facility il I o gpd 6) Proposed upgrade of existing system is: a) 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) _insp=�fior WA-S v .1,�., � . .�� �.�r,-+ (date) . sjb:t+CV. b) Describe the proposed upgrade to the system: /)e, sn fis1,0 i v. a ne,- /s << f o"- 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 pert 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) rr,;.- Zj,,(j„__ I i�lr r I 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 3 feet As determined by: Evaluator's name: Evaluator's Signature: Date of evaluation: •7/ Z lY h.Q 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 ' µ List of affected - � . s cted abutters. v Abutter Name Date notified is 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 e� f system in full compliance with 310 CMR/15.000 is not fjeasible: ('ts_ eRii 111 t l e— l e, 5L C c ci P�^i +✓ "dC G.c /" Le c� cQ grr4 �Q sbysl�w, cc.-.D v.a"�`' b) An alternative system approved pursuant to 310 CMR 15.2183�-1�5�{..288 is not feasible. Ph Q��Cftilc./��� S./S/c'LN !S �f.LS 1 �/'o V .�►U�V� c) A..,.sfhared system is not fe��a//sible. / �7 6t e weT1---,& 0-1 cl�rlic� cy� ��oPGTes G.-�✓ nci447Aee cnr ro�- d) Co - A n 'nection to a sewer is not feasible. Y `'i no SC-cl/!� /•. /LG 1772°Gc. 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 f Page 5 of 5 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." 6 ss Fac' ity Owner's SigdWture D to j Print 14ame 12 Name of Preparer ate _q78- 69&-L76 --73 Wlkl, /1.Q S.- 03 V �vL Telephone No. &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. Town of North Andover, Massachusetts Form No.2 f NORM BOARD OF HEALTH 19 o � F w p ^� 4 DESIGN APPROVAL FOR CHUSEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 9Test No. Site Location I I q Reference Plans and Specs. On— ENGINEER DEAIdW DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIR�'ly AN,'BOARD OF HEALTH D) Fee oZJ Site System Permit No. 1Q3 P 4 IN Town of North Andover, Massachusetts Form No.3 f p0R7lj BOARD OF HEALTHK. - - 19 l A � '°�,.:o •�"� DISPOSAL WORKS CONSTRUCTION PERMIT . - .. ,SSACHUSEt Applicant NA f7RESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair (�) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 10,31 CHAIRMAN, BARD OF HEALTH Fee D.W.C. No. . a APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: K CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTAL R: Spw CA SIGNATURE: TELE ONE# '7 T 7 S^ I CHECK ONE REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. i i Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: 9 r 3;: Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(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: ..•i ose f 1. D; Jl41s Address: ' I►4 PC.„r; 1-4 n c, N. ►4-•Q��e2 Phone#: q19- (88-- coag l Address of facility: 2) Applicant (if different from above) Name:' Address: Phone #: 3) Type of Facility: Residential Commercial School Institutional (Specify) y Be'o mo " Hc-' • Nl jrF.. Page 2 of 5 4) Type of Existing System: _privy cesspool(s) _conventional system other(describe) Type of soil absorption system(trenches, chambers, pits,etc.) l.e—c, 5) Design Flow Based on 310 CMR 15.203: a) Design.flow of existing system gpd Approved: _yes Approval date: no Why: b) Design flow of proposed upgraded system y gpd Why c) Design flow of facility gpd 6) Proposed upgrade of existing system is: a) Voluntary required by order, letter, etc. (attach copy) y/Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) v:.l,1n+=,-�� A�. �.�� (date) b) Describe the proposed upgrade to the system: n / �n Oatl/n!)Jn j- /1JG, n D-QJ K ArcX l�G.c 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) 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) y ,.►,,.- � iIA k • °..ft's: Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met(specify sections .u; 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) Xf 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 3 feet As determined by: Evaluator's name: i'6R p 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. V Page 4 of 5 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:' t ( C, 5L SC C,Pry +✓n c1L Cvt c alicQ an1000, i , s�y-sl�w. ca.�� ►�a�' ix ci b) An alternative system approved pursuant to 310 CUR 15.283-15.288 is not feasible. A-1 elff,, I\f., SUSki-,, co.1 v c) A shared system is not feasible.. !! / tnt, Ir// ore_ we ��45 on Gid�iac Get44:4 0-0 d) Connection to a sewer is not feasible. n� 7�c�ic� 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 _y-' no r Wt.e: Page 5 of 5 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." 9b t 96 Fac' ity Owner's SigLqture D to cnwan+ w C Q� �� wiz Print lqame Name of Preparer ate 696--L7 6 33 W,1kc, /90 Sti03 AV Telephone No. & 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. NEW ENGLAND ENGINEERING SERVICES, INC. 33 Walker Rd. Suite 23 NORTH ANDOVER, MA 01845 DATE JOB NO. PHONE (508) 686-1768 FAX (508) 685-1099 ATTEN ,22 1 TO ��D2�I7 �KCSI¢ CIt_ � C RE: TnvyN oF NORTH ANDOVER/ BOARD AL-) w WE ARE SENDING YOU 1)4 Attached ❑ Under separate cover via the following items: ❑ Shop drawings Q' Prints ❑ Plans ❑ Samples ❑ Specifications ElC Copy of letter ❑ Change order ❑ ?*&M/eJn COPIES DATE NO. DESCRIPTION 6 Aa,14 .Se c S r 1no&-Xj cue, 40 ggj / ear" la,,c N v 12 n case; o j S tvYl C cr THESE ARE TRANSMITTED as checked below: 19 For approval ❑ Approved as submitted ❑ Resubmit copies for approval For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS ctst e-a, C2v CC)jn a toslZ-C �✓/t [_J e G7 COPY TO 4IHSS SIGNED: If enclosures are not as noted,kindly notify ust once. Sep 18 06 10:28a D.F. Clark Inc. 978-356-5500 p.1 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 114 Penni Lane North Andover MA 01845 SEP 18 2006 Owner's Name: Fred 5harifi TOWN OF NORTH ANDOVER Owner's Address: 114 Penni Lane HEALTH DEPARTMENT North Andover,MA 01845 Date of Inspection: August 12,2005 Name of Inspector:(please print) Matthew A.Boucher Company Name: D.F.Clark Inc. Mailing Address: P.O.Box 265 Ipswich,NIA 01938 Telephone Number. 478 356-5638 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: X Passes -�� Conditionally Passes Needs Further Evaluation by the Local Appro Authority Fails Inspector's Signature: ` r Date: �t The system inspector shall submit a copy of this inspection report to the Appro g Authority(Board of Health or DE within(30)days of completing this inspection. If the system is a shared system or s a design flow of 10,000 gpd greater, the inspector and the system owner shall submit the report to the appropriate regional o of the DEP. Th_ ginal should be sent to the system owner and copies sent to the buyer,if applicable,and the approving aathort . Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6115,,'00 page 1 Sep 18 06 10:28a D.F. Clark Inc. 978-356-5500 p.2 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12 2005 Inspection summary: Check A,B,C,D or E 1 ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. System Conditionally Passes: One or more system components as described in the`Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If`hot 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 exfiitration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): —broken pipe(s) are replaced _obstruction is removed _distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _ obstruction is removed ND explain: 2 I Sep 18 06 10:29a D.F. Clark Inc. 978-356-5500 p.3 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 114 Penni Lane North Andover.MA 01845 Owner: Fred Sharift Date of Inspection: August 12,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require funther 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(l)(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 and Public Water Sulier,if ao 2. System will fail unless the Board of Health( pp � y)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 DBP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy ofthe analysis must be attached to this form. 3. Other: 3 Sep 18 06 10:29a D.F. Clark Inc. 978-356-5500 p.4 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 114 Penni Lane North Andover,NIA 01845_ Owner: Fred Sharifi Date of Inspection: August 12.2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no" to each of the foIIowing for all inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped _ X Any portion of the SAS,cesspool or privy is below the high ground water elevation X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 fleet of a private water supply well X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`�vs"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone E 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. 4 Sep 18 06 10:30a D.F. Clark Inc. 978-356-5500 p.5 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12.2005 Check if the following have been done: You must indicate` es"or"no"as to each of the followine: Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X ! Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined? (if they were not available note as NIA) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site. X 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? m owner)provided with information on the proper X _ Was the facility owner{and occupants,if different fro o }p p p maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] i 5 Sep 18 06 10;30a D.F. Clark Inc, 978-356-5500 p.6 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 114 Penni Lane North Andover.MA 01845 Owner: Fred Sharifi Date of Inspection. August 12.2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual). 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x ff of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system (yes or no): o ; [if yes,separate inspection required] Laundry system'inspected(yes or no): No Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 7/2,103—7126105—159 750 gallons 212 2Dd Sump Pump Cves or no): Yes Last date of occupancy:_ Currently Occupied COMMERCIALA DUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(-ves or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter reading,if available: Last date of occupancy,'use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: System was last pumped in the early Fail of 2004 according to the owner Was system pumped as part of inspection(yes or no): No If yes,volume pumped:r�allons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no)(if yes,attach previous inspection records,if any) fnnovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: _ Certificate of Compliance dated January 27 1999 according to Board of Health file. Were sewage odors detected when arriving at the site(yes or no): No 6 Sep 18 06 10:30a D.F. Clark Inc. 978-356-5500 p.7 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address. 114 Penni Lane North Andover MA 01845 Owner: Fred Sharifi Date of Inspection: August 12 2005 BUILDING SEWER(locate on site plan) Depth below grade: 10" Material of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: 34' Comments:(on condition of joints,venting,evidence of leakage,etc.): Building sewer pipe and joints are in good condition with no evidence of leakage SEPTIC TAINK: Yes (locate on site plan) Depth below grade. 4" Material of construction: X concrete metal^fiberglass_polyethylene _other(explain) confirmed b a Certificate of Compliance yes or no): (attach a copy of metal list age Is age P � If tank is me g � g Y certificate) Dimensions: 5' W x 10' L x 48"D Sludge depth: 2" � g � Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: NIA Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: Taped measure&sludge iudge Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Wet and outlet tees are in place Water level at outlet invertSeptic tank is in good condition with no evidence of leakage. GREASE TRAR No (locate on site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping. Comments:(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related j to outlet invert,evidence of leakage;etc.): 7 Sep 18 06 10:31a D.F. Clark Inc. 978-356-5500 p.8 Page 8 of I1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 TIGHT or HOLDING TANK No (tank must be pumped at time of in spection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene_other(explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present(yes or no): Alarm level: AIarm in working order Lyes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan) (Depth below grade= l 5") 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.): Distribution is equal No evidence of solids carryover or leaks(in or out).D-box is in good condition. PUMP CHAIIIBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc): 8 Sep 18 06 10:31a D.F. Clark Inc. 978-356-5500 p.9 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Perini Lane North Andover.MA 01845 C+vner: Fred Sharifi Date of Inspection: August 12.2005 SOIL,ABSORPTION SYSTEM(SAS): Yes (locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number: _ leaching chambers,number: _leaching galleries,number: leaching trenches,number,length: X leaching fields,number, dimensions: 1 leach field—30' W x 30' L overflow cesspool,number: 'innovative/altemative system Typeiname of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): _SAS was inspected with a video inspection camera and found no signs of hydraulic failure or ponding.Soil is dry and sandy.SAS is in good condition.No evidence of solids over_ CESSPOOLS: No (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: No (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.): 9 I Sep 18 06 10:32a D.F. Clark Inc. 978-356-5500 p.10 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 114 Penni Lane North Andover.MA 01845 Owner: Fred Sharifi Date of inspection: August 12.2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. S r JA B W ter A— 1= 14"2"- #1-Septic tank(center cover) • B- 1 =50'5" A—2=70'9" #2—D-box B-2=56'5" Driveway Woods Woods Penni Lane 10 Sep 18 06 10:32a D.F. Clark Inc. 978-356-5500 p.11 a Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 114 Penni Lane North Andover,MA 01845 Owner: Fred Sharifi Date of Inspection: August 12,2005 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated depth to ground water 3.4 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record—If checked,date of design plan reviewed: _Observed Site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Heaith-explain: Checked local excavators,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: SAS is 28"below erade under front lawn Test holes performed by Richard C.Tangard on 7/2811998 found in TP 41 (area__ of SAS)mottling La 58" TP#2(area of SAS)mottling A 40" TP 43 (in rear of house)mottlingchi 45".There is a sump pump in basement.Elevation at bottom of SAS to bottom of sump is>4.0". 11 Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH ED b�ti 46 oL 19 o ` 'A4...�.... *�o s m 4 aE•w° ' � TED APPLICATION FOR SITE TESTING/INSPECTION 7 A�AAPPP`�h �SSACH0 n Applicant G N ADDRESS TELEPHONE Site Location—j—/4— Engineer� �� �� NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee - �— Test No. 4RS4 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. .. Town of North Andover, Massachusetts Form No. 1 NORTH r BOARD OF HEALTH n J pSt�Eo 160 19 ns' p sr m t� APPLICATION FOR SITE TESTING/INSPECTION TED SS CRUS v � Applicant-- GX44az ID6 .•d /� NAME �/ j� ADDRESS TELEPHONE Site Location_ P' Engineer AA A b NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee - Test No. '�� S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. TOWN 0 ONF R AHT N©OVER/ R0AR►J OF HEALTH r NOATM 3? '` BOARD OF HEALTH �' f� FO- D j �,SSICMUSE<�� 30 SCHOOL STREET TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: g'9 LOCATION OF SOIL TESTS: )ILA Pec.,n L'.1 Assessor's map & parcel number: l© 7-p G OWNER:ja--cD, $Mas i TEL. NO.: Cog S - �c'U1 L1 ADDRESS: CL ENGINEER: I)CO-' TEL. NO.:--7 ,7 IR 6 3 6- )7(. ';6 CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the 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. Ail Ydl i DATE: i 1 N. G 1 LCAT • EE E� _1 .. j - BOH WITNESS: / PEF:C0L^,T10N TEST 60 i I OM DEPTH OF FERC TEST: TIME OF SOAK: _ d. S (,AL -s Icnc) TIME AT 12" TIME AT 9" / _o / l A I IME AT E" .C\/c:- zNIGrT SO ' K T iiviL---" .T ED I V`X DA >vIE ==II I2" TIME, AT S" - ':rte NEW ENGLAND ENGINEERING SERVICES INC TOWN OF FORTH ANDOVER BOARD OF HEALTH OCT 3 0 1998 October 29, 1998 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT 114 Penni Lane. Enclosed is a copy of the Title V report for 114 Penni,North Andover, MA. The system failed our inspection.. Inhere are any questions please call me at my office, 686=1768. d i Yours truly, Benjamin C. Osgood Jr., E.I.T. President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 :.r ,per - a.t,��•���, i -\ COtitMONWTALTH OF MASSACHUSETTS 7. ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 617-:92-5500 TRUDY COXE WILLIAM F WELD Govcmo: Scactar5 DAVID S.STRUHS ARGEO PAUL CELLUCCI Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: //j/ PCvr.1; �Csrf� /(). #j pv EL Address of Owner: Date of Inspection: a) j ZZ.j q Rc (If different) Name of Inspector: BENJAMIN C. OSGOOD JR. ' I _m a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SERVICES INC. � Y Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA_0 184 5 Telephone Number: 508-686-1768 CERTIFICATION STATEMENT ' I cenify that 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Condrtronall% Passes _ Needs Further Evaluaoon By the Local Approving Authority Fails Inspector's Signature•. LLr� Date:L7^11 Z c7 The Svstem !nspector shall submit a copy of this inspection report to the Approving Authority twithin thirty (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 repos to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the byyer, if applicable. and the approving authority INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure c::teria u defiled in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: iced. The system. upon replaced or r Ys need to be epa One or more system components as described in the 'Conditional Pass section P completion of the replacement or repair, as approved by the Board of Health, will pus. Indicate yes, no, or not determined (Y. N.or ND). Describe basis of determination in a instances: if-not determined',explain why not. ' with a c of a Certificate of v' Iles `tem inspector t dal _ The septic tank is metal. unless the owner or operator has provided t ys rs rior to the date of the inspection; or indi i that the tank was installed within twee (20) yea P om liance (attached) indicating s cd C ' g twenty the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. I e .......... ..... ... ...... . .�". ..x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .:.. PART A CERTIFICATION (continua!) xyt} CER • J-,�t�: g. Property Address: l(`l pc,-n; ka.ez A), 4,L0,eL � ;. 1 rn , Owner.- 1105C Date of Inspection: w1 Z z 12 `: B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health;. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than (our times a year due to broken or obstructed pipe(s1. The system will pass in coon if with approval of the Board of Health): spe l PP. _ . r broken pipets) are replaces obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which (eouire further evaluation by the Board of Health in order to determine if the system.is failing to protect the public health. safety and the environment: 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONOENT: Cesspool or privy is within 50 feet of a surface water Cesspool or p(t%t•is within 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but SO feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (r.vi..d 04/25/77) r.q. ] or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ) l Pei,,n,' �a rt1 c Al Owner: �J �e Lt Date of Inspection: Le Z [48 D) SYSTEM FAILS: You must indicate either 'Yes"or-No"as to each of the following: 1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due to an 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). / Number of tiAies pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation A✓ Am•portion of a 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 I of a public well. 1 i/ Any portion of a cesspool or privy is within 50 feet of a private water supply well _ Am•portion of a cesspool or privy is less than 100 feet but greater than So feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable. attach copv of well water analysis for coluorm bactgria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: I I You must indicate either'Yes-or-No-as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 go or greater (Large Systeml and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. • (revised 01/25/91) rage 3 of to o r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART B CHECKLIST w' Property Address: J I L n v,; �U v1 e /,- 0Q0 i7 u� P \ ` Pe � _ Owner: J c�Se F 1n 0 -j1a5 i Date of Inspection: Check if the following have been done: You must indicate either "Yes'or"No" as to each-of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. I'i _✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. large volumes of water have not been introduced into the system recently or as part of this inspections As built plans have been obtained and examined. Note ii they are not available with N/A. ✓ _ The iacilitv or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. V _ The site was inspected for signs of breakout. I _ All system components, excluding the Soil Absorption Sysiem, have been located on the site. t/ _ The septic tank manholets %were uncovered, opened• and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The iacility owner(and occupants, if different irom owner were provided with information on the proper maintenance of Sub-Surface Disposal System. `l Existing information. Ex.IPlan at B.O.H. t Determined in the field(d any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) (15.302(31(b)) I (revised 04/25/971 Page 4 or 10 •• / • Ili SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION Property Address: 1;,.l den h, )_a„c Owner: J_0 -S � Date of Inspection: �1�,ZL lqg FLOW CONDITIONS RESIDENTIAL: Design flow: R.p.dJbedroom for S.A.S Number of bedrooms: Y Number of current residents: Z Garbage gr-r.der (yes or no):�-es Laundry connected to system (yes or no):_ALi& �c s Seasonal use (yes or no): jWater meter readings, if available (last two (2) year usage(gpd): 7i7w n Sump Pump (yes or no): VD Last date of occupant!-: 'C.z, r ren—f- COMMERCIAIJINDUSTRIAL: Type of establishment: Design flow: gallons/dav Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: ryes or nol_ Non-sanitary waste discharged to the Title S system ryes or not_ Water meter readings, d available i Last date of occupancy: t t OTHER: (Describe! last date of occupancy. �I GENERAL INFORMATION PUMPING REfORDS and source of tniormation t ✓i e2.. L^eA 0ed[ /1A vti 1. System pumped as part of inspection: (yes or no)_ If yes, volume pumped: eallo�s Reason for pumping- 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) VA Technology etc. Copy of up to date contractl Other APPROXIMATE AGE of all components, date installed (i(known) and source of information: ) q 7 S Sewage odors detected when arriving at the site: (yes or no)11,A / L (reviled 04/25/!71 Pape S of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) rt.' Property Address: Owner. Dale of Inspection 1.1'L BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: ,]L cast iron _40 PVC _other (explain) Distance from private water supply well or suction lirc Diameter Comments: (condition of joints. venting. evidence of leakage, etc.) I SEPTIC TANK:_ (locate on site plana Depth below grade: (Z- Material of construction: /concrete _metal _Fiberglas) _Polyethylene —other(explain) If tank is metal. Inst age _ is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: /ocvv GTA)lo hs: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: r Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bonom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, stru4lural integrity, evidence of leakage, etc.) 7-A.J )h (r'/ O K co - I GREASE TRANAZI (locate on site plan! Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. etc.) „$ (r•vi�•d 04/]1/77) r 10 t F, 3 s " ,t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMY °+r PART C _ + SYSTEM INFORMATION (continued) ,}°� Property Address: 1 1 L( "^ c. Owner: , Date of Inspection: �I�L2�%9 • TIGHT OR HOLDING TANK--LV frank must be pumped prior to,or at time,of inspection) (locate on site plan) iA • Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons , Design flow- gallonJda\ Alarm level Alarm in working order Yes: No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) t t t DISTRIBUTION BOX:_ (locate on site plani Depth of liquid level above outlet invent C13 Comments: i (note if level and distrib tion is equal• evidenceof solids /carryoier, evidence of leakage into or out of box, etc.) i 17�X Y, ll. J( br Ct-► LUenT - I PUMP CHAMBER:-A—),eq (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) • (revised 04/2S/971 fey. 7 or 10 ' yf t Y! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,vfyp; Property Address: !1`1 Owner: Date of Inspection:�osc��t SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: 13or' overflow cesspool. number: Alternative system: Name of Technology: r Comments: (note condition of soil• signs of hydraulic failure, level of ponding, condition of vegetation. etc.) 6� ?I LA IQ tocUs C l CESSPOOLS: (locate on site plan) Number and configuration. Depth-top of liquid to inlet invert: Drpth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: I I Indication of groundwater: inflow(cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic (ailure, level of ponding, condition of vegetation, etc.) PRIVY- AM (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (mote condition of soil, signs of hydraulic failure• level of ponding, condition of vegetaaMn• etc.) (r.viv.d 04/2S/971 P.y. 0 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��� PcnY%; Owner: J o S e Date of Inspection: 13�a5 y�z2� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100"(Locate where public water supply comes into house) LIPP - 15 C_ I t 3�l�l�ca c% 1 I � _ i3 l g: Sir 4- I , ' �idcQ L•cu�*S �'"`� � JQ q 1 j i (revised 04/25/97) rag. f of 10 w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMi �;;' PART C SYSTEM INFORMATION (continued) Propertv Address: I n[ Owner: 3o Date of Inspection: L2- ��� Depth to Groundwater 3 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abuning property, observation hole, basement sump etc.) _,.�Determine it irom local conditions Check %vlth !oca! Sua(d of health Chea FEMA naps Check pumping records Check local excavators, Installers ✓ Use USGS Data Describe in your own .cords ho%v you established the High Groundwater Elevation.'(Must be completed) Vcr) C�wc io c� WG�,Gwd 5 I I ' (r.vi..d 04/71/971 P.y. 10 or 10 a TO: NORTH ANDOVER, MASS 9 19 7-) BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at Z- /O f F/Y/y/ Lq%V E North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated Reg. ^r;� n ii e�Hr7z'_, Sanitarian / i \ "r la_ PIN ! AN e t�A►T�: t i-1 C)-7t JOM r I 0 � O r J'/ " A i oo r A �1 .�Cf'AN5;� ,j s .� _ -A e�= in m L- AL,w� A7 --- zz" or LO a 75� 00 d 0 JA Co , joseph j. barbagello, r.s. I westward circle no. reading,m ' ss. TAT TE5T M"rE a2 m1m.Tor sol L. Goo-am T Z 54 3"WAzMSO t'MSnWC VWV` tz" Toe Sop.60L 41%�P�ag�yr�otILAUD�U �S IbdA m 6HAIJ.Q/ Li -rURATIr;IJ 15 /A 14, rp /AIN, oil 6 /AIN P,4 �E: Z/rt N/INGN = `dao ch ti 4S' e Lire ��V.4J + ftJW 97-o 1- 1000 0.� va I sS l� SpTIG TANK �a N "� '✓ o d w JOT Or- Fbso 10 a vj,6LTr=z aT to-o �paEPH VAFu)VAG*A LLo ,!'RC2. Qp� -• 1 -