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Miscellaneous - 121 FARNUM STREET 4/30/2018
121 FARNUM STREET � `:')10/107:A-0059-00000 j r I t%ORTfj BUILDING .PERMIT. TOWN OF NORTH ANDOVER - APPLICATION FOR PLAN EXAMINATION x Permit No#: Date Received cHus�`� Date Issued: IMPORTANT:Applicant must complete all items on this page Y�}e��'�L A �Yek ,M# ^+�►*+�,i Y�'��r,'n�y�i , t. a �v� r11,,+a;�' -t '''{{jj��`,��C �, l'rn F'`��'t �Y� k t ' a' �jS t'�!' �5•�`�.' �'e Y 1 K7?a ,�$a,,,�,.>.p F t • F�hn..• f �•** s +S ? r.Y J S ro s z a C •. 5 s LOCATI.ON �' cr ,, dam. fM� ra ? i � {x �, w ,,,•.. ;, z, n . ....,. a ME 2 ru r n� )ixP. 4 rtrig� `#v= 1 Fa`'aaaf ` f4 IR s h €. rDt r PR'®PER�T�®WER+ ����ly� � ' �. �k � �;� � MAP�.� 4 +[jt� ZONA—I:aN'��G'�s•DISTIRIaCi T n Historic Distnct �} ' yes no , M d -rjeaff$'kTY�.F.h^i,.'Pt?{T� f'? aje''s•.(!'i+tsj'Qt °�'�, .Yy P +"�17�':`=#� {.. 9*".z{ �''��"�"'� +a�L-0s.Sq. Village yeS no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ®-6ne family ❑Addition 0 Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other �e• el ;' and anc ,Wt41a ds . �® �111/a ere'r ®st��c _�� � rs g,., 5 •• - k'£ of i� d, .e f DESCRIPTION OF WORK TO BE PERFORMED: 2-v ),.t U)14 5e f FP6 dq� 6'fd Pa/� y - Y! ( n ed A 2cv,)m (OKJ-1e&-e(cru) aYJkq I~Raah s 1W 4'11 g W�A Identification- Please Type or Print Clearly OWNER: Name: TCt# rPtli PO Q Phone:b� ' V7$ Llogl Address: �—� To t n Y-4 5 r dt,�� 44 c. •` ^''/' xa h�t't aln`P r L S ,+,4 d t A a S� � +qty rrh''4 x �� nsA.u.i.. "+Me �t.Y v a }'`f<f,'+ 'ar* /, ya%� 4 r vw+,Yd pYd/t I �F��", r�? Contractor arrie �. . �/ ('l Phone ( VV ,A -.�, ks ori. - t3A4. 3 ;�"" n a •. xP-�,, a^�;s.T y. :,. ..,�. � ;s.y vim.;v, +i*.".+rY. na;?�s. 4. - , • y� ,e"'�+ '� #�/�fij� ✓t�r4,J:}� J.§i^�`tr •d,., -I, .2r^ �,r � .�t •�. Em a i Lam; 1� `'?fS$� ,YU;'Hr?,rd C7{At%r�3U=sr s 9frtfsSu 42/,nrri setir`{t�a #H i ff, .... gr")L°3t`."�'� r ,.n.G. w!. .,•� t 7147...,:, .q^i*tsrs{+�;; -z €'h*- � Y• 7 > 1 .,,jt� a3Y :"t yr .:i!ti 'aA�+$'4?c" �s _ . � :�r �>a�-rr^� •, y X> �ra�c. -,Mr tiw�,•,.��,. r ..���..�..,. e•a,�::a�"".'� +�z�'�'t r � t,�k�`"�,r.+�•t�-�`.a�j,�'>:rjG� `•+7�dts, f ryr�i�;<��'3 Yx � =c. < u.r �. a t t t, e/� r/�lt - k• ;��•.rzx•�Jif�;';��•7 ,'y��/y �r/�yJ .�a3tlpsr'`:rJ di, J7, Supervisor ss ronnhnstruction License§ .r �� �T Exp Date t fiy'.7"TX trg '; ``�'fn}7 S s ��i`at t'rr "+• +. ,'r,`"°t' •{r ,m .4 ,�t` a. + y 4ti �C f f 'c r `�' _?*y >BA 'C,&a13� 1��tf r°•h+,^� t +��'�tr.�jt..; d. '1'� � �' r s d t �y'°y^"i w''��*a�'tK�� 1 - ,. cc- Mz.r{%= T�' Q Hprovement ,Lyicens;e •.,,r. ll,ry:. .Kssl, ,.5.� > ., = �„<,•n,Exp Date .�.... . .�;. d.�,,v. ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $_^ ' FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund s�X .sT Fes— e i_ m �t b s r.o i77. Plans Submitted-❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL, Public Sewer ❑ Tanning/Massage/Body Art ❑ SwinmmingPools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpstex on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF a U PORN! PLANNING DEVELOPMENT Reviewed On Signature COMMENTS - CONSERVATION Reviewed on � -`�`' Signature � ;o �- COMMENTS pr-c) HEALTH Reviewed on� Sr2o, Signature ` 9 COMMENTS / Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision:- Comments Conservation Decision: ' Comments Water& Sewer Connection/si nature&Date Driveway Permit- DPW Town Engineer: Signature: FIR€ DEP,gRl iVIEIVI' Tern ®um sg fr et Lo Locatetl at 124 ain Street *ppserton slt yes 3no O ca ed -.. Fire®epartment'�ix. gni tur T ate �. tt3f 7e ",nz, `3• a - r,..,..Kfr�.i.�-._ -R tins t.t, ,.moi.# `r$. '° s t, § »s+ r,!r Alt, A, )01 To -Ir -,���jl �tailin1 �1 rd u ydYIO �� Li acopy PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 8/20/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair and Construction of an On-Site Sewage Disposal System By: John Chongris At: 121 Farnum Street Map 107A Lot 59 r'l Iorth Andover, MA 01845 The Is uanc of this e is all ri t be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 0 • f g ' P f p+ t PUBLIC HEALTH DEPARTMENT i Community Development Division TOWN OF NORTH[ANDOVER SEPTIC DISPOSAL,SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal.System( )constructed;( )repaired; By: ACh1 .�! �1` 1 � r (Print Name) Located at: 1 Y* C (Installation Address) ; Was installed in conformance with the North Andover Boardof Health approved plan,originally dated and.last revised on ,with a design flow of gallons per day. The materials used were in conformance with those specified on the Ilk approved 4 i approved pian;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 plana All work is accurately represented on the As-built which has been submitted to the Board of Health. Bottom of Bed..Inspection.Date: ! ! Engineer Representative(Signature) And—Print Name ln [dwl Final Construction Inspection Date: . Engineer Representative(Signature) And—Print Name Installer. (Signature) Date: C-�l 22L,=4.1 =_ I And—Print Name Engineer• (Signature) Date.- l2U ! And—Print Name 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 970.688.9540 Fax 978.688.8476 Web http://www.townofnorthdndover.toni i Commonwealth of Massachusetts RECEIV.E® City/Town of North Andover AUu 2 n2014 Certificate of Compliance ;"Pi0WROFNORTH ANLjJ„ER G„M ; Form 3 ; il1�ALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. This is to Certify that the following work on an On-Site Sewage Disposal System Important: When filling out ❑ Construction of a new system forms on the ® Repair or replacement of an existing system computer,use ❑ Repair or replacement of an existing system component only the tab key to move your cursor-do not Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): use the return key. DSCP Number DSCP Date Paul Hutchins Facility Owner 121 Farnum Street 'em Street Address or Lot# North Andover Ma. 01845 City/Town State Zip Code Designer Information: Doug Smith Soilsmith Designs Name Name of Company August 20, 2014 Signature Date Installer Information: John Chon risytc a e Na of Company 444 go Ig'ature Date A ?0/Y' se of this system is conditioned on compliance with the provisions set forth below: F The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. Approving Authority Signature Date t5form3.doc•06/03 Certificate of Compliance•Page 1 of 1 l Blackburn, Lisa From: Sawyer, Susan Sent: Wednesday,August 13, 2014 10:20 AM To: Blackburn, Lisa Cc: Isaac Rowe <irowe@millriverconsulting.com> (irowe@millriverconsulting.com) Subject: FW: 121 Farnum heads up Lisa, Make note that the 121 Farnum is ok according to Doug Smith. See below However, I spoke with John Chongris yesterday and the electrician still needs to do his thing before we send it off to Isaac. I copied him on this because we had discussed it previously and I just want him to be in the loop. John will call for an inspection when he is ready and then the usual protocol will go from there. More than likely will be Monday, but he is still hoping/trying to get it ready for a Friday inspection. Susan From: SOILSMITHO)aol.com [mailto:SOILSMITH@aol.com] Sent: Wednesday, August 13, 2014 8:53 AM To: Sawyer, Susan Subject: Re: 121 Farnum Hi Susan Did the as built transit shots yesterday, plotted them last night All Good! I will wait to hear from John when to do final grades. Pump tank had the full 6 inches of stone under. Thanks Doug Douglas J. Smith Soilsmith Designs 15 Foxberry Drive New Boston, NH 03070 603-487-2298 i, In a message dated 8/12/2014 11 :52:44 A.M. Eastern Daylight Time, �, er ssawy townofnorthandover.com writes: I heard about the tank move. Good idea Susan From: SOILSMITH@aol.com [mailto:SOILSMITH@aol.com] Sent: Tuesday, August 12, 2014 9:54 AM To: Sawyer, Susan Subject: Re: 121 Farnum 1 Town of North Andover -- Septic. System - AS-BUILT CHECKLIST 1) JAll changes to the design plan have been reflected on the as-built 2) s of suitable scale; (one inch =40 feet or fewer for plot plans and one inch = 20 or fewer for details of system components) 3) _LzLot ntunber,Street Name,Assessors Map and Parcel Number 4) —IzLot Lines and Location of Dwellings served by the system 5) Locations,Elevations and Dimensions of system,including reserve (if applicable) 6) -ZI--fies to dwelling or Permanent Structure&Wells V a.From Septic Tank&Distribution (D) Box b.From Leach Area 7) Nies to Lot Lines from leach area 8) Locations of Deep Holes&Peres 9) -LzTop of Foundation Elevation 10) cations of Wells,Drains,Watercourses within 150 feet of system 11) cation of water,gas,electric lines,cable 12) —LZL/O cation of Structures within 6 Inches of Finished Grade 13) VOriginal Stamp&Signature I4jcation and holder of any easements which could impact the system V/� j°F aSs�c o y � DOUGLAS �, � � oL�,� � 15) npervious Areas;Driveways,etc ,) SMITH 16) l/iV or th Arrow No. 1155 L---L � 9FG/STERtiO 17) /Location &Elevations of Benchmark used sq �w�a 18) STATEMENT ON PLAN (NA 5.3) a. "I certify the locations, elevations, ties,cover material;exposed component covers etc.,shown on this as-built substantiallyagree with the approved plan and have determined that the break out eleva " ,i pplicable,have been met." �% Hy02 Signature of igner Date b. "If a.STUCTURAL WALL IS PRESENT(NA 4.9)a Letter or statement on the as-built indicating th wall- was,or was not,constructed in accordance with the intended design and any manztfacturer's specifications." Signature of Designer Date As of:Tuesday,July 30,2013 Town of North Andover — Se 'c $ stem - AS-BUILT CHECKLIST 1) All changes to the design plan have been reflected on the as-built 2) Is of suitable scale; (one inch= 40 feet or fewer for plot plans and one inch= 20 or fewer for details of system . components)' lors 3 Lot nalliber Street ame AsseMap and Parcel Number 4) �/ Lot Lines and Location of Dwellings served by the system 5) Locations,Elevations and Dimensions of system,including reserve (if applicable) 6) Tie o d �lling o Permanent Structure&Wells a. om Septic Tank&Distribution (D) Box b. From Leach Area Ties to Lot Lines from leach area 8) Locations of Deep Holes&Peres T f 9) opo foundation Elevation 1 v 10) Locations of Wells,Dr ins,Watercourses within 150 feet of system J 11) Location of water,gas,electric lines,cable 12) ILocation of Structures within 6 Inches of Finished Grade 13) 70riginal Stamp&Signature 14) d Location and holder of any easements which could impact the system 15) V Impervious Areas;Driveways,etc 16) North Arrow 1' Location&Elevations of Benchmark used 18) STATEMENT ON PLAN (NA 5.3) a. "I certify the locations, elevations, ties, cover material;exposed component covers etc.,shown on this as-built substantially agree with the approved plan and have determined that the break out elevations,if applicable,have been met." I Signature of Designer Date b. "If a STUCTURAL WALL IS PRESENT(NA 4.9)a Letter or statement on the as-built indicating tAe wall- was, or was not, constructed in accordance with the intended design and anymanufacturers srecifications." i Signature of Designer Date As of:Tuesday,July 30,2D13 . 1 _ N L A ACJ I K' Blackburn, Lisa From: Blackburn, Lisa Sent: Friday,August 15, 2014 11:40 AM To: Isaac Rowe (irowe@millriverconsulting.com) Subject: 121 Farnum St. Attachments: 121 Farnum St..doc Hi.Isaac, Could you please call John Chongris for final construction inspection?Thank you. 508.509.9442 Lisa Blackburn Health Department Town of North Andover 1600 Osgood Street,Suite 2035 North Andover, MA 01845 Phone 978-688-9540 Fax 978-688-8476 Email Iblackburn@townofnorthandover.com Web www.TownofNorthAndover.com i I 1 F,. . i Rq p North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 121 Farnum St. MAP: 107A LOT: 59 INSTALLER: John Chongris DESIGNER: Douglas Smith - PLAN DATE: 6/1/14 rev. 6/9/14 BOH APPROVAL DATE ON PLAN: 7/15/14 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: 8/5/14 v DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan 111PBottom of tank hole has 6" stone base Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Y ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ` Bottom of tank hole has 6" stone base Weep hole plugged ��a-Y. v� , ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base ❑ H-20 D-Box ❑ Inlet tee (if pumped or >0.087foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: i i -F SOIL ABSOR TION SYSTE General) it S fit, Bottom of SAS excavated down t soil la er, Y ` as provided on plan Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to W �,/,o3 header (and vented if impervious material h6 w above) f�v ❑ Elevations of laterals and chambers installed as on approved plan >✓I" ❑ Retaining wall (boulder/ concrete /timber/ block) 14 k L� ❑ Final cover as per plan f �, a� ornm) ents: y l �:/��^'1/0 r/ ` �lV �,( 0 ot*' � V� SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE Loamed Seeded Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws • 4Af F North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 121 Farnum St. MAP: 107A LOT: 59 INSTALLER: John Chongris DESIGNER: Douglas Smith PLAN DATE: 6/1/14 rev. 6/9/14 BOH APPROVAL DATE ON PLAN: 7/15/14 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: 8/5/14 DATE OF FINAL CONSTRUCTION INSPECTIO : 8/18/14 DATE OF FINAL GRADE INSPECTION: ��vA D SITE CONDITIONS ® Contractor reports any changes to design plan ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SEPTIC TANK ® Building sewer in continuous grade, on compacted firm base NA Cleanouts per plan X Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ® Monolithic tank construction ® Water tightness of tank has been achieved by visual testing ® Inlet tee installed, centered under access port Y, ® Outlet tee installed, centered under access port (effluent filter) ® 24" inch cover to within 6" of finish grade installed over one access port ® Neoprene boots around inlet & outlet Comments: PUMP CHAMBER X Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1000 gallon Pump Chamber installed ® H-10 loading ® Monolithic tank construction Z Inlet tee installed, centered under access port ® Pump(s) installed on stable base ® Alarm float working ® Pump On/Off floats working ® Separate on/off floats ® Drain hole in pressure line ® 24" cover at final grade installed over pump access port ® Water tightness of tank has been achieved by Visual testing ® Neoprene boots around inlet & outlet Comments: Chamber location changed due to ledge. OK'd by S. Sawyer and D. Smith 8/12/14 CONTROLPANEL ® Alarm & Pump are on separate circuits ® Alarm sounds when float is tripped ® Location of control panel: basement ® Alarm signal located inside: basement and outside on wooden post next to pump chamber Comments: DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet &outlets Z Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: ti SOIL ABSORPTION SYSTEM (General) X Bottom of SAS excavated down to B soil layer, as provided on plan — System has a reduction and is being built in the B layer X Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan N/A 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: overdig 52x25 depth of hole 48". 1 st inspection - Width is 1' short— will dig out. Lots of large rocks in bed. Will remove. No sand on site. 2nd inspection — no sand. Will call me to let me know when they will be here. FINAL GRADE dLoamed Seeded Cover per plan Comments: DOCUMENTS NEEDED Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer T,,/As-Built Plan BM = 101.35 HR = 5.01 HI = 106.36 SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT 7.28 98.73 99.28 Septic Tank IN 7.38 98.63 99.00 Septic Tank OUT 7.74 98.27 98.75 Pump Chamber IN 8.08 97.93 98.70 (2") Pump Chamber OUT 8.28 97.91 98.45 (2") Distribution Box IN 3.32 102.87 102.82 Distribution Box OUT 3.34 102.67 102.65 Lateral 1 TOP 3.38 / 3.58 Lateral 1 INVERT 102.63 / 102.43 102.59 / 102.40 Lateral 2 TOP 3.38 / 3.58 Lateral 2 INVERT 102.63 / 102.43 102.59 / 102.40 Lateral 3 TOP 3.38 / 3.58 Lateral 3 INVERT 102.63 / 102.43 102.59 / 102.40 Bottom of Bed 4.47 101.89 101.90 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 10' Z. Private drinking well 75 1002 50 ® Irrigation well 75 100 Z Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains(intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 I ` Suction line 222(2) z 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws OK Will do thanks Doug Douglas J. Smith Soilsmith Designs 15 Foxberry Drive New Boston, NH 03070 603-487-2298 In a message dated 8/12/2014 8:55:26 A.M. Eastern Daylight Time, ssgMerk ownofnorthandover.com writes: Doug, Please be sure to show all changes or list any allowances on the as-built that you have approved at 121 Farnum. Such as - Minimum pitch into the pump tank rather than preferred due to ledge encountered Depth of 3/ stone under the pump tank; 3 inches rather than 6 or as found on inspection Adding paper or fabric over pea stone Locations of tanks due to ledge or other. - Locations Ledge found?? The installer stated that you are personally inspecting the bottom of the pump tank hole and verifying the depth of stone. He says that you will be ok with it if he can get 3 inches of stone. The choice to not change to a pump tank, in this ledge situation, is the engineers preference. Health is still concerned about the tank cracking without the allotted stone or at least 4 inches. Thank you Susan 2 c Also, don't forget to call the office after you have done the as-built to confirm that it is acceptable to you. Susan Sawyer I Public Health Director Town of North Andover 1600 Osgood Street Suite 2035 North Andover,MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email mai Ito:ssaw er ,town ofnorthandover.com i Web www.TownofNorthAndover.com 3 �Y Commonwealth of Massachusetts Map-Block-Lot 107.A0059 . BOARD OF HEALTH Permit No North Andover BHP-2014-0730 FEE $250.00 ---------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John_Chongris---------------------------------------------- to(Construct)an Individual Sewage Disposal System. at No 121 FARNUVI STREET ---------- ------------------------------------------------------------- ---------------------------------------------------------------------- --------- as shown on the application for Disposal Works Construction Permit No. BHP-2014-073 ech Au ust 04,2014 -- -------- �� � PY------ --- ------- -------- -------- -------- -------- --------- Issued On:Aug-04-2014 BOARD OF HEALTH °F'M 696 • Town of North Andover HEALTH DEPARTMENT ,SSACHUSE� (� 6 CHECK#: 1 { �P a DATE: LOCATION: i H/O NAME: _ y� CONTRACTOR NAME:)( �i I 1 1�b j E � T_yRe of Permit or License: (Check box) ❑ Animal $ 0 Body Art Establishment $ ❑ Body Art Practitioner $ 0 Dumpster $ ❑ Food Service-Type: $ 0 Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ Septic Disposal Works Construction(DWC) $� Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials' White-Applicant Yellow-Health Pink-Treasurer NORTH Application for Septic Disposal System f 1 ��. r �-Construction Permit — TOWN OF TODAY'S TE $250.00—Full Repair �9SSACHU t - ORTH ANDOVER LMA 01845 $125.00-Component Important: Application-is-Itereby made fora permit to: When filling out Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your ❑ Repair or replace an existing system component—What? cursor-do not use the return key. A. Facility Information l a I IarNy H IQcjae Hop 10-) A L.yi- -S9 Address or Lot# IJocit'1 Ad1kUUAar City/Town Z.-,.'�If YPE OF SEPTIC SYSTEM*: 0 Pump ❑ Gravity (choose one) ***If pump system,attach copy of electrical permit to application*** conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information TC&U I Ho `�C.k i !3 S Name I a I �-CL U M �oo, cl Address(if different from above) loo r.1-ti A n cl c,j-e r City/Town State Zip Code �► W hP (n 333 Telephone Number 3. Installer Information C�� 0 r1 S or'1 ri5 0 �,`S j h �A � Name Name of Company JA01 dick RaP-"s �o�c� V_C1o'j Address City/Town State Zip Code 503 S09 � y ( a Telephone Number(Cell Phone#if possible please) 4. Designer Information 'DC)Ua So► Srnl '0'0_ SIGIn,.$ Name I Name of Company 1 '5 Tox-berN Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 t- P µ°R,h Application for Septic Disposal System O a O TODAY'S DATE =Construction Permit - TOWN OF ORTH ANDOVER, Na 01845 $250.00-Full Repair ^CMSt� $125.00-Component I PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: atesidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of No ndover and to place the system in operation until a Certificate of Compliance has b en i sued this o d of Health. 416 5� �f Date 67 Applic fin pprov (Board of Health Representative) p d A//I W N/me Date AtionDisappro ed for the following reasons: i 4 For Office Use Only: 1. Fee Attached? Yes,,---' No 2. Project Manager OhIgation Form Attached? Ye.%� No 3. Pump S s� tem? If so,Attach copy ofElectrical Permit Yes V No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. F1oorPlans?(new construction only): Yes N Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: 'Far ti U M V—Oc,A For plans b 5,0 �1 1+i'1 E�"C� 1.3 (Address of septic system) P Y i 1 Cn (Engineer) (Installer's name) Relative to the application of —5O� n (�S And dated rigina date) Dated o ay s ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Tide 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first (VS inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK (or e-mail to: healthdeptQtownofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic stems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer,I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: o y's Date) JL (( o r (Name—Print a e—Signed) riyvnervme -iou30rouUZO P.'I Pitcherville Sanas& Gravel 36 Brawn Drive Greenville, NH 03048 ,, 603-878-0035 (fax) 603-878-0025 Sieve Analysis SEPTIC C-33 Source WILTON Date 7125!2014 <. SJEVE SCREEN CUMLATIVE CUMLATIVE TOTAL% C-33 _$1ZE WGT. WGF %RETAINED PASSING SPEC 318" 0 0.00 0.00 100.0 100 #4 22.00 3.87 96.1 95--100 #8 50.00 8.79 91.2 #16 121.00 21.27 78.7 45--80 #30 254.00 44.54 55A #50 434.00 76.27 23.7 10-30 #100 514.00 90.33 . ' 9.7 2-10 #200 560.00 98.42 1.58 0-3 , PAN 569.00 100.00 0.0 FM 2.45 GROSS 428 L FAA Using C 3.259345794 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION 15.255: continued (f) where a retaining wail to stabilize the slope is required and also is proposed as an impervious barrier,in addition to meeting the requirements in 310 CMR 15.255(2),it shall be constructed of suitable structural material and be designed by a Massachusetts Registered Professional Engineer. (3) Fill material for systems constructed in fill shall consist of select on-site or imported soil material. The fill shall be comprised of clean granular sand,be free from organic matter and deleterious substances, and shall not contain Remediation Waste as that term is defined in 310 CMR 40.0000. Mixtures and layers of different classes of soil shall not be used. The fill shall not contain any material larger than two inches.A sieve analysis,using a#4 sieve,shall be performed on a representative sample of the fill.Up to 45%by weight of the fill sample may be retained on the#4 sieve. Sieve analyses also shall be performed on the fraction of the fill sample passing the #4 sieve, such analyses must demonstrate that the material meets each of the following specifications: SIEVE SIZE EFFECTIVE %THAT MUST . . PARTICLE SIZE PASS SIEVE # 4 4.75 mm 100% #50 0.30 mm 10%-100% #100 0.15 mm 0%- 20% #200 0.075 mm 0%- 5% A plot of the sieve analyses of the portion of the sample passing the#4 sieve shall fall on or between the lines on the following graph: PARTICLE SIZE DISTRIBUTION - #200 #100 #50 #4 Sieve Size 100 I 90 I 80 , 0 0 t 70 z I 0 to 60 co a s a_ 0 CW7 50 J/- Z 40 � 30 / 0 20 01 10 1000 Micron 60 200 600 2 6 10 mm 4/21/06 310 CMR-534 j le KEY ELEVATIONS BUILDING SEWER[/NE Rif txe uiax�nxwxmmHe �H�um u TOP CONCRETE IN, SHALLiSANDBECaED ON T r op4r a E°snmm t/e'm i/z'pst xxsn store TYPICAL E CROSS SECTION e 20 — Pw Ir l: }iy o w nP 4 e• CELLARFLOOR fop B1 A COMPACTANO FIRM BASE Pro can tsfnI J rsv mra_fw Mmww HOUSE OUT. 99TH" �- 6 OUTLET B0 BOX OX NL BOX \ 2.3 SEPTIC TANK IN: 99 00" �] - SEPTIC TANK OUT, 98.75' n L.! ' 25'. n oa]s ortA mu pp a•"soi rx JJ w rT.m rn'ow wwmarae[ PUMP IN 98.10 .�. a • +I cnvE c _ x� 'f^<S rf•w PUMP OUT 98.45 IN: P/o cw rsuN PUMP 9500 r r/Y m xwm sm2 D-BOX Pro ux mMR D-BOX OUT 11021.65 sa .TCOMPARD DL R nOOP SEO � •••.••••~•. . -Y � � �, /,�pb ,4 • START PIPf 102.59 H-fO LOAOIN °- t/2'OBL xL.�EU StaN[ ^t02b sor."101.90 ENO PIPE 10140' 1' N-10LOADING .rv2Aa (010 cMR 162,i) w -s ✓ una trona• ran vc ort BEO BOTTOM 101.80 o r°m e°Mn - °^/^ pi x40 yW y ALL SYSTEM COMPONENTS raxemf ave run t fa, iOP OF STONE 10290 ^./^'f°eu�n®y^ ,,e ms 87 FFL ATTgg'fpp�.1�L 00{� µo Xb1�0Mw'�m WTNMAGNE—TAPE \., \` `•( °x BW LAYER IS TO REMAIN IN PLACE FINISHGRAOE: fOS90 ON FLSATi1 FROM FLOOR - ® PER 310 CMR 11,121(l 1) r wow un f mw - reu ALARM FLOAT 16.5'FROM FLOOR 2 ,:, \ -xi ✓f'. GENERAL NOTESc n ,ecomnoeE'LAonxro Jr " ANY 11,1,1,RIPAIII 1-1111rr .,xncnxrrr'rr x,t III. +.cumnn R teoultEMnsnuarruMs. .y�� �� O ,�?�'� ��Q- s/Q ' LOCUS (1" - 800' + -� L r 'lj� 005 //. tGP�P P STL 0,0 V TEST PITLOG O 17 umw w,I .1- Ns. V 1O 1 ce....At10N - x I- p - p m - - m __ -- —_ s1.sMlt IIII s, Q���� pl �/• i va+r �h, eFPoi tc °"e _ ronLr n mnrnY,mw� 7/ � M^° /` O 0 44" FILL 0 20" FILL r nn Uf /' M1 SYSTEM SPECIFICATIONS QQ_\�D1 c ' ��w oR. �yo ,�8 I 44 ss 20 27 A OOM 1Vry Mw PEnr \ OVER 27-43- C 7 43` 'tet/'°°n awmr —=HOUtp, SE, n�vV F1'aeVuraen s�o SV.n. �' S IG-- N _ ��' O 55"-82'G.`"'°Pry:� w.w nrsrnor,'nrr as rvor,vmnn ntT uesrunnr[o,vnr[nsxno oe LnnS x cx B -� m 43"-B2"G IN 4'4j O! APPR¶N MT11 P K TO --- �, /'! i' /LAN tt�1�c�. BISAeANDONEE npU.V / MAY 14.2014 BATE s. LAN Lu rrv `a - / 1U.1Py,LN Mp(jOLITNUC��\- _- '/ �V C PERC TEST,f-1 0-24" FILL (� `` PERC TEST 40 DEEP x / y 1 SLOPE 1500 tANK 1 /' \_\`\ \V 107 START PRESOAK 24"-38"A / I 4 0 00 V V .. \ 1:26-EN,P PRESOAK BOX NNICOICREPE.—I 1.,V n / 1 P NQ SE'1gq\ { n - 1tI 22q668 12 ,n run furor wr /�yI SYSTEM TO k �� �V 212 8" 38"-60".B uv a NBli WB - rn p _. �(c� -`- ABA24/\ OQ�n� 24/3-8 MIN INCH 60"77"C - /�' - FRosl N c°Nne - Q!�5� ✓ OO .TEST PIT LOG TEST PIT LOG un so. ER .. ; // AND A P TO USE STALLE - J 'fi°mA1ro°ESannxYi eeK,a'"xA .rSnec [o'INA- ns arum ,nor nvivr.nns 3RPRIOR°Y CONSRVA,.IIOyi 'SO•\/. ` \\\ w^ • �x rxm,,°°k`" . S c. / R7 / 4Ck.'. \ - O tP s�MxT lour Bp,eJ um LOCAL UPGRADE VARIANCES - - I - - ,E- - - 310 CMR 15.405((h A REDUCTION IN THE 4'SEPARATION i - - 7 1 I 1 - BATE 0-16" mFILL s e an` °• 6— RBgUIRED BETWEE4 THE BOTTOM OF THE SOIL ABSOPPTION Z1' ° 3'SE1B 1 �\ '�' SYSTEM AND HIGH GROUNDWATER, REQUESTING A 12"REDUCTION - ACA' I6"-22' RESULTING IN SEWAGE ABSORPTION SYSTEM BEING 36"ABOVE B" 22 B HIGH GROUNDWATER WITH A 6 MIN PER INCH PERC RATE / A / arw..n 7 .. 22"-32"B'wxe°.ne=L'- 22--60-C 310 CMR 15.4050) A REDUCTION OF THE REgUIREMENT OF A TWELVE INCH$EPERATION BETWEEN THE INLET AND OUTLET ' 32^-64^G 'mY}o, e� TEES AND HIGH GROUNDWATER NOTE TANKS AS SPECIFIED HAVE , INSTALLED WATERPROOF RUBBER BOOTS AND CLAMPS OWNER 2INFORMATION Mnnx„P,xex,,,t, ��� �aa�J� ! OF SOIL CERTIFICATION .. �0 '..(OG'L� H toot r em wmmt r waewe M1>tna oePe.tmmtter Enwmmmtm JJ .�/ ` aet etlm�rwent b]la fIAR is olT to<anMel eaA eMuutlane ane Mat le M1ee Gem pMmneEM�mF Metmt w Ary nax ABC t, 5 rvn nEeo rvrxn xssn[ 9 nnRnt nS .' .. J=� .. ._ ;e M9.eyPMlee and eepmrm<e ox ]i0 EMR 5M lM1e reeulre4 S lu N] cMRy Mal Me rew to p1 me epeA i wuatlm pe in`�ce1.E m1 Me ellpAee eM C O'` t p OYp - .. ? ewluelkn Imo ma o w on n va ce w 310 CMR 15.tOG G .. M1reu9M1, tOT DOUGLAS J.3MLTR,R 9#1155 SCA 1>, - 20' �O, DOUGLAS J.BMffH Mx ..11evel xtu,•s,2267 LEGEND SOILSMITH DESIGNS PAUL HUTCHINS GRAPHIC SCALE "E' '°" DOUGLAS J. SMITH. R.S.#1155 121 FARNUM ST. NORTH ANDOVER LAND use CONSULTANT REVISED JULY 9 2014 V w� `�MY1201• 15FGXBERHYDRIVE. MAP 107-A LOT59 JUNE 1, 2014 a°x° °—G m " wL�R s eba&9 oz�2�6HPt�d�r��o REVISED JULY 31,2014 so NITN®A04COM Job 2014-23 SHEET 1 OF 2 Ch � � _54 Commonwealth ®f Massachusetts Official Use Only Department ®f Fire Services Permit No. �'��E Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(ME ),527 MR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATI01V Date: 30 . City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) , Owner or Tenant Ilz_ U— ` Telephone No. Owner's Address /v .��L/f�i/'l r' Is this permit in conj unction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undg rd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 4�a� 1s27alj ----•" ,,.-- ,- . ._ -r- r..;__.___�_.� ._._�, ,,� Completion of the following table may be waived by the Inspector of Wires. of.. Total ansformers KVA h� nerators KVA Date......./:......�..-�� 1,o Emergency ig ting ittery Units tAORTh TOWN OF NORTH ANDOVER E2EALARMS No. of Zones of Detection and PERMIT FOR WIRING Initiating Devices *�o - `,�y �.of Alerting Devices C �� of Hes _ ktection/Alerting Devices Municipal ' ❑ Other l t1 kcal❑ Connection This certifies that ...........: .. © US SC Z ....... �T L/ 'purity Systems:* has permission to perform � � �^ � 7 No.of Devices or Equivalent • ... ....:. lta firing: No.of Devices or Equivalent wiring in the building of............... ................................................ fl No.of Devices or E u'valent ! uons ecommunicati at .j.Z t... �f�/1/l//� 7�............................. North Andover,Mass: 'Fee......... ...............Lic.No. •�Q3a M(' �� l-.................... rl!.. ., .........:..... .d,or as required by the Inspector of Mres. ELECT CAL SPECTOR U ;policy.) Check# =� / Rule 10,and upon completion. r� O t/ pce of electrical work may issue unless r`' 5 / age or its substantial equivalent. The _ ae permit issuing office. CHECK ONE: INSURANCE M BOND ❑ OTHER ❑ (Specify:) I cert,sander thepains andpenalties ofp��ry,that thein ormation on this application is true and compdete. FIRM[NAME: . r s s oCif LIC.NO.: Licensee: els Signature _ LTC.NO.: �f��L� (If applicable,enter "exempt"in he license nymber line) Bus.Tel.No.- 4 " Address: zf - 11a �� � Alt.Tel.N�!.��_e'o *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lia No. �� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one ❑owner ❑owner's agent. Owner/Agent p PkRmITFEE.- $ Signature Telephone No. FILE COPY North Andover Health Department Community Development Division July 15, 2014 Paul Hutchins 121 Farnum Street North Andover, MA 01845 Re: Subsurface Sewage Disposal System Plan for 121 Farnum Street; Map107A Lot 59 Dear Mr. Hutchins: The proposed wastewater system design plan for the above site dated June 1, 2014 with a final revision date July 9, 2014 and received on July 10, 2014 has been approved. The design has been approved for use in the construction of a replacement onsite septic system for a 3-bedroom(max 8-room) home. This plan is generally good for 3-years from the date of approval however, as this is for a repair system,this is reduced to 2- years. The plan received the following local upgrade approval. 1) Separation from Soil Absorption System(SAS)to Estimate Seasonal High Water Table (ESWT) from 4 feet to 3 feet 2) The use of a reduction of 12-ince separation between inlet and outlet tees and high groundwater. During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. In the event an imminent health problem, such as sewage backup into the dwelling is occurring, the North Andover Board of Health may reduce the time period for which this plan is valid. This approval is also subject to the following conditions: 1. Please keep the attached DEP Form 9b for your records (attached) 2. This system utilizes an infiltrator system and the owner has certified the understanding of this system, as found in the document submitted (see attached) Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 121 Farnum Street July 15, 2014 3. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 4. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincere us Y. Saer, RE Pu is Heal Direc Encl. Form 9B Local Installers List cc: Doug Smith, RS File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Commonwealth of Massachusetts City/Town of North Andover a Local Upgrade Approval Form 913 4'M DEP has provided this form for use by local Boards of Health if they choose to do so. The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. A. Facility Information Important:When filling out forms 1. Facility Name and Address on the computer, use only the tab Paul Hutchins key to move your Name cursor-do not 121 Farnum Street use the return key. Street Address North Andover MA 01845 r� City/Town State Zip Code 2. Owner Name and Address (if different from above): Name Street Address City/Town State I Zip Code Telephone Number 3. Type of Facility (check all that apply): x Residential ❑ Institutional ❑ Commercial ❑ School 4. Design flow per 310 CMR 15.203: 330 gpd 5. System Designer: Doug Smith PE ®RS Name 15 Foxberry Drive New Boston NH 03070 Address Citylrown State,ZIP B. Approval 1. Local Upgrade Approval is granted for: ❑ Reduction in setback(s)—specify: ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction 450 Boston Street Local Upgrade Approval* Page 1 of 2 u Commonwealth of Massachusetts City/Town of North Andover o Local Upgrade Approval Form 913 i7y B. Approval (continued) ® Reduction in separation between the SAS and high groundwater: Separation reduction 1 ft ft. Percolation rate 8min min./inch Depth to groundwater 3 ft ft. ❑ Relocation of water supply well (explain): ® Reduction of 12-inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: North Andover Health Dept Approving Authority Susan Sawyer July 16, 2014 Print or Type Name and Title nagre Date I 450 Boston Street Local Upgrade Approval, Page 2 of 2 Of NORT1�1y 6764 Town of North Andover ,; ::' HEALTH DEPARTMENT ,SS C US CHECK#: DATE: 1 LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SE TIC Systems: Septic-Soil Testing $� � - -�-��,/ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DW.C) $ I ❑ Septic Disposal Works Installers(DWI) $ I ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; SUITE 2035 ''R fv NORTH ANDOVER,MASSACHUSETTS 01845 Susan Y.Sawyer,RENS,RS 978.688.9540-Phone Public Health Director 978.688.8476-FAX healthdept@townofnorthandover.com www.townofnorthandover.com APPLICATION FOR SOIL TESTS DATE: 01 1 MAP&PARCEL: 19)P i oo L( 51 LOCATION OF SOIL TESTS: B1q c, 1 n rl-t o F L o'� Pc e evi G to ) OWNERTOul- oy�-cin �5 c l,cCo��#: �8 Cogs 3 33 �0 e APPLICANT: �� l— y�"G Ms Contact#: ADDRESS: 1 I 1gR0VVV) StV4,-ef,"T Q"0-+ 1 \A Of 0 Lllf✓z 0) SolLSYniT-)j 'F-S 16\15 ENGINEER: Contact#: — / 9 LW CERTIFIED SOIL EVALUATOR: ,Sv-n tt l-) Myi S E ZZCp Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: ( enUndeveloped Lot Testing: Upgrade for Addition: In the Lake Cochichewick Watershed? Yes No RECEIVED THE FOLLOWING MUST BE INCLUDED WITH THIS FORM ➢ Proof of land ownership(Tax bill,or letter from owner permitting test) APR 2 3 2014 ➢ 8.5"x 11"Plot plan&Location of Testing(please indicate test nit sites on the plan) TOWN OF NORTH ANDOVER ➢ Fee of$425.00 per lot for new construction. This covers the minimum two deep holes d HEALTH DEPARTMENT two percolation tests required for each disposal area. Fee of3$ 60.00 per lot for repairs or uuerades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass.Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. ➢ 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). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval Date:1 f -so I 1'( Signature of Conservation Agent"'-' CA Wil l��-�i - Q.SCJ r- 6&Aa Q Y I'S VS OLVp I Date back to Health Department: (stamp in): jc�' P ro - i ate• C)LtJ LQ Residential Property Record Card PARCEL ID:210/107.A-0059-0000.0 MAP:107.A BLOCK:0059 LOT:0000.0 PARCEL ADDRESS:121 FARNUM STREET FY:2014 PARCEL INFORMATION Use-Code: 101 Sale Price: 1 Book: 04462 Road Type:. T Inspect Date:_ 04/65/2012 Tax Class: T Sale Date: 03/24/96 Page: 0338 Rd Condition: P Meas Date: 04/05/2012 Owner: Tot Fin Area: 1248 Sale Type: P Cert/Doc: Traffic: M Entrance: X ' � HUTCHINS=CATHERIWL-a yP. ti _ - Tot Land Area: 1.50 Sale Valid: F Water: Collect Id: RRC Address. 121 FARNUM STREET Grantor: HUTCHINS,PAUL Sewer: Inspect Reas: C NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / RESIDENCE INFORMATION LAND INFORMATION Style: SL Tot Rooms: 6 Main Fn Area: 1248 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R2 Story Height: 1.00 Bedrooms: 3 Up Fn Area Bsmt Area: 1200 Seg „- Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 624 1 P 101 S 43560 1.000 195,305 Ext Wall: WS Half Baths: Unfin Area: Bsmt Grade: 2 R 101 A 0 0.500 3,800 Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 1248 DETACHED STRUCTURE INFORMATION Foundation: CN Bath Qual: T RCNLD: 152521 Str Unit <Msr-1 Msr-2 -E-YR-Blt Grade Cond%Good.P/F/E/R Cost Class Kitch Qual: T Eff Yr`Built: 1977 Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1964 Sound Value: SE S 80 0.00 1994 A A ///89 1,100 .Fuel Type: : O Grade: AG Cost Bldg: 152,500 G1 S 624 0.00 1994 A A /50//45 8,800 1 Fireplace: 1 Bsmt Gar Cap: Condition:' AG Aft Str Vall: VALUATION INFORMATION Central AC: .N Bsmt Gar SF: Pct Complete: Aft Str Val2: Aft Gar SF: %Good P/F/E/R: /100/100/79 Current Total: 361,500 Bldg: 162,400 Land: 199,100 MktLnd: 199,100 Prior Total: 361,500 Bldg: 162,400 Land: 199,100 MktLnd: 199,100 Porch Tyg_e Porch Area Porch Grade Factor E 36 W 168 SKETCH PHOTO 14 a / 1 fMi} 12 168 Sq. 2; ` 5C 34 FM/B 9tR MIiIY 1200 Sq.Rr 24FM 24 so a- 24 0 121 FARNUM STREET Parcel ID:210/107.A-0059-0000.0 as of 4/21/14 Page 1 of 1 milk reT,I MIMI• - , FA t1 � }?"L - 9Kaa '� 'SSR � .� � r �" � S.y� F^ � �'n., 6� .•� i•: t ^t'F.P y442'i • 4 a ` vkY..kt �'z F�•{y�f��y-'.J � s � F `��,'-:'::_ r �,! �'..: It� t Fir r •a� qt� � dr �• f �;h �a�. y� �F �,�,�v . 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Datum NAD83, Roads Meters tData Sources:The data for this map ms produced by Merrimack 1 Easements AORTN Valley Planning Commission(MVPC)using data provided by the Tom of '60 North And r.Additional data provided by the Executive Office at C3 MVPC Boundary .,'a rnvironmenteal Affairs(MassGIS.The information depicted on this map is El r legal boundary Parcels - for planning e purposes adequate• �NORTH .. VER MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING 4t THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF • OF •• DOES NOT INFORMATIONASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS 19 �. �. rY SE'TTL'ED vac • F LE COPY North Andover Health Department (ommunity Development Division July 1, 2014 Douglas J. Smith, R.S. Soil Smith Designs 15 Foxberry Drive New Boston,NH 03070 Re: 121 Farnum Street (Map107A, Lot 59) Dear Mr. Smith: The proposed wastewater system design plan for the above site dated June 1, 2014 and received on June 9, 2014 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item. 1. Please correct the address of the project site from Farnum Road to Farnum Street. A The plan was stamped but not signed by the designer(3 10 CMR 15.220(4). 1�kOn sheet 1 of 2,please sign and date the survey statement(NA 3.2). Please indicate that all system components shall be marked with magnetic tape (3 10 CMR 15.221(11). Please specify that the building sewer line shall have watertight joints and be laid on a compact firm base (3 10 CMR 15.222(5). lease specify the required annual maintenance for the effluent filter(3 10 CMR 5.227(7). Please indicate that the septic tank and.distribution box shall be made watertight(3 10 CMR 15.221(1). Buoyancy calculations are required for the septic tank and pump chamber(3 10 CMR r. 15.221(8). It appears the inlet and outlet invert elevations of the septic tank and pump chamber are less than 12" above the seasonal high ground water table. Based on the existing grade of ,Q`G approximately 100.5' and an ESHWT of 30",the ESHWT elevation is approximately 98.0'. A Local Upgrade Approval is required(3 10 CMR 15.227(5). Tease indicate the flow back volume of the force main pipe (3 10 CMR 15.231(2). Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 I 1/T�he p parameters appear to be at the end of the pump performance curve. You may /Y wish to consider re-sizing the pump based on the parameters. Please indicate the size and material of the access covers above the septic tank and pump chamber. 'Please specify the sand fill specifications in the leach field (3 10 CMR 15.255(1). 14. Please indicate that the Bw layer is proposed to remain in place. Sheet 1 of 2, indicates the removal of the subsoil layer in the "Typical End Cross Section" detail. On sheet 1 of 2,please indicate the scale for the site plan view. On sheet 1 of 2,the proposed contour lines are not labeled. In addition, please confirm the breakout elevation on the high side of the leach field is met with the proposed finish grades. On sheet 1 of 2, the septic tank outlet elevation is incorrect. 8. On sheet 1 of 2, the pump chamber outlet elevation appears to be higher than the knockout of the outlet side of the tank. Although not required, it is preferred to use the knockout instead of boring a hole into the tank. 9. On sheet 1 of 2,the distribution box outlet invert is too low for a minimum I% slope - m the leach field to the distribution box: Please modify this accordingly. 20 Please indicate the breakout elevation on the high side (104.09') of the leach as well as the low side (103.90'). 2 lease indicate if the proposed pump chambers H-10 H-20 loading tank. 2. On sheet 2 of 2, the elevatio s the leach field an ESHWT are not graphically depicted correcting on the profile view and the tanks do not have adequate cover material proposed above them. You may wish to use different line types to distinguish between the existing and finish grade lines. Please indicate design ESHWT on the design plan. It appears to be 98.9'. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincere , Su`an Y. Sawyer, H,/�RSS 1` Public Health Director cc: Paul Hutchins Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 } � 1 fAli 2Ai 3 j o-44 '4/ ? TLS ' Z.5 alb 64 �Z Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd,where full compliance, as defined in 310 CMR 15.404(1), is not feasible. System upgrades that cannot b6 performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.415. NOTE:Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. A. Facility Information Important: When filling out 1. Facility Name and Address: forms on the computer,use Paul Hutchins only the tab key Name to move your 121 Famum Street cursor-do not Street Address use the return key. North Andover Ma 01845 City/Town State Zip Code rub I� 2. Owner Name and Address(if different from above): Name Street Address City/Town State k Zip Code Telephone Number r RECEIVED t 3. Type of Facility(check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School JUL 102014 4. Describe Facility: L_?HWEN OF NORTH ANDOVER .LTH DEPARTMENT 3 bedroom house 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): i" stone and pipe field I i upgrade NORTH ANDOVER FARNUM-rev.7/06 Application for Local Upgrade pgrade Approval• Page 1 of 4 J rf I Commonwealth of Massachusetts City/Town of North Andover v o Form 9A — Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: 330 gpd Design flow of proposed upgraded system 330 gpd Design flow of facility: 330 gpd B. Proposed Upgrade of System 1. Proposed upgrade is(check one): ® Voluntary ❑ Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: date of inspection 2. Describe the proposed upgrade to the system: a 1500 gallon tank, 1000 gallon pump chamber+stone and pipe system 3. Local Upgrade Approval is requested for(check all that apply): ❑ Reduction in setback(s)—describe reductions: ❑ Reduction in SAS area of up to 25%: sas size,sq.ft. %reduction ® Reduction in separation between the SAS and high groundwater: Separation reduction 1' ft. Percolation rate 8 min/inch min./inch Depth to groundwater 30" ft. upgrade NORTH ANDOVER FARNUM•rev.7/06 Application for Local Upgrade Approval* Page 2 of 4 Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): Reduction of 12-inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test ❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation,an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by: Doug Smith 5-14-2014 Evaluator's Name(type or print) Signature Date of evaluation C. Explanation Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: The plumbing out of house cannot change therefore the 12"seperation to outlet tees is necessary 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: costrohibitiv p eon this site upgrade NORTH ANDOVER FARNUM•rev.7/06 Application for Local Upgrade Approval* Page 3 of 4 1 Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval G M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: not possibile 4. Connection to a public sewer is not feasible: muncipal sewer is not available 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ® Application for Disposal System Construction Permit ® Complete plans and specifications ® Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other(List): D. Certification "l,the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for deliberate violations." Cpl 7 Facility Owner' ignature Date (' Paul+49athy Hutchins v Print Name Doug Smith July 9. 2014 Name of Preparer Date 15 Foxberry Dr. New Boston Preparer's address City/Town NH 03070 603 487 2298 State2lP Code Telephone upgrade NORTH ANDOVER FARNUM•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4 Blackburn, Lisa From: Isaac Rowe <irowe@mill riverconsulting.com> Sent: Tuesday,July 01, 2014 3:42 PM To: Blackburn, Lisa;Sawyer, Susan Cc: 'Pam Lally'; 'Isaac Rowe' Subject: RE: 121 Farnum Rd. Attachments: 121 Farnum Street- Disapproval Letter 7-1-14.doc Susan/Lisa, Attached is the disapproval letter for the above referenced property. Unfortunately there are a lot of mistakes and the plan is difficult to read. Please let me know if you would like to review further. I tried to limit the number of comments a little by combining some.... . . Thanks, Isaac M. Rowe, R.S. Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930-2719 Phone:978-282-0014 ext.804. Fax:978-282-1318 irowe@millriverconsulting.com www.millriverconsulting.com -----Original Message----- From Blackburn, Lisa [mailto:LBlackburn@townofnorthandover.com] Sent: Monday,June 09,20141;09 PM To: Isaac Rowe (irowe@millriverconsulting:coin) Subject: 121 Farnum Rd. Good Afternoon, Hope you had a great weekend! Attached is paperwork for a septic plan review for 121 Farnum Rd. -----Original Message----- From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Monday,June 09, 2014 1:13 PM To: Blackburn, Lisa Subject: Message from "ComDev-Health-Ricoh" This E-mail was sent from "ComDev-Health-Ricoh" (Aficio MP C3002). Scan Date:06.09.2014 13:13:09 (-0400) Queries to: noreply@.townofnorthandover.com ;y,. Of 4NOR4.,y 681 8 . O ti:a�.f`.o; .• Lp • Town of North Andover HEALTH DEPARTMENT ,SSACMU5�4 CHECK#: DATE: CQ LOCATION: Y nunA H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer a �ce�K1:R�,r/dam TOWN OF NORTH ANDOVER " Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENTy>q < 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER,MASSACHUSETTS 01845 978.688.9540-Phone Susan Y.Sawyer,REHS/RS 978.688.8476-FAX Public Health Director E-MAIL:healthde t towner encom _ WEBSITE:http://www.towno71orth ED SEPTIC PLAN SUBMITTAL FORM 014 ��� �� 2� NDOVERDate of Submission: I `I MENT Site Location: 2 FyiYzhvyvi r`oWo ! L ` v)dDve✓� Engineer: D-0 V n Son (SoiLsy"yiq4') Des 17j✓l S J} New Plans? Yes �$225/Plan Check#-- (includes 1St submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes I/ No t Local Upgrade Form Included? Yes No Telephone#: O 3> g7 2 29 Fax#: E-mail:_ 1 L5vy)&La 60L- — c o✓v) Homeowner Name: � V� O V i-c� .)n S z �1yw-n �_Q� OFFICE USE ONLY When the submission is complete(including check): ➢ i/ Date stamp plans and letter ➢ 1/ Complete and attach Receipt ➢ 1/ Copy File; Forward to Consultant ➢ y1 Enter on Log Sheet and Database Mn al RECEIVE, Commonwealth of Massachusetts City/Town of North Andover i JUN ', P 'L'A F Form 11 - Soil Suitability Assessment for On-Site Sewage Disp l ' a Al OF NORTH Ea LTH DEPARTMENT MassDEP has provided this form for use by on-site professionals and local Boards of Health..Other forms may be used, but the information must be substantially the same as provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information Paul Hutchins Owner Name 121 Farnum Rd. map 107-A Lot 59 Street Address Map/Lot# North Andover Ma 01845 City State Zip Code B. Site Information 1. (Check one) ❑ New Construction ® Upgrade ❑ Repair 2. Published Soil Survey Available? ® Yes r7 No soil 2014 421-b No If yes: Year Published Publication Scale Soil Map Unit Canton Soil Name Soil Limitations 3. Surficial Geological Report Available? ❑ Yes ® No If yes: Year Published Publication Scale Map Unit till Geologic Material Landform 4. Flood Rate Insurance Map Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ® No Within the 500-year flood boundary? ❑. Yes ® No Within a velocity zone? ❑ Yes ❑ No 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name north andover farnum•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8 -C--\ Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal B. Site Information (Continued) 6. Current Water Resource Conditions (USGS): June 14, Range: ❑ Above Normal ® Normal ❑ Below Normal 2014 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: 1 June 14, 2014 11:30 sunny Date Time Weather 1. Location Ground Elevation at Surface of Hole: 102.13 Location (identify on plan): 2. Land Use house lot 4 % (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) grass Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body none Drainage Way none possible Wet Area none feet feet feet Property Line 45-1 feet Drinking Water Well NE feet Other feet 4. Parent Material: till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ® Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 54" 57" 5. Groundwater Observed: ® Yes [1 No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 30" 99.63' inches elevation north andover farnum•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal r' C. On-Site Review (Continued) Deep Observation Hole Number: 1 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist Munsell USDA Structure Consistence Other y (Munsell) Depth Color Percent (USDA) Gravel Cobbles& (Moist) Stones 0 16" fill 16"-22" A 10YR2/2 SANDY granular friable loam 22"-32" B 10YR 4/6 30" 10YR5/8 5% fine sandy granular friable loam 32"-64" C 2.5Y4/4 loamy sand Additional Notes: north andover farnum-rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 �C_\' Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal y C. On-Site Review (Continued) Deep Observation Hole Number: 2 May 14, 2014 11:45 sunnyDate Time Weather 1. Location Ground Elevation at Surface of Hole: 101.40 Location (identify on plan): 2, Land Use house lot none 4% (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) grass Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body none Drainage Way none possible Wet Area none feet feet feet Property Line feet Drinking Water Well Nonefeet Other feet 4. Parent Material: till Unsuitable Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 57" 60" 5. Groundwater Observed: ® Yes ❑ NO If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 30" 98.90 inches elevation north andover farnum•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 Commonwealth of Massachusetts City/Town of North Andover R Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 2 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist Munsell (USDA) Structure Consistence Other y (Munsell) Depth Color Percent ) Gravel Cobbles& (Moist) Stones 0-6" A 10YR 3/2 loamy granular friable 6"-22" B 10YR5/6 sandy granular friable loam 22"-60" C 2.5Y5/6 30" 7.5YR5/6 5% loamy 20% sand Additional Notes: north andover farnum•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal Page 5 of 8 . Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal r D. Determination of High Groundwater Elevation 1. Method Used: ❑ Depth observed standing water in observation hole A. B. inches inches ❑ Depth weeping from side of observation hole A. B. inches inches ® Depth to soil redoximorphic features (mottles) A. #30" B. 30" inches inches ❑ Groundwater adjustment(USGS methodology) A. B. inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed? Upper boundary: inches Lower boundary: inches north andover farnum•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 <C\1 Commonwealth of Massachusetts City/Town of North Andover F Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal B. Site Information (Continued) 6. Current Water Resource Conditions (USGS): June 14, Range: ❑ Above Normal ® Normal ❑ Below Normal 2014 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: 3 June 14, 2014 12:00 sunny Date Time Weather 1. Location Ground Elevation at Surface of Hole: 100.25 Location (identify on plan): 2. Land Use house lot 4 % (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) grass Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body none Drainage Way none Possible Wet Area none feet feet feet 11 Property Line Bet Drinking Water Well NONE. Other feet 4. Parent Material: till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ® Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 66" 5. Groundwater Observed: ® Yes [:1 No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 30" 97.75' inches elevation north andover farnum 3 4•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8 Commonwealth of Massachusetts City/Town of North Andover A Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal r"( C. On-Site Review (Continued) Deep Observation Hole Number: 3 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist Munsell (USDA) Structure Consistence Other (Munsell) Depth Color Percent ) Gravel Cobbles 8 (Moist) Stones 0 44" fill 44"-55" A 10YR 3/2 SANDY granular friable loam 55"-82" C 2.5Y6/3 30" 10YR5/8 15% fine sandy granular friable loam Additional Notes: north andover farnum 3 4•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts City/-rown of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 4 May 14, 2014 12:30 sunnyDate Time Weather 1. Location Ground Elevation at Surface of Hole: 101.40 Location (identify on plan): 2. Land Use house lot none 4% (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) grass Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body none Drainage Way none Possible Wet Area none feet feet feet , Property Line feet Drinking Water Well Nonefeet Other feet 4. Parent Material: till Unsuitable Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 67" 76" 5. Groundwater Observed: ® Yes [:1 No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 30" 98.90 inches elevation north andover farnum 3 4•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 �L\_ Commonwealth of Massachusetts City/Town of North Andover F Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 4 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist Munsell USDA Structure Consistence Other y (Munsell) Depth Color Percent ( ) Gravel Cobbles&Stones (Moist) 0-20" Fill 20"-27" A 10YR3/3 sandy granular friable loam 27"-43' B 10YR4/4 30" 7.5YR5/6 5% loamy sand 43"-82" C 2.5Y6/4 loamysand20% Additional Notes: I north andover farnum 3 4•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal y` D. Determination of High Groundwater Elevation 1. Method Used: ❑ Depth observed standing water in observation hole A. B. inches inches ❑ Depth weeping from side of observation hole A. B. inches inches ® Depth to soil redoximorphic features (mottles) A. # 30" B. 30" inches inches ❑ Groundwater adjustment(USGS methodology) A. B. inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed? Upper boundary: inches Lower boundary: inches north andover farnum 3 4•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 ` Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal a. B. Site Information (Continued) 6. Current Water Resource Conditions(USGS): June 14, Range: ❑ Above Normal ® Normal ❑ Below Normal 2014 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: 5 June 14, 2014 1:00 sunny Date Time Weather 1. Location Ground Elevation at Surface of Hole: 101.90 Location (identify on plan): 2. Land Use house lot 4 % (e.g.,woodland, agricultural field,vacant lot,etc.) Surface Stones Slope(%) grass Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body none Drainage Way none Possible Wet Area none feet feet feet Property Line 50 Drinking Water Well NONE Other feet feet feet 4. Parent Material: till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ® Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ® Yes ❑ No If yes: 64" 72" Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 30" 99.63 inches elevation north andover farnum 5•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal -Page 2 of 8 t �L\. Commonwealth of Massachusetts ` City/Town of North Andover a Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 5 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist Munsell (USDA) Structure Consistence Other y (Munsell) Depth Color Percent ) Gravel Cobbles&Stones (Moist) 0-24" fill 24"-38" A 10YR 3/3 SANDY granular friable loam 38"-60" B 10YR5/6 30" 10YR5/8 15% fine sandy friable loam 60-77" C 2.5Y6/4 loamy sand Additional Notes: north andover farnum 5•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts City/Town of North Andover Jr. Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. May 14, 2014 Signature of S6nvaluator Date Doug Smith se2267 Nov 11, 1999 Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam Isaac Rowe North Andover Name of Board of Health Witness Board of Health Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. north andover farnum•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8 Commonwealth of Massachusetts City/Town of North Andover r Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Field Diagrams Use this sheet for field diagrams: I north andover farnum•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 8 of 8 r Commonwealth of Massachusetts City/Town of North Andover p Percolation Test Form 12 M Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage .Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. Important: A. Site Information When filling out forms on the computer,use Paul Hutchins only the tab key Owner Name to move your 121 Farnum Rd cursor-do not Street Address or Lot# use the return key. North Andover Ma 01845 CitylTown State Zip Code tab Contact Person(if different from Owner) Telephone Number B. Test Res u its 5-14-2014 1:07 Date Time Date Time Observation Hole# P-1 Depth of Perc P 40" Start Pre-Soak 1:07 End Pre-Soak 128 Time at 12" 128 Time at 9" 1:48 I Time at 6" 2.12 Time(9"-6") 24/3= .8 MIN PER INCH Rate(Min.11nch) 8 min/inch Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ Doug Smith Test Performed By: Isaac Rowe BOH North Andover Witnessed By: Comments: t5forrn12.doc•06/03 Perc Test•Page 1 of 1 I Add ress//.r C NIC-ym S Title of File page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and nates. action Document/ document/ Num.— Action Department Board of Appeals - Board of Health - Planniing Board - Conservatiion Commission - Building Department GF 3� f . a . IOHM U TOWN OF NOR111 ANDOVER LUT RELEASE FUM t • "I SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS ASSIGNED BY D.P.W. STREET tZ-d � APPLICANT '�,J'T-t4k tJ S PHONE 3 DATE OF APPLICATION TOWN USE BELOW 1'1115 LINE PLANNING BOARD DATE' APPROVED TOWN PLANNER DATE REJECTED CONSERVATION COMMISSION DA11: APPROVEID CONSERVATION ADMIN. DAI'E REJECTED j BOARD OF HEALTH DATE APPItcJ E11) 4 iro�g EAL7 SANITARIAN DATE REJECTED --- DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. i RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Plannlug and llenl.th Bornrdn, the Conservation Commission prior to Che issuance of any buildtlig permlts for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town .requirement or Bylaw. 1 I Lowell, Ralph APPLICATION FOR SEWAGE DISPOSAL INT'ALIATI/OsoN HEALTH DEPARTMENT - NORTH ANDOVER, KSS. I hereby make aRlicaUpn for a permit for a sewage disposal installation at / / .• -.t--- I will install this system in ac- cordance with all the laws of the Commonwealth of Nhssachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 21a. I will install a con- crete septic tank of 1000 gal. in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro vide a minimum of 180 lineal (NgyM) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia. ) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the _inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DA TE atur� of�p�alira t I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts, DATE 3 (e g gnature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE— 7 3 Signature o specting Officer Percolation Test 4 min. A _ Garbage Grinderh . i November 3, 1962 Miss Mary Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear IG7iss Sheridan: �C An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage on the proposed Farnum Street building site of Ralph D. Powell. ,The land in general is high. The subsoil in the area was of sandy clay content and a 4-minute percolation test was conducted. It is recommended that a 1,000 gallon concrete septic tank be installed together with 180 lineal feet of drain pipe. Very truly yours, William J. Driscoll WJD:hd I lilp yL, •` ! �, � J, . BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. t _ � L prig f 1. NAME .� i�l-:�.. �. . V. �,..... . . . . . . DATE 2. ADDRESS .! .�`':' '�":`';` . LOT NO. TEL* . 3. NO. OF EEDROOIJ5 DEN YES . . . . . N0. 4. GARBAGE GRIIMER YES . NO..,. 5. SHOW DIIJENSIONS OF HOUSE b. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINdES 7, SHOW DIIAENIOM OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTAD?CE OF WELL FROT:I SEGJERAGE SYSTEM �a 10. SHOW LOCATION OF BROOKS, STRE LB0 DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATION SHOULD EE READ CAREFULLY. ', MUGFORD ENTERPRISES INC. DBA:John Zanni Pumping Co. DBA: Mugford Brothers Construction P.O.BOX 4 READING,MA 01867 Phone:781-944-0149 R�C�Ia��D Fax:978-475-3520 JAN 16 2007 December 19, 2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Town of North Andover Health Department Town Hall North Andover,Ma 01845 Gentlemen: Enclosed please find System Pumping Records. If you have any questions,please call this office. Very truly yours, John Zanni Pumping Co. Debbie Mugford - J I Commonwealth of Massachusetts RECEIVED -- � City/Town of NORTH ANDOVER MASSAGHU TTS System Pumping Record 200 Form 4 TOWN OF NORTH ANDOVER " HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer, use only the tab key Address to move your d /9 aj e d 1,C- cursor-do not use the return City/Town State Zip Code key. 2. System Owner: — _ s nt /-/- IC4 IN�, Name --- — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping p g Date 2. Quantity Pumped: Gauons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes EN No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Nam Vehicle License Number Ya� '-, ' 4 /aj a- Location where contents were disposed: Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5fomt4.doc•06!03 System Pumping Record•Page 1 of 1