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Home My WebLink AboutMiscellaneous - 127 VEST WAY 4/30/2018 (2)I - z O � � � 0 LLz -j LU Q � a kk\) meee \\{p 0o« % a SG \ \@ 0 CL- /\\k 3R oa000 /])]]} ƒJ23 ) ± 0-000 Y m \ U) �$\Ja k Vim§/& t,E=m = K \ k» < /a/ 2 a)cn ]I3{f � R 2 LLI Ro q §\ / 04 SE 0= \§ \ e e / $0 ƒ g/ate/ eII 2 2 a) \ 2 « L ry# k \ �® ® IL 0 0 ®GjL� U O22 )))]§\\\)2 ƒ mmmmo 0U)< » �� 00 cu k = \\ CN 0)� _� eek\ 22 0 Lo LLEE V) co ƒ\o zFF b2$ =m Q eke �) #.. a CL O a�e< A) a§) 5 a _ =®<7 o� 2�tt2 ) 9Q/£ a) moo coj/&/ °x-- [@£a/ _2E0_ ƒ k 2 0 � � �� \ \ U O )) p\ \§ � m c� z O � � � 0 LLz -j LU Q � a kk\) meee \\{p 0o« p G ¥ ) o \ \ )a a /<k <Eo 6e-0 »E zf§«$a o�== $3J) w2mo0o<< = k RS 3 gG G z \2 n &200 \ & 0 7 F- §�§§ � k� \ °<°<§?~ @ c < c < 32.0E o 0 LL -a §�7ao8 5 L \CL70 c §tc 5 2 I=<:/ E¥oola I Lu r-- #CN \ z .. 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M a LU x E§/// \ \\§ § $ G°®®«/o) (D < LU ref/co 223M mt- inco= 8 e=LL=w=yw MM< a /Ncƒ j $o -z LL % 7/ ƒ8 U-7 2 \ 3 4 2 [ % % ( § u CL ƒ )�CL eam F- 0 CL- /\\k /])]]} ƒJ23 ) ± m£ i\ Y m U) LL % 7/ ƒ8 U-7 2 \ 3 4 2 [ % m£ i\ cc) U) )\ LL % 7/ ƒ8 U-7 2 \ 3 4 2 [ d 7 vp"�wcu� , of North Andover — Septic Svstem - AS -BUILT 1) All changes to the design plan have been reflected and noted on the as -built plan 2) / As -built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans) 3) Street Address, Assessor's Map and Lot Number 4) Lot Lines and Location of Dwellings served by the system 5) " Locations, Elevations and Dimensions of As -built system components, including reserve (if applicable) 6) Ties to all tank openings, d -box, and leach area from dwelling or Permanent Structure Setback distances are shown on the as -built plan from system components to: Subsurface, interceptor & foundation drains Catch basins Property lines Dwellings or other structures Private water supply or irrigation wells Watercourses or wetlands 8) /Locations of Wells, Drains, Wetland Resource Areas within 150 feet of system 9) --"� Location of water, gas, electric lines, cable, control panel (if applicable) 10) Location of Structures within 6 Inches of Finished Grade 11) �riginal Stamp & Signature 12) --4 cation and holder of any easements which could impact the system 13) Impervious Areas; Driveways, etc 14) i—North Arrow 15) Location & Elevation of Benchmark used 16) 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." Signature of Designer Date b. "If a STUCTURAL WALL IS PRESENT (NA 4.9) a Letter or statement on the as -built indicating the wall -was or was not constructed in accordance with the intended design and an v manufacturer's specifications." Signature of Designer Date As of: Tuesday, March 17, 2015 CO �9SSA c H lIS��C PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: November 22, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Full Repair of the On -Site Sewage Disposal System The By: John T. Shaw, III At: 127 Vest Way Map 104.B Lot 158 North Andover, MA 01845 of this certify sjWl not be construed as a guarantee that the system will function satisfactorily. LaGrv(sse `CEH7 r of Public Health 120 Main St., North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.9542 Web www.northandoverma.gov i NORTy qti 5 ��SSA C HUS North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 127 Vest Way MAP: 104.13 LOT: 0033 INSTALLER: John Shaw Wildwood Excavation Inc. jtshaw3@gmail.com DESIGNER: Joseph Serwatka PLAN DATE: 11/17/2016 final revision 7/26/2017 received on July 28, 2017 BOH APPROVAL DATE ON PLAN: 8/10/2017 INSPECTIONS TANK INSPECTION: 10/6/2017 DATE OF BED BOTTOM INSPECTION: 10/5/2017 DATE OF FINAL CONSTRUCTION INSPECTION: 10/18/2017 DATE OF FINAL GRADE INSPECTION: 10/23/2017 SITE CONDITIONS Comments: SEPTIC TANK ® Contractor reports any changes to design plan ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered ® Building sewer in continuous grade, on compacted firm base ® Cleanouts per plan ® 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 ® Outlet tee installed, centered under access port (gas baffle/effluent filter) ® 24" inch cover to within 6" of finish grade installed over one access port ® Neoprene boots around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 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 >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: s SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, 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 header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan N/A Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: Added vent to the leach field. Sand in trench - good per B. LaGrasse 45 x 30 SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ® Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ® Number of chambers per row: 7 ® Number of rows (trenches): 6 Comments: Total Chambers = 42 FINAL GRADE ® Loamed ® Seeded ® Cover per plan Comments: looks great per Michele Grant DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer y ❑ As -Built Plan Setup#1 BM = 100.00 HR = 0.74 HI = 100.74 SYSTEM ELEVATIONS Setup#2 BM = 93.00 HR= 1.86 HI = 94.86 ROD ELEVATION AS -BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Setup #1 Building Sewer OUT 3.72 96.67 96.45 Septic Tank IN 4.08 96.31 96.25 Septic Tank OUT 4.41 95.98 96.00 Pump Chamber IN Pump Chamber OUT Setup #2 Distribution Box IN 3.43 91.08 91.00 Distribution Box OUT 3.65 90.86 90.83 Lateral 1 TOP 3.78 Lateral 1 INVERT 90.73 90.78 Lateral 2 TOP 3.78 Lateral 2 INVERT 90.73 90.78 Lateral 3 TOP 3.78 Lateral 3 INVERT 90.73 90.78 Lateral 4 TOP 3.78 Lateral 4 INVERT 90.73 90.78 Lateral 5 TOP 3.78 Lateral 5 INVERT 90.73 90.78 Lateral 6 TOP 3.78 Lateral 6 INVERT 90.73 90.78 Lateral 7 TOP 3.78 Lateral 7 INVERT 90.73 90.78 Top of Chamber 91.2 91.2 Bottom of Bed/Chamber 90.5 90.5 i SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ® Wetlands bordering surface water supply or trib. (in Watershed) 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 ' Suction line 222(2) 2 100 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 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). 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 NOV 14 2011 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT PUBUC HEALTH DEPARTMENT Community I Economic Development TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( } constructed; (} repaired; By: ��9•y �Sl�ci J (Print Name) Located at:9 �2 Ile 5--/- &,� 4, (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated At -,.0 e/ / % 4�5 and last revised on —r: X G o� 6� , with a design flow of - gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310_ CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: 1,9 Z?�W9- fes. And — Print Name Final Construction Inspection Date:_ 17 And — Print Name Engineer Installer: SL,� �� '! (Signature) Date: 2,;g 7 / Engineer: And --- Print Name Date: And — Print Name 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov August 10, 2017 Joseph A. Marino 127 Vest Way North Andover, MA 01845 North Andover Health Department (ommunity and Economic Development Division FILE 8to& Re: Subsurface Sewage Disposal System Plan for 127 Vest Way (Map 104B, Lot 3313) Dear Mr. Marino: The proposed wastewater system design plan for the above site dated November 17, 2016 with a final revision date of July 26, 2017 and received on July 28, 2017 has been approved. The Health Department has granted a variance to the bordering vegetated wetland setback of 100' down to 50'. The design plan has been approved for use in the construction of a new on-site septic system for a 4 -bedroom (max 9 -room) home utilizing an Infiltrator Quick 4 Plus Standard LP Chamber system. This design plan approval is valid until August 10, 2020. 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. 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)) Page 1 of 2 North Andover Health Department, 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 y.' J / 127 Vest Way August 10, 2017 k- I- 2. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely w B an J. LaGrasse, CEHT Director of Public Health Encl. Installers list cc: Joseph J. Serwatka, P.E. PO Box 1016, North Andover, MA 01845 File Page 2 of 2 North Andover Health Department, 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 TOWN OF NORTH ANDOVER ' Community & Economic Development HEALTH DEPARTMENT 120 Main Street NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 - Phone 978.688.9542- FAX E-MAIL: healthdept@northandoverma.gov WEBSITE: h_q://www.northandoverma.gov SEPTIC PLAN SUBMITTAL FORM REQ OWED 11 Date of Submission: - 2� 20 �pViR Site Location: 12--) Engineer: Toe- 5e(- o,1 1� Q. New Plans? Yes $275/Plan Check # (includes 1St submission and one re- review only) Revised Plans?Yes )/'S125/Plan Check # 113 Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes No Telephone #: 9 % 8 ' 3 73 / Fax #: E-mail: UQ a P -r Homeowner Name: J O Sep 7 //-�. 1" 2 . /-/ 1--) D OFFICE USE ONLY When the submission is complete (including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt ➢ IV/ Copy File; Forward to Consultant ➢ _\Enter on Log Sheet and Database 7/24/2017 Town of North Andover Mail - Fwd: Fwd: 127 vest way NO OVER Michele Grant <m rant northandoverm > Massachusetts �� Fwd: Fwd: 127 vest way 1 message Jennifer Hughes <jhughes@northandoverma.gov> Mon, Jul 24, 2017 at 1:51 PM To: Michele Grant <mgrant@northandoverma.gov>, Brian LaGrasse <blagrasse@northandoverma.gov> See below. Jennifer A. Hughes �l Conservation Administrator Town of North Andover 120 Main Street North Andover, MA 01845 Phone 978.688.9530 Fax 978.688.9542 Email jhughes@northandoverma.gov Web www.northandoverma.gov ---------- Forwarded message ---------- From: JOSEPH SERWATKA <joeserwatka@comcast.net> Date: Mon, Jul 24, 2017 at 1:48 PM Subject: Re: Fwd: 127 vest way To: Jennifer Hughes <jhughes@northandoverma.gov> Jennifer: the existing system has been flooded for the year that I have been involved with the site. it is failing, and this is a . voluntary upgrade by the homeowner. I am guessing the old system is the original, and it has reached the end of its usefulness. the board of health approved the plan, as I mentioned in the meeting. after I added the erosion control line, they considered it a change, and asked that I submit the plan for review. I mentioned this in the meeting. I wanted to make sure you, or DEP, had no further changes to the plan before I re -submit to board of health. I will do that this week. as I mentioned, the only change was adding the erosion control line, so I see no issues with them. joe https://mail.google.com/mail/u/0/?ui=2&ik=d4458df3d9&jsver-H FKfDbXmXEw.en.&view=pt&search=inbox&th=l 505ba50ceOdea 1 &siml=15d75ba50c... 1/2 7/24/2017 Town of North Andover Mail - Fwd: Fwd: 127 vest way On July 24, 2017 at 1:38 PM Jennifer Hughes <jhughes@northandoverma.gov> wrote: Joe, Would you confirm if this septic replacement is the result of a failed system? Your NO1 does not state that and the WPA regulations vary depending on the reason for the replacement. Also, the Health Dept. (copied on this email) stated they do not have your revised plan that include the erosion controls. I thought you had stated at the meeting that it had been approved? I am trying to get the Order of Conditions drafted for Wednesday and would appreciate it if you would update- me on the status of your filing with Health and the status of the existing system. Thanks. Jennifer A. Hughes Conservation Administrator Town of North Andover 120 Main Street North Andover, MA 01845 Phone 978.688.9530 Fax 978.688.9542 Email jhughes@northandoverma.gov Web www.northandoverma.gov ---------- Forwarded message ---------- From: JOSEPH SERWATKA <joeserwatka@comcast.net> Date: Thu, Jun 8, 2017 at 12:35 PM Subject: 127 vest way To: jhughes@northandoverma.gov All email messages and attached content sent from and to this email account are public records unless qualified as an exemption under the Massachusetts Public Records Law. Visit us online at www.northandoverma.gov. https://mail.google.com/mail/u/0/?ui=2&ik=d4458df3d9&jsver—HFKfDbXmXEw.en.&view=pt&search=inbox&th=15d75ba50ce0dea1 &siml=15d75ba50c... 2/2 Joseph J. Serwatka, P.E. Post Office Box 1016 North Andover, MA 01845 (978)-314-8731 ioeserwatkaAcomcast. net February 25, 2017 Mr. Brian J. LaGrasse, CEHT Director of Public Health North Andover Health Department 120 Main Street North Andover, MA 01845 Re: 127 Vest Way Septic System Plan Revisions Dear Mr. LaGrasse: I am in receipt of your review letter dated December 9, 2016 for the proposed septic system at 127 Vest Way. I offer the following to address your letter: 1. The north arrow has been added to sheet I of 2, as requested. 2. The log for test pit T-6 has been revised based on the Board of Health representative's notes. 3. A note has been added that the existing system should be abandoned per Title 5. 4. A riser has been depicted on the proposed distribution box, as requested. 5. A note has been added to the plan sheet 1 of 2 that the wetlands have been delineated by William Manuell, wetland scientist. I met with the conservation agent, Jennifer Hughes, who requested that a wetland scientist be enlisted to flag the wetlands. 6. The outlet elevation of the septic tank has been revised. 7. The layout of the leach field has been revised to accommodate the required 50 foot setback to the wetlands delineation. The calculations are based on the allowable loading rate of 4.73sf/lf, plus end caps, as allowed by the DEP approval. The design incorporates 7 rows, or 33.1sf/lf, by 25.5 ft, which is 6 chamber lengths plus end caps for a total of 844 sf. The calculations are provided on the plan. 8. Section II(7): A "best feasible replacement area" has been depicted on the plan, as required. Section II(18)a: There is no required training by the Infiltrator company, that I am aware of We have been designing hundreds of septic systems using the infiltrator over the past 10-15 years. Section II(18)c: A certification has been placed on the plan that the design conforms to the Approval, any Company Design Guidance, and 310 CMR 15.000. Section II(18)d: Copies of required materials have been provided to the homeowner along with a certification, which they have been instructed to review, sign and return a copy to the board of health. any questions concerning this letter, please contact me. April 7, 2017 Joseph A. Mar no 127 Vest Way North Andove , MA 01845 North Andover Health Department [ommunity and Economic Development Division Re: Subsurfac Sewage Disposal System Plan for 127 Vest Way (Ma 104B, Lot 33B) Dear Mr. Marino. The proposed waste ater system design plan for the above site da d November 17, 2016 with a final revision date of Nbruary 14, 2017 and received on March , 2017 has been approved. The Health Department granted a variance to the borderi vegetated wetland setback of 100' down to 50'. The design plan has been approved for us e construction of a new on-site septic system for a 4 -bedroom (max 9 -room) home utilizing an Infiltrator Quick 4 Plus Standard LP Chamber system. This design plan approval is valid until April 7, 2020. 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. 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(l)) Page 1 of 2 North Andover Health Department, 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 127 Vest Way April 7, 2017 2. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. 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. Sincerel , Brian J. LaGrasse, CEHT Director of Public Health Encl. Installers list cc: Joseph J. Serwatka, P.E. PO Box 1016, North Andover, MA 01845 File Page 2 of 2 North Andover Health Department, 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.9542 TOWN OF NORTH ANDOVER NORTH ANDOVER, MASSACHUSETTS 01845 Jackie's Law — Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant M iJ p r?C'LtlC. Phone Cell Street Address br I City/Town ,Aq*. ZIP gym sfr�{ A,// o-7wy Name of gxcavator (if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s) of Property ::Teth rj' NU Phone Cell Street Address (2 -� V e S f WAY City/Town MA ZIP Permit Fee Received No Yes Other Contact Description, location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose (include a description of what is (or is intended) to be laid in proposed trench (eg; pipes/cable lines etc..) Please use reverse side if additional space is needed. all of A0'P<r DO 1'° 3 -T--CJ} hdti Insurance Certificate #: Name and Contact Information of Insurer: 5UI N C (_ -Policy Expiration Date: Dig Safe 9: Name of Competent Person (as defined by 520 CMR 7.02): G Massachusetts Hoisting License # #6- 1396 1/6) License Grade:Expiration Z, Date• BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSHA REGULATIONS, G.L. e. 82A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT, INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH, AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE O ^I7 l6 EXCAVATOR SIGNATURE (IF DIFFERENT) DATE OWNER'S SIGNATURE (IF DIFFERENT) DATE: 2 1 P a g e CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the application, the applicant understands and agrees to comply with the following: No trench maybe excavated unless the requirements of sections 40 through 40D of chapter 82, and any accompanying regulations, have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including, but not limited to, the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164 (DIG SAFE); ii. Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws, an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations: 29 CFR 1926.650 et.seq., entitled Subpart P `Excavations". iv. Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; vi. By applying for, accepting and signing this permit, the applicant hereby attests to the following: (1) that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety; (2) that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations: 29 CMR 1926.650 et.seq., entitled Subpart P "Excavations" as well as any other excavation requirements established by this municipality; and (3) that he is aware of and has, with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the permit application, complied with the requirements of sections 40- 40D of chapter 82A. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www.mass.gov/dns 3 1 P a g e CERTIFICATE OF LIABILITY INSURANCE ii;4, 0 5'' ATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES iIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED `4TATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to ns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the .,Cate holder in lieu of such endorsement(s). GER CONTACT Heidi SanSouci N ME: i Insurance Group - Manchester PHONE (603)641-$111 L CN ;(603)641-0222 o a89 Elm 5t E-MAADDRESS: IHeidi.SanSouci@FopInsurance.cam INSURERS AFFORDING COVERAGE NAIC # Manchester NS 03104 INSURER AMerchants Mutual Insurance 23329 INSURED INSURER B: Boraczek Septic & Drain Inc INSURERC: 7 Chisholm Road INSURER D: INSURER E: Kingston NH 03848-3233 INSURER F: COVERAGES CERTIFICATE NUMRER*aster 15/16 oculeinm Rif 11111000. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MWDD1Y POLICY EXP MWD LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: 17 POLICY PRO-JFCT LOC GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINE SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURYPer aoddent $ ( ) PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ —:4EXCESS A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEWMEMBER EXCLUDED? ® (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A I JAMBORACZER EXCLUDED TATE: IVH & MA CA9098749 /10/2015 /10/2016 X WCSTATU OTH- 4RY11M1-L E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1 000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space is required) Town of Andover 36 Bartlett Street Andover, MA 01810 ACORD 25 (2010/05) INSn95 r9mnnst m SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ssa Fini/MMrLIS ©1988-2010 ACORD CORPORATION. All rights reserved. The Anntan nem- --A Inn^ ern ramie}uraA merlre of Annan I DATE(MM/UWY1'►r) CERTIFICATE OF LIABILITY INSURANCE 11/4/2015 ATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ,rS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED DATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. .NT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to ,s and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the ;ate holder In lieu of such endorsement(s). CONTACT Bob 8@8n ,ER NAME: A Insurance Agency LLC PHONE 60FAX (603)926-0283 3 926 3830 ,1 Winnacunnet Road ?.0. Box 660 NH 03843-0660 INSURED Boraczek's Septic a Drain Inc 7 Chisholm Rd E-MAIL bob@beaninsurance.com Indemni Co NAIC Kingston NH [)3848 ^^' c l INSURER F I or-VICInM MI IMRFR_ en, c 1 COVERAGES GCIT 111-ItrA 1 G IYYIYI�Gn.��++ —�— BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH{S INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL UB POLICY NUMBER POLICY EFF POLICY EXP LIMITS MM/DD MM/DD/Y LTR EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY a 3EC4324 100,000 D I S( (Ea 10/30/2015 10/30/2016 PREMISES Ea occurrence) $ A CLAIMS -MADE OCCUR 10, 000 MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,000,000. GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 2,000,000 S ❑ LOC POLICY ❑ PRODUCTS -COMP/OP AGG $ JECTPRO- $ OTHER: COMBINED SINGLE LIMIT $ 1,000,000 AUTOMOBILE LIABILITY Ea accident[ __ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED $ SCHEDULED 70APE001049 10/16/2015 10/16/2016 BODILY INJURY (Peraccident} $ B AUTOS AUTOS NON -OWNED PROPERTY DAMAGE $ Peraccdent HIRED AUTOS AUTOS $ 5,000 MEDICAL PAYMENT UMBRELLA LIAROCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAR DED RETENTION $PER WORKERS COMPENSATION OTH- STATUTE ER E.L. EACH ACCIDENT $ AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N/A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below;a E.L. DISEASE - POLICY LIMIT $ rpaulreen DESCRIPTION OF OPERATIONS / LOCATIUNti r VrnivLra ihwr.0 ru r, ...,�.., .,,a ___._, •.._, __ Town of Andover 36 Bartlett Street Andover, MA 01810 ACORD 25 (2014/01) INS025 r2marrn TION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ISob Bean ©1988-2014 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD 9/29/2016 Town of North Andover Mail - RE: CommDev-Ricoh NORT'HER Lisa Hadge <Ihadge@northandoverma.gov> Massach��r� RE: CommDev-Ricoh 1 message Isaac Rowe <irowe@millriverconsulting.com> Wed, Sep 28, 2016 at 2:36 PM To: Lisa Hadge <Ihadge@northandoverma.gov>, Pam Lally<plally@millriverconsulting.com> Cc: Michele Grant <mgrant@northandoverma.gov>, Brian LaGrasse <blagrasse@northandoverma.gov>, Isaac Rowe <irowe@millriverconsulting.com> Brian/Lisa, Attached are the soil testing results from today. We tried 2 test pits and a perc test in the front yard but the water did not move during the presoak due to very compacted soil. The proposed system will be in the back yard near TP -1 and P-1. This is a sloping site with a lot of areas that have been cut and filled. Joe was trying to put the new system in an area with the most amount of natural soil and least amount of fill but it is a challenging site. Let me know if you have any questions. Thanks, Isaac Rowe Project Manager Ado a• " . MILL RIVER CONSULTING Cit"utty "-�ihidions Pit Land Sk�rirryxn�it 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 www.millriverconsulting.com From: Lisa Hadge [mailto:Ihadge@northandoverma.gov] Sent: Monday, September 19, 2016 11:16 AM https://mail.google.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&th=1577215960d 181 a6&siml=1577215960d 181 a6 1/3 TOWN OF NORTH ANDOVER 'fice of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER, MASSACHUSETTS 01845 OF NORTri 4ti �� o0 m o a. qsq 5 ssgcNUS� 978.688.9540 — Phone 978.688.8476 — FAX healthdept@northandoverma.gov www.northandoverma.gov SEP 19 2016 APPLICATION FOR SOIL TESTS TOWN OF NORTH ANDOVER Q HEALTH DEPARTMENT DATE: % G% lv MAP & PARCEL: /Jo LOCATION OF SOIL TESTS: V25%7r WW OWNER:Q1�/! /J!1 Contact #: _ APPLICANT: !j I -A Contact #: ADDRESS: _% lyz�r Uv y /U 0 l p ENGINEER: 6f'il"GiI�G'Y _ Contact CERTIFIED SOIL EVALUATOR: Intended Use of Land: Residential Subdivision Single Famil Conunercial Is This: Repair Testin� Undeveloped Lot Testing: Upgrade for Addition: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM ➢ Proof of land ownership (Tax bill, or letter from owner permitting test) ➢ 8.5"x 11"Plot plan & Location of Testin_e (please indicate test pit sites on the plan) ➢ Fee of $585.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $440.00 per lot for repairs or upgrades. 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. 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N_ 00 'O 'y fn O U o u c ` N N a) N C U) N N dL L7 on L O mO U LL > d T N L L C f6 0 O U � R U m x aa) 0 H U) _ a 0 U) c w m LL .- U N a) L 0.0 L O £ O Ev U X O Q-' L a m O- O N U O XCC �L C C� n G U O N L O >. — 2 J 0 c - - 00 L O0 Q O i6 (D O Z co O 70 Q 00 1 0) m a Commonwealth of Massachusetts City/Town of North Andover W Percolation Test Form 12 (c 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: When A. Site Information filling out forms on the computer, usa nnly tha tah Marino key to move your Owner Name 10:40 cursor - do not 127 Vest Way Date use the return key. Street Address or Lot # F� Noirth Andover MA r� City/Town State Zip Code Joseph Serwatka 978-314-8731 Contact Person (if different from Owner) Telephone Number B. Test Results Witnessed By: Comments: t5form12.doc• 06/03 Perc Test • Page 1 of 1 8/18/16 10:40 Date Time Date Time T-1 Observation Hole # 33(20) total 53" Depth of Perc 10:40 Start Pre -Soak 10:55 End Pre -Soak 10:55 Time at 12" 11:22 Time at 9" 12:08 Time at 6" 46 Time (9"-6") _ 15.3 Rate (Min./Inch) Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ Joseph Serwatka Test Performed By: Isaac Rowe Witnessed By: Comments: t5form12.doc• 06/03 Perc Test • Page 1 of 1 TOWN OF NORTH ANDOVER ' S�Fo, •. Office of COMMUNITY DEVELOPMENT AND SERVICES ' HEALTH DEPARTMENT 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 — Phone 978.688.8476 — FAX healthdept@nortbandovermaiRECEIVED www.northandoverma.gov APPLICATION FOR SOIL TESTS AUG 0 8 2016 TOWN OF NORTH ANDOVER DATE: �` rO MAP & PARCEL: /b �f %aj / /,(J HEILTH DEPARTMENT LOCATION OF SOIL TESTS: �Z7 V �E � OWNER: 7;�-o / o Contact #: ZOO Dg7 APPLICANT: ' A ` / Contact #: ADDRESS: 12.%1 / ec --ryV 1�5� �O � 4'�2V Ab i 41 ;e ENGINEER: �p—�le-�• Contact #: CERTIFIED SOIL EVALUATOR: T�) Cj Intended Use of Land: Residential Subdivision sjzge mil Home Commercial Is This: Repair Testing: 6 Undeveloped Lot Testing: Upgrade for Addition: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM ➢ Proof of land ownership (Tax bill, or letter from owner permitting test) ➢ 8.5"x 11 "Plot plan & Location of Testing (please indicate test pit sites on the plan) ➢ Fee of $585.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $440.00 per lot for repairs or upgrades. 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: J t Signature of Conservation Agent: ...a VIOAL-1 ^ � �— ,.p I Q -o- qv-� NL �Y\ Date back to Health Department: (stamp in): � , � ro ("\ t;�CL.-C( bu) od� O O • O O N _N � � U N N O 0 o x U o 0 N \ @ m @ U1 co 0 (6 N O_ a m m a aa) w 2 W U S O N LL. o L- 4 o N O O A � U N N o � LL o Z c c e Z n Q— �- Z J J > D m o O Q ~ O U Z O Q o 0 j Q u. m m _ co J co J V Q o� 'L R' U) — Q y V ; M M U y Q 0 0 2 L m m N ao Z 2 In Q m m Q) n ro D a o 0 D O o O O O Q O O d N n � r Uo 0 0 m ro co n U a � o Q J 0 2 C9 4 °a o m �t E p @ m o n. U z U U @ z U o _ `o_ L m . p m y Z m C,4 U d J o O M o O N W O O O h O O O N O LL J U) O co co O M N ro m co a Y 0 o U r' roi Y @ o @ U N N O v @ Q D 04 i U@ T@ .. m N .O O '7 2>> CO d o H> .o Q N C7 0 m m m @ m@@@ 0 ii E m E U) m m m Of Q m Li m LL W� U Q Q m v 0 o m ro 0 w O n U CD u @ LL. co o @ a) N Q N a 10 7 L O E @ Li Q c Q c d.2 «- p n i7 C O .@ J- CL .0 C D Q D Y Lu 0 U a° a° a a � n v N m 0 a w X @ � N N N N LL EE L w c C' a `@ m a oo 0 m m m m F F (7 U o s w m Z O H m LL 2 W 2 m LL. m 00 p N m o d N N 0 0 d O fD @ o O m . Z N 0 o U _@ c c .. a U J o m N a) 0 E f x3 x mF°F° -i MassDEP Online Map Viewer Awy Areas a�'Wetland and Wetland Chang Z 4 r $ g j4; � \ t ,A ,V s yz M 2. 6 t� l� «�AN, ' Ft s� as�� x aCON r = f r f grr 71 $ G� ;'1$, 4- T i W" f' — �Y' •--7 j LZ , t . 1 ! "' � ._ } ��_ I � �.. � ! 8/9/2016 ,{ Town of North Andover Mail - Fwd: CommDev-Ricoh NORT'ti ANDOVER Massachus is Lisa Hadge <lhadge@northandoverma.gov> Fwd: CommDev-Ricoh 1 message Lisa Hadge <Ihadge@northandoverma.gov> Tue, Aug 9, 2016 at 4:37 PM To: Dan Ottenheimer <dano@millriverconsulting.com>, Isaac Rowe<irowe@miliriverconsulting.com>, Pam Lally <plaIly@mi 11 rive rconsulting.com> Cc: Brian LaGrasse <blagrasse@northandoverma.gov>, Michele Grant <mgrant@northandoverma.gov> Please call Joe Serwatka to set up soil testing. Lisa ---------- Forwarded message ---------- From: <spiceworks@northandoverma.gov> Date: Tue, Aug 9, 2016 at 4:35 PM Subject: CommDev-Ricoh To: "Deems, Maura" <mdeems@northandoverma.gov>, "Hadge, Lisa" <Ihadge@northandoverma.gov> This E-mail was sent from "RNP002673C141A2" (MP C4504). Scan Date: 08.09.2016 16:35:01 (-0400) Queries to: spiceworks@northandoverma.gov Lisa Hadge Health Department Town of North Andover 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone 978-688-9540 Fax 978-688-8476 Email Ihadge@northandoverma.gov Web www.northandoverma.gov in 20160809163501808.pdf 1981K https://mail.google.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=sent&th=l 567106317fa8050&sim1=1567106317fa8050 1/1 TOWN OF NOWFI-1 ANDOVER x 4i C'ommunit)• & Economic Development HEALTH DEPARTMENT 120 Main Stred NORTLi ANC7{:)VFR, N-1ASSACNt.1SE-1"1'S 01845 978.688.9510 -- Phone 978.688.9542...... FAX F' -MAIL: healthclcpt@iiorth�aii(lover3ria.-,,ov WEL?_SI,TE:littt)::,,"/Nv%N,w.noi tltanclovveriii�i.(Iov SEPTIC PLAN SUBMITTAL .FORM RECEIVED Date of Submission:._...__..._........ ... _..._.._.._._....._.. DEC .1 2016 Site Location: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT IJngineer:__._____-Q _ ____......__...�`Ti New flans'? Yes i,/ $275/Plan Check it �(iticl ides I" SLibinission and one re- review only) Revised Plans?Yes $125/1'lan Check 11 Site lvaluation Forms Included? Yes No Local Upgrade Form Included? Yes _ _ No /-2 Telephone #:_ l•'ax #: E-mail:_-�� I-lorneowller Name: ._... .__._ 0... .....r�..1........_tt...---..__. _........_ OFFICE USE ONLY When the sub ission is complete (including check): y _ Date stamp plans and letter 4�Complete and attach Receipt Copy File; For«-ard to Consultant. on. Log Sheet and Database North Andover Health Department Community and Economic Development Division December 9, 2016 Joseph Serwatka, P. E. P.O. Box 1016 North Andover, MA 01845 Re: Subsurface Sewage Disposal System Plan for 127 Vest Way (Map 104B, Lot 158) Dear Mr. Serwatka: The proposed wastewater system design plan for the above site dated November 17, 2016 and received on December 2, 2016 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 where applicable. 1. On sheet 1 of 2, the north arrow is missing from the site plan view (3 10 CMR 15.220(4)(g)). 2. On sheet 1 of 2, the test pit log for T-6 does not match the field notes of the Board of Health representative. A copy of the field book notes are attached for reference. 3. A note indicating the proper abandonment for the existing system should be on the design plan (3 10 CMR 15.354). 4. A riser to within 6 inches of finish grade is required above the distribution box if greater than 9 inches below grade (3 10 CMR 15.232(3)(f). 5. On sheet 1 of 2, indicate how the wetland resource area was determined. 6. The outlet elevation of the septic tank is incorrect. 7. The size of the leach field provided (794 so appears to be less than the required (830 so size. Based on the following: Effective length of each chamber = 4' Square footage per chamber = 4' x 4.73 sf/If = 18.92 sf/chamber 6 Rows of 7 chambers = 42 chambers Provided leach field = 42 chambers x 18.92 sf/chamber = 794 sf Required leach field = 830 sf / 18.92 sf/chamber = 43.8 chambers 8. Since the Infiltrator Chamber system is proposed as an alternative soil absorption system the "Standard Conditions for Alternative Soil Absorption Systems with General Use Page 1 of 2 North Andover Health Department, Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688. 9542 1 J.". Certification and/or Approved for Remedial Use" will apply. Please provide the following as required by the approval conditions Section II(7): e) The record drawings, approved by the LAA, must clearly indicate an area for the best feasible replacement system that could be installed in the event that the proposed Alternative Soil Absorption System fails or it is determined that it is not capable of providing equivalent environmental protection; Section II(18): a) proof that the Designer has satisfactorily completed any required training by the Company for the design and installation of the Technology; c) certification by the Designer that the design conforms to the Approval, any Company Design Guidance, and 310 CMR 15.000; and d) a certification, signed by the Owner of record for the property to be served by the Technology, stating that the property Owner: 1. has been provided a copy of the Title 5 IIA technology Approval, the Owner's Manual, and the Operation and Maintenance Manual, and the Owner agrees to comply with all terms and conditions; iii if the design does not provide for the use of garbage grinders, the restriction is understood and accepted; and iv whether or not covered by a warranty, the System Owner understands the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303. Please feel free to contact the office or Mill River Consulting at 978-282-0014 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. Sincer/LaGrasse, l 4 ian CEHT Director of Public Health cc: Joseph Marino File Page 2 of 2 North Andover Health Department, Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688. 9542 12/13/2016 Town of North Andover Mail - RE: 127 Vest Way NORT-HOVER Lisa Hadge <lhadge@northandoverma.gov> MassachAts RE: 127. Vest Way 1 message Isaac Rowe <irowe@millriverconsulting.com> Fri, Dec 9, 2016 at 3:47 PM To: Lisa Hadge <Ihadge@northandoverma.gov>, Pam Lally<plally@millriverconsulting.com> Cc: Michele Grant <mgrant@northandoverma.gov>, Brian LaGrasse <blagrasse@northandoverma.gov>, Isaac Rowe <irowe@millriverconsulting.com> Brian/Lisa, Attached is the disapproval letter for the initial plan review for the above referenced property. The leach field appears to be sized too small based on the calculations. The plan indicated 42 chambers but 44 chambers are required. Let me know if you have any questions. Thanks, Isaac Rowe Project Manager Cm%LL RIVER CONSULTING C117.1riirS01114ifSmf6k 1 jnd 1k%K-atq-11w1A 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 www.millriverconsulting.com From: Lisa Hadge [Mai Ito: Ihadge@northandoverma.gov] Sent: Friday, December 02, 2016 9:37 AM To: Isaac Rowe; Pam Lally https://mail.google.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&th=158e557af279ebca&siml=158e557af279ebca 1/2 Commonwealth of Massachusetts Map -Block -Lot 104.BO158 BOARD OF HEALTH -- Permit No - North Andover�l` COPY - BHP -2017- - - 05 - 68- ----- ----------- FEE $350.00 --------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John -T. -Shaw, -111 ------------------------------------------------------------------------------------ to (Construct) an Individual Sewage Disposal System. atNo --12-7-VEST--WAY ----------------------------------------------------------------------------------------------------------------------------- 5 as shown on the application for Disposal Works Construction Permit No. BBP-2017-056 ,-Vated ...Sept �,mbpK<77�j 017 -------------------- ------ ---- ---- - --- Issued On: Sep -27-2017 AV OF HEALTH ------------------------------------------------- I OF Application for Septic Disposal System Construction Permit — TOWN OF NORTH ANDOVER, MA 01845 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _ I�= 9- a-)-A0/-j TODAY'S DATE $350.00 - Full Repair $175.00 - Component _Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system" [X Repair or replace an existing on-site sewage disposal system* RECEIVED ❑ Repair or replace an existing system component — What? A. Facility Information SEP 2017 J r7 . /.*14 . _ , n ✓ TOWN OF NORTH ANDOVER or Lot # City/Town SEP 2 7 2017 2.- *TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER ➢ ❑ Pump 9 Gravity (choose one) HEALTH DEPARTMENT ***If pump system, attach copy of electrical permit to application*** ➢ ❑ Conventional System (pipe and stone system) ➢ ff Infiltrator or Biodiff user (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S: ➢ ❑ Does the system require an effluent filter? Yeses No If yes, does plan specify make and model of filter? YES = (no further info, needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? 2. Owner Information What is the Model. Name /o? i7 Ur! KT w,4 t/ Address (if different from above) /%/a r o City/Town State Zip Code f-7 706 013'79 Email address Telephone Number 3. Installer Information /j , J �� ,� w�-L / ��OQc��oCC 01J a 14) 0 / �C Name Name of Company Address Cityffown State Zip Code Telephone Number (Cell Phone # if possible please) 4. Designer Information Namecc Name of Company of 'iCe /S,)& /D /6 Address Cityffown State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 • 01111 :A,,,; • Application for Septic Disposal System q a 7 Construction Permit -TOWN OF TODAY'S DATE $350.00 - Full Repair Mo NORTH ANDOVER, MA 01845 $175.00 - Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: Residential 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 North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. me Date I Ztpprov4Y::0 of resentative) ame Date Application Disapproved for the following reasons: For Office Use Only: / 1. Fee Attached? Yes '' No 2. Project Manager Ohligation Form Attached. Yes No 3. Pump S stem? If so, Attach co ofElectrical Permit Yes No Applicantreceived copy of "Electrical Inspection Notes for Septic Systems" Yes Nq�' Handout? 4. Reviewed approvalletter, all paperwork received.? Yes1l No 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) G. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: 61e Wo (Address of septic system) For plans by '10 S Q P "+ e ra-Kq ` 6",-T (Engineer) Relative to the application of `( p 6",- / S� er •/ / (Installer's name) And dated1;_Ft!ff woy / 7 /4 j (Original ate Dated 7 1 (Foday s ate With revisions dated /�/ I'ar, (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 apprr oved 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 reauestinP an insbection. without comaletion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine beim levied against me and/or Inv companT. a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@northandoverma.gov) 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 theinstaller, I understand that only I may perform the work (other than imple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or susuension of my license to ot)erate 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 ofHealth 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 ab -Droved clans. No instructions by the homeowner. _aeneral contractor. or anv other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: ,JG�w S�G_ (Today's Date) (Name — Print ame —Signed) JA • f' 8055 NORTH p Town of North Andover ''•'� HEALTH DEPARTMENT �ss�cNust� CHECK #: 7-2 y3 DATE: ?-),?-;0/? LOCATION: H/O NAME: CONTRACTO NAME: Shia, w (�yi / wo0 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 Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ xSeptic Disposal Works Construction (DWC) $350— ❑Septic Disposal Works Installersl(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ (qje--� Healt gent Initials White - Applicant Yellow - Health Pink - Treasurer I Con-i1'1'1C,t1"14"JE;altr of M'aciar":3ci ui .,;e.tts ' Exectvltttu�i..", Officeof ne Cgy !L& 1--nv;l onrn 1u,8 /�li<?Ir's Department of Environmental Protection One t il" ter 9,,rE'et Boston, MA 02 7 CK3 + lJ Charles D. Baker n Matthew A. Beaton Governor , "b� Secretary Karyn E. Polito / r /% Martin Suuberg Lieutenant Governor /� Commissioner APPROVAL FOR GENERAL USE Pursuant to Title 5, 310 CMR 15.000 Name and Address of Applicant: Infiltrator Water Technologies, LLC. P.O. Box 768 6 Business Park Road Old Saybrook, CT 06475 Trade name of technology and model: High Capacity chamber, High Capacity H-20 chamber', Quick4 High Capacity chamber, Quick4 High Capacity HD chamber, Quick4 Plus High Capacity chamber (8 - inch invert), Quick4 Plus High Capacity chamber (13 -inch invert), Standard chamber, Quick4 Standard chamber, Quick4 Standard HD chamber, Quick4 Plus Standard chamber (5.3 -inch invert), Quick4 Plus Standard chamber (8.0 -inch invert), Quick4 Plus Standard LP (Low Profile) chamber (3.3 -inch invert), Quick4 Plus Standard LP (Low Profile) chamber (8 -inch invert), Infiltrator 3050 (Storm Tech SC -740) chamber, Equalizer 24 chamber, Quick4 Equalizer 24 chamber, Equalizer 36 chamber, Quick4 Equalizer 36 chamber, Quick4 Equalizer 24 LP (Low Profile) chamber (6 inch invert), and Quick4 Equalizer 24 LP (Low Profile) chamber (2 inch invert) (hereinafter the "System"). Schematic drawings of the System and a design and installation manual are a part of this Certification. This approval allows the installation of the above identified chambers without aggregate. Transmittal Number: X259183 Date of Revision: February 19, 2015, modified June 12, 2015 Authority for Issuance Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000, the Department of Environmental Protection hereby issues this Certification to: Infiltrator Water Technologies, LLC., P.O. Box 768, 6 Business Park Road, Old Saybrook, CT 06475 (hereinafter "the Company"), for General Use of the System described herein. The sale, design, installation, and use of the System are conditioned on compliance by the Company, the Designer, the Installer and the System Owner with the terms and conditions set forth below. Any noncompliance with the terms or conditions of this Approval constitutes a violation of 310 CMR 15.000. OJ44r.-, David Ferris, Director Wastewater Management Program Bureau of Water Resources June 12, 2015 Date This information is available in alternate format. Call Michelle Waters-Ekanem, Diversity Director, at 617-292-5751. TTY# Mass Relay Service 1-800-439-2370 MassDEP Webs te. wwwmass gov+dep Printed on Recycied Paper Jt Infiltrator Chamber, Infiltrator Water Technologies. Approval for General Use — June 12, 2015 I. Design Standards The models listed in Table 1 are covered under this Certification. Table 1: Chamber Dimensions Page 2 of 6 Model Dimensions W x L x H Inches Invert Height Inches Equalizer 24 15 x 100 x 11 6 Quick4 Equalizer 24 16 x 48 x 11 6 Quick4 Equalizer 24 LP (6 -inch invert) 16 x 48 x 8 6z Quick4 Equalizer 24 LP (2 -inch invert) 16 x 48 x 8 2 Equalizer 36 22 x 100 x 13.5 6 Quick4 Equalizer 36 22 x 48 x 12 6 Standard Chamber 34 x 75 x 12 6.5 Quick4 Standard 34 x 48 x 12 8 Quick4 Standard HD 34 x 48 x 12 8 Quick4 Plus Standard (5.3 -inch invert) 34 x 48 x 12 5.3 Quick4 Plus Standard (8 -inch invert) 34 x 48 x 12 8 Quick4 Plus Standard LP (3.3 -inch invert) 34 x 48 x 8 3.3 Quick4 Plus Standard LP (8 -inch invert) 34 x 48 x 8 83 Infiltrator 3050 or StortnTech SC -740 51 x 85.4 x 30 22.25" High Capacity Chamber 34 x 75 x 16 11 High Capacity H-20' Chamber 34 x 75 x 16 11 Quick4 High Capacity 34 x 48 x 16 11.5 Quick4 High Capacity HD 34 x 48 x 16 11.5 Quick4 Plus High Capacity (8 -inch invert) 34 x 48 x 14 8 Quick4 Plus High Capacity (13 -inch invert) 34 x 48 x 14 135 This approval allows the use of the high capacity H-20 chambers but makes no determination as to the chambers meeting the H-20 loading requirements. 2 Includes Infiltrator MultiportTM invert adapter attached to the side of the end cap. ' hicludes Quick4 Plus Periscope adapter attached to the top of the Quick4 Plus All -in -One 8 Endcap. 4 Only systems installed with this invert height shall be allowed to use the effective leaching area associated with this model in Table 2. 5 Includes Quick4 Plus Periscope adapter attached to the top of the Quick4 Plus All -in -One 12 Endcap. 2. The System is an open -bottom leaching unit molded from polyolefin resin. It can be installed without aggregate or distribution pipe as an absorption trench or as a bed or field. If the System is installed with stone aggregate then the "Effective Leaching Area" in Tables 2 and 3 is not applicable, and must be designed in accordance with the provisions of 310 CMR 15.000. Infiltrator Chamber, Infiltrator Water Technologies. Approval for General Use — June 12, 2015 Page 3 of 6 The total effective leaching area for any Chamber Model shall be calculated by multiplying the Effective Leaching Area per square foot of chamber times the total length of chamber from end cap to end cap including end caps. For new construction or upgrades, the applicant can size the System in a trench configuration, using the effective leaching areas presented in Table 2. Table 2: Effective Leaching Area in Trench Configuration for New Construction and Remedial Sites' Model Effective Leaching? Area SF/LF Effective Leaching Area SF/LF Equalizer 24 3.76 N/A Quick4 Equalizer 24 3.90 N/A Quick4 Equalizer 24 LP (6 -inch invert) 3.90 N/A Quick4 Equalizer 24 LP (2 -inch invert) 2.78 N/A Equalizer 36 4.73 N/A Quick4 Equalizer 36 4.73 N/A Standard Chamber 6.53 N/A Quick4 Standard 6.96 N/A Quick4 Standard HD 6.96 N/A Quick4 Plus Standard (5.3 -inch invert) 6.20 N/A Quick4 Plus Standard (8 -inch invert) 6.96 N/A Quick4 Plus Standard LP (3.3 -inch invert) 5.65 N/A Quick4 Plus Standard LP (8 -inch -invert) 6.96 N/A Infiltrator 3050 or StormTech SC -740 N/A 6.71 High Capacity Chamber 7.79 N/A High Capacity H-20' Chamber' 7.79 N/A Quick4 High Capacity 7.93 N/A Quick4 High Capacity HD 7.93 N/A Quick4 Plus High Capacity (8 -inch invert) 6.96 N/A Quick4 Plus High Capacity (13 -inch invert) 7.93 N/A 6. Effective April 21, 2006, 310 CMR 15.251(1)(b) maximum trench width is 3 feet. '. Effective leaching area is equal to 1.67 (bottom width + (2x invert height)) for Systems 3 feet or less in width. 8. Effective leaching area is equal to 1.0 (3 + (2x invert Height)) for Systems with a width greater than 3 feet. 9. The maximum trench width allowed to calculate effective leaching area is 3 feet. Systems installed on remedial sites shall be allowed to utilize the effective leaching areas presented in Tables 2 or 3, or additional reductions in soil absorption system may be allowed. In no instance shall the reduction in the soil absorption system required in 310 CMR 15.242 exceed the maximum reduction allowed for alternative systems approved in accordance with 310 CMR 15.284. Infiltrator Chamber, Infiltrator Water Technologies. Approval for General Use — June 12, 2015 Page 4 of 6 6. For new construction or an upgrade, the applicant can size the System in bed or field configuration, using the effective leaching areas presented in Table 3. Table 3: Effective Leaching Area for Bed or Field Configuration New Construction and Remedial Sites Model Effective Leaching10 Area SF/LF Equalizer 24 2.09 Quick4 Equalizer 24 2.23 Quick4 Equalizer 24 LP (6 -inch invert) 2.23 Quick4 Equalizer 24 LP (2 -inch invert) 2.23 Equalizer 36 3.06 Quick4 Equalizer 36 3.06 Standard Chamber 4.73 Quick4 Standard 4.73 Quick4 Standard HD 4.73 Quick4 Plus Standard (5.3 -inch invert) 4.73 Quick4 Plus Standard (8 -inch invert) 4.73 Quick4 Plus Standard LP (3.3 -inch invert) 4.73 Quick4 Plus Standard LP (8 -inch invert) 4.73 Infiltrator 3050 or StormTech SC -740 7.10 High Capacity Chamber 4.73 High Capacity H-20' Chamber 4.73 Quick4 High Capacity 4.73 Quick4 High Capacity HD 4.73 Quick4 Plus High Capacity (8 -inch invert) 4.73 Quick4 Plus High Capacity (13 -inch invert) 4.73 10 Effective Leaching area is equal to 1.67 times bottom width only. When the System is used with a secondary treatment unit approved in accordance with 310 CMR 15.284 or 15.288, additional reductions in soil absorption system may be allowed. In these situations the reduction in the SAS cannot exceed the maximum allowed under the secondary treatment units approval. In no instance shall the reduction in the soil absorption system area required in 310 CMR 15.242 exceed the maximum reduction allowed for alternative systems approved in accordance with 310 CMR 15.284. II. Special Conditions The System is an approved Alternative Chamber for use as an Alternative Soil Absorption System. In addition to the Special Conditions contained in this Approval, the System shall comply with the "Standard Conditions.for Alternative SAS with General Use Certification and/or Approved for Remedial Use" (the Infiltrator Chamber, Infiltrator Water Technologies. Approval for General Use — June 12, 2015 Page 5 of 6 'Standard Conditions'), except where stated otherwise in these Special Conditions. 2. New Construction This Certification is for the installation of a System to serve new construction or an existing facility with a proposed increase in flow, for which a site evaluation in compliance with 310 CMR 15.000 has been approved by the Approving Authority and the site meets the siting requirements for new construction, as provided in Paragraph 6 in section II Design and Installation Requirements of the Standard Conditions. 3. Remedial Site This General Use Certification also applies to the installation of a System for the upgrade or replacement of an existing failed or nonconforming system, provided that the facility meets the siting requirements for upgrades, as provided in Paragraph 7 in section Il Design and Installation Requirements of the Standard Conditions 4. The System shall be exempt from the minimum inlet spacing requirements of 310 CMR15.253. 5. The System shall have a minimum of one inspection port through the top of one of the chambers. The inspection port shall be capped with a screw type cap and accessible to within three inches of finish grade. 6. When the System is installed in trench configuration, then the system shall comply with these requirements: a) Length (each trench) 100 feet maximum (3 10 CMR 15.251(1)(a)); b) Width (each trench) 2 feet minimum to 3 feet maximum (3 10 CMR 15.251(1)(b)). - Chambers greater than 3 feet wide, when specifically approved, are subject to other Special Conditions and limitations; c) The minimum separation distance between any two trenches shall be two times the effective width or depth of each trench, whichever is greater, or where the area between trenches is designated as reserve area, three times the effective width or depth of each trench, whichever is greater (3 10 CMR 15.251(1)(d)); d) The effective leaching area shall be calculated using the bottom area and a maximum of two feet (per side) of side wall area for each trench (31.0 CMR 15.251(1)(e)); e) Trenches shall be situated, where possible, with their long dimension perpendicular to the slope of the natural soil. Where possible they shall follow the contour lines (310 CMR 15.251(2)); f) Trenches constructed at different elevations shall be designed to prevent effluent from the higher trench(es) flowing into the lower trench(es) (3 10 CMR 15.251(3)); g) The area between trenches may be designated as system reserve area only where the separation distance between the excavation sidewalls of the primary trenches is at least three times the effective width or depth of each trench, whichever is greater (3 10 CMR 15.251(4)) - Chambers greater than 3 feet Infiltrator Chamber, Infiltrator Water Technologies. Approval for General Use — June 12, 2015 Page 6 of 6 wide, when specifically approved, shall be separated by three times the actual width and are subject to other Special Conditions and limitations; and h) Effluent distribution lines exceeding 50 feet in length shall be connected and venting provided in accordance with 310 CMR 15.241 (3 10 CMR 15.251(11)). 7. When installed in trench configuration, approved Alternative Chambers greater than 3 feet wide: a) shall be installed with a minimum separation distance between any two trenches of two times the actual width of the chamber, or where the area between trenches is designated as reserve area, three times the actual width of the chamber; and b) shall only be entitled to a maximum effective width of 3 feet for the purposes of calculating total effective leaching area. When installed in a bed or field configuration, the System may be installed without distribution piping, but must comply with the following requirements in 310 CMR 15.252: a) the use of leaching beds or fields is restricted to systems with a calculated design flow of less than 5,000 gpd per leaching bed or field (3 10 CMR 15.252(1)); b) the maximum length of chambers in series shall be 100 feet (3 10 CMR 15.252(2)(b)); c) separation distance between adjacent beds/fields shall be ten feet (310 CMR 15.252(2)(1)); and d) the effective leaching area shall include only the bottom area, not the sidewalls (3 10 CMR 15.252(2)(i)). 9. For Systems constructed in fill and installed, the System shall be installed as specified in 310 CMR 15.255 Construction in Fill, except the minimum 15 foot horizontal separation distance to be provided between the soil absorption area and the adjacent side slope shall be measured horizontally from the top of the chamber. 10. The System is exempt from 310 CMR 15.287, specifically items: (5) requiring written notification of alternative system prior to property transfer, (6) need for a certified operator, (9) need for an operation and maintenance contract with an operator and (10) deed notice requirement. Title 5 INNOVATIVE/ALTERNATIVE SOIL ABSORPTION SYSTEM (SA DESIGNER & OWNER CERTIFICATION ' In accordance with the Standard Conditions for Alternative Soil Absorption System with General Use Certification and/or Approval for Remedial Use, modifed June 12, 2015, I, b !E;. Designer name (Printed) hereby certify to the Local Approving Authority (LAA) the following: • 1 have provided to the property owner copies of the Infiltrator Systems, Inc. approval and the current Infiltrator Systems, Inc. Septic System Owner's Manual for the State of Massachusetts; and • the system is desi ned in accordance with the Approval, any Company Design Guidance, and 310 CMR 15.00. Signed: RECEIVED Designer's nature 3-0 S L4 -m --F1 MAR 17 2011 Designer's name (Printed) TOWN OF NORTH ANDOVER HEALTH DEPARTMENT c�S� � Property Owner's name (Printed) hereby certify to the Local Approving Authority (LAA) the following: • 1 have been given copies of the Infiltrator Systems, Inc. approval and the current Infiltrator Systems, Inc. Septic System Owner's Manual for the State of Massachusetts; and • the Installer is locally certified. • the design does not provide for the use of garbage grinders, and this restriction is understood and accepted. • I understand the requirement to repair, replace, modify or take action as required by the Department or the LAA, if the Department or LAA determines the System to be failing to protect p c health nd the en 'ronment as defined in 310 CMR 15.303. Signed: _ t Pr erty Owner's Signature l fA Property Owner's name (Printed) Property Address: ) Z-7 V6,S7- Enter property address Date: 3I l ( (Zn 1 A-90 P-lW 47f-9'©eL)F Z Enter town name RECEIVED MAR 1 2017 TOVER HEA F NORTH THD PARTMEN�R T 0 A co V O � m 00 6 O D O O O O lV - Commonweonh ._;f mi=octiuset rxeafte Office of Envircnmenlc: Affairs Department of Environmental Protection 19 UH&M F, Wooid Trudy Gose C*WWn w teary $4900 pssul s �ttlwml David B. Seiko* BUMURFACE SEWAGE DISPOSAL SY:TITEM INSPECTIOH I'ORM PART A CERT WICA1'10N property Addrew; Ce<AA.;t...`f L) ; ,! Address of Owner. AD*W sof laspacu ru (It different) Nsune of Irosipeotor: Company Nemo, Addr,aaa .nd Toluphone Number. 'I'II! ATION ` TA71 F.RtE1r a 1 Mrltify t eat 1 have peraonnllv irapected the sewage disposal systen; at this e,& ecs and that the inforri ation-report dbelow is rue, occur v and complete as of the time of ixupectiou. The inapertion was perfermed based m my traitting and experience in the proper function cad mxit`,tenance of on-site sewage disprxai systems. The system: PaaseaV/ Y' �V'�' Conditi"'rn11y Passes Ne>Eds Further Evaluation By the Local Approving Autliority sada innpeotur's Signature: The System Inspector shall submit a copy of this inspection report to the Apprcr ing Authority within th..rty (30) days of eompletirg this iuspaction. If the system is a shams system or has a design flow of 10,000 gpd or greater, the inspector ,and the system owner othail submit thi report to the appropriate vvgional office of the Department of Environmental Pr.itection. The origiuel should. be cent to the system owner and oopies sent to the buyer, if ,applicable and the appri iving authority. Y1sdSPEC710N SUAMAP?Y: Cbeck6B, C, or D: Al SYSTFId PASSF S, ,^ 1 )ucve not ff—I au,' izts:;.-mation which indicates that the uystem vice,, ._.s any of the failure cri:eris as defined in 310 CMR 15.303. Any f-Iiiu1V CT.'t,16k, cot evaluated arse indicmtbd below. I9) SY- TTM COINDITIO V:kLLY F'A SES: One or more sg,-,�t.em cor,; SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPWTION FORM PART ,A CERTIFICATION (continued) Property Address l ti Owner. Date of Inspection: 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 pix or due to a broken, settled ar uneven distribution box. 'I %m system will pea inspaM n if (with approval of the Board o. Health): broken pipe(s) ars replaced Obstruction is removed distribution box is levelled o r replaced The system required pumping more than four timae a year due to broken or obstructed pipe(s). The system will Paas inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HE,\LTH: Al f) I Conditions exist which requite further evaluation by the Board of 1. ealth in order to determine if the m is s blit °g Protect t. public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETEIL4INES THAT THE SYSTEM IS NOT FUNCTIONING IN, MANNER WHICH WILL PROTECT THE PUBLIC HEALTH A 4D 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 vegetate•, wetland or a salt marsli. Z) SY87MM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER S JPPLIER. 1F APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A ,MANNER THAT PRO'T'ECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and coil absorption system and is within 100 feet to a surface water supply or tributary to surface water supply. — The system has a septic tank and soil absorption system a rd is within a Zone I of ci public water supply well. — The system has a septic tank and sail absorption system and is within 50 feet of a private water supply weu• — The system has a septic tank and soil absorption system acrd is less than 100 feet )rut 50 feet or more from a private wale supply well, unless a well water analysis for coliform bacUtia and volatile,oraanic nampounds indicates that the well is in from pollution from that f Ldlity and the presence of ammo-nia nitrogen and nitraw nitrogen is equal to or lass than 5 pp S) OTHER (revised 11/03/95) 2 1. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION VORM PART A CERTIFICATION (ountinued) Property Address: Owner. Date of Inspection: Dl SYSTEM FAIL: I 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 am. the iailurs. Backup of sewage into facility or system component due to on overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the grounc or surface waters due t) an overloaded or clogged SAS or cesspool. Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is leas than 6" below invert or available volume is leas than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(a). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any 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. Any portion of a cesspool or privy is within 50 feet of a privi.te water supply well. Any portion of a cesspool or privy is less than 100 feet but 90eater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bazueria, volatile organic compounds, ammonia nitro#len and nitrate nitrogen, El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves e focality with a design flow of 10,000 gpd or greaten (Large System) and the system is a significant threat to pttbli health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water cup.>ly 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 Wr.11head Protection Area (IWPA) or a mapped Zone II of a pubo, water supply 'ell) The owner or operator of any such system shall bring the system and facility int> fWl compliance with the groundwater treatment program requirements of 314 CMR 6.00 and 6.00. Please conrilt the local regional office >f the Department for further information. (revised 11/03/95) a SUBSURFACE SEWAGE DISPOSAL I�:YSTEM INSPECTION FORM PART B CHECKLI:3T Addrew Date of lospeotiow Check if the following have been done: Pumping information was requested of the owner, occupant, ane Board of Health. None of the system components have been pumped for at least I.wO weeks and the system has been reoeiviag normal flow rate, `` during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. A I'As built plans hove been obtained and examined. Note if they are not available with N/A. ✓� The facility or dwelling was inspected for signs of sewage back-rp. The system does not receive non -sanitary or industrial waste flow The site was inspected for signs of breakout. ZAll system components, excluding the Soil Absorption System, hr ve been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank wail inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The site and location of the Soil Absorption System on the site has been determined based on existing information or appra dmated by non -intrusive methods. Thi facility owner (and occupant,, if different from owner) were )rovided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORM, TION Property Address: `• Owper. Date of Inspection: FLOW CONDITI(iNS MroENTIAI j Dssip i1ow.- jj,�on. r Number of bedrooms:_ / Number of current residents: Y t/ Garbage Finder (yes or no):/,., .- Laundq ne concted to system (yew or no): y i Seasonal use (yes or no): ^10 Water meter readings, if available: D c,1,) txA W , L L -f-,pp.L-, Last date of occupancy: C (✓C ` ,� I COMMERCIALA NDUSTRIAL: Type of establishment: N` Design llow:---.gallons/day Cruses trap present: (yes or no)_ I»dtlstrial Waste Holding Tank present: (yes or no)_ Non.sanitary waste discharged to the Title b system: (yea or no)— Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped u part of inspection: (yes or no) 'S If yes, volume pumped: -,Ir Qallons Reason for pumping:(rte e ( CLIC JA FFt-ej l d o c- -j ?/I.,i(c 7v -f�Cr IF "),i -1 w4 r �° ,,4 Co -I-4/ b 15A COC47-� • f TYPE F SYSTEM /�?(''F, 2 s - Q r, ► rS ? 1,4-4 �� vt�%t/ ;77/-:1 C ._.,_. Septic tankldiaRribution box/soil absorption system Sin& cesspool Over1low cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, Lf Iuty) Other (explain) APPROXIMATE AGE of an components, date installed (if known) and source of <nformation: _ %�� ✓ y` YA J U Lj _ jo y L v 3 tL-, /6 /1 1 t, o /%, /0 C .- (;,r 7-j 2:J'7- SOevage *don detected when arrwing at the site: (yes or no) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL f YSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. Date of Inspection: SEPTIC TAMIL (lock" an site plan) Depth below grada:_Lj Material of onAnwtion:,concrete metal _FRP _oSher(e:plain) Dimensions: J, u to 1 L` Shnage depth: L _, Distance tirom top of sludgy to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ,r Distance from bottom of scum to bottom of outlet tee or baffle: y L Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, ,depth of liquid level in relation to outlet invert, structural integrii evidence of leakage, etc.) Q lr in/ (.,., c�•✓Q / T, ^. ti/ sis►FF(� i �R L" S7/`t_( / v �Ac<r /l a/0 /�✓ 6oq,0 `�a�`Tia.✓, /-/;4 vtD LVL/CrC l,✓ t�t�✓�L � 7 J i s A�vPtf� l��i� El r, Al S/'� .✓� a F Lt_14 K t o _1ic._(tf✓6n22s _)-r-' ??fiS T/m Lr, GREASE TRAP:_ /v (locate on site plan) Depth below grade: Material of construction: _concrete _meta) _FRP __other(e:plain) Dimensions: Scum thickaw: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or bathes, depth of liquid level in rela'iion to outlet invert, structural integri,: evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: Owners Date of Inapeotion: TIGHT OR HOLDING TANK: P. (locate an site plan) Depth below pude: Material of construiction: ooncrste _wetal _M _other(esplain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX (locate on site plan) Depth of liquid level above outset invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of .eakage into or out of ban, etc.) ya V06/ c C_ L t ��► � A c tzJ1�o Nc A/aLi!= [: v: c D 0/f. A c,l l.f f VEL 4n./O 0-4 4 PtACS A -J12 FLO t.. PUMP CHAMBER_„ /V f . (locate on site plan) Pumps in working order.(yu or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) . (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL S''%STEM INSPECTION FORM PART C SYSTEM INFORIILATIOiV (oontinued) )Property Address: Owner. Date of Inspiotlon: BOIL ABSORPTION SYSTEM (SAS). -.j,/ (locsts an site plan, if potable; excavation not required, but may be approaime- ed by non -intrusive methods) U not determined to be present, explain 7*: low-bie Phj, number:_ leaching chambers, number._ leaching galleries, number: leaching trenches, number,length: leeching fields, number, dimensions: overflow cesspool, number: lents: (nota condition of soil, signs of hydraulic failure, level of ponding, o)ndition of vegetation ew CESSPOOLS: ,N n (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 oonstruction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydmulie failure, level of ponding, condition of vegetation, etc.) PRIVY; �� 9 (locate on site plan) Material of construction: Liimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, cot clition of vegetation, etc.) (revised 11/03/95) BUBEURFACE SEWAGE DISPOSAL SYS'T'EM INSPECTION FORM .x PART C SYSTEM INFORMATION twmUnued) Property Addr.,#.& Owner. Date of Inspeouou,: OMM11 OF SEWAGE SYSTEM: Inch rds tiw to at iert t..o psivAwnt roforYucw landxnKrlu or beuchxab; km I i nt:ate al iiwl]Y DFP M TO GROUNDWATER Doth to pauwwawr, nwtbad of deteratination or aj pr�aiu,,.t. u:,: p+s(. /� IAj-• .r v-' :?r LV��J N1 J� 1 1 ►t/� rte._ — (r�viaed 11Jo�JyS) $ i. SEPTIC INSPECTION DATE: e "� " I P TIME: n - r4, PROPERTY OWNER° ADDRESS: )d % VL -r 7 -w1 -IV (0, )1"' On the above date and time, I made a visual inspection of the septic system at the above -referenced property. Based upon my visual inspection, I certify that the septic was in proper working order as of the date and time of the inspe;:tion. This certification does not constitute a guaranty nor warrant and because of the age and unpredictable characteristics of the septic system, it is not to be interpreted as insuring that the system will continue to be in working order for an;y future period of time, no matter how brief. Owner further agrees to indemnify and hole harmless inspecting company from any liability and costs incurred from the resu:.t of any third party reliance upon information provided. Acknowledged by: Raymond N. Lepore DEE RAY, INC. 5 Allenhurst Way Wilmington, MA 01887 Important: When filling out forma on the oomptw use only the tab key to move your cursor - do not use the return key. Q �Ity/ 1 own oT System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health.Other forms maybe used, but the information must to suostantially the some as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The Syj%M Pumping Record must be submitted to the local Board of Health or other approving authority within 14,days from the pumping date in accordance with 31.10 CMR 15.351. r_—. A. Facility Information 1. System Location: /a -7 >r Address /J / _T ilcr City/rown 2014 TOWN ur NuKI H ANDOVER HEAL rh f 5E%. � _ state Zip Code 2. System Owner. Name Address (if different from location) Cityrrown state ' Zip Code -7(F/- -70�- 0k-77 Telephone Number B. Pumping Record 1. Date of Pumping /S -00p g oats 2. quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) q!Septic Tank ❑ Tight Tank Q Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? [] Y If yes, was it cleaned? ❑ Yes [] No 5. Condition of System: 6. System Pumped By: Name -13()f6k Z (2 k S e? +r�Q Company 7. Location where contents were disposed: ZSD Signature of Hauler Signature of Receiving Facility Vehicle License Number Date Date t5fonn4.doc- 03106 System Pumping Record • Page I of FORM 4 - SYSTE'1 M /TLNG RECORD Commonwealth of Massachusetts 41 APIDOV-Cq , Massachusetts SYsten� pum} ring Record 7 :v/ner ystem tion 1 � `7 V Type: Emergency O Routine 9 ❑ No ❑ Yes ��""^ Cesspc DI: No ❑ Yes S� ptic Tan1:: Date Pumpine: L; �'3 Quantity Pumped: t�'�`C� _ gallons BORACZEK'S permit S\ step:. Pumped by (Company): Conte Is trnsiened to: Cont, its d,sposed at: C� � Date Pumper Si umgnature � �- P .. Condition of system/other comments: M k-- 1) DE.° nP'R0YEJ F'ORSi I:107i9S FORM 4 • SYSTEYt PUNTNG RECORD Comm'o.nwealth of Massachusetts 0ZrL,MassachusetIs SYst__ in Record Ty ovation )y51e Cr R` I�'C cls L +j(q a S F q X57` 7 Vie/+ +0 w,� l i A- `7 06, 0 7 � Tvpe Emergency Cl Routine Cessp( )I: No ❑ Yes ❑ Septic Tank: No ❑ Yes Dale Pumpine: 17Quan(iry Pumped: 0 _ gelIons BO RA.CZEK'S Permit S\ste,- Pumped by (Companv): C ontc is UEnsferr.ed .to: iLS disposed at: Da;� S'ly-Pumper Sienarvre Cone !tion of syslen her comments: oco FtE JUN 0 6 2005 TOWN ER HEALTH DEPARTMENT FORM 4 • SYSTEM FLrMYNG R.ECOR^ Commonwealth of Massachusetts V/.k/Do()@k , Massachusetts �2stem Pumpz�tg Record V �tslt 1 Uwncr Av -(u No i A,) #Pi�o ve-r\- A-0 , (7016 OS 17� �yslem t,oc31101) 16 0 01 exl- -to RECEIVED JUL 13 2007 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Type Emergency ❑ Routine Ccssp( )I' No ❑ Yes ❑ Suptic Taal: No ❑ Yes bait t 'Pumping- �'-t�'� Quantiry Pumped: 900 _gallons Sster• Pumped by (Company): BC�CZiEK'S S.% Permit Conic ;s transfe-rd to: f Com- its disposed at: D: t 5—[G' umper SienaNre Co.% :tion of system/other comments: COOS k OV .,»gpvID roR„ . 1:101,h Rcc;t1VE`" � Commonwealth of Massachusetts \ OWNN City/Town of NOV 10 2009 System Pumping Record Form 4 T HEALTH DETM 0VTTEERR 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health or- other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, L r o Right rear of house. Left rear of building. Right rear of building. Address City/Town tate Zip Code 2. System Owner. him V\ - Name Address (if different from location) City/Town Stat �.. (, �O(t Code Telephone Number B. Pumping Record j 1. Date of Pumping Date 2. Quantity Pumped: gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location® gntents were disposed: Lowell Waste Water Signature of Hauler F5821 Vehicle License Number Date t5form4.doc- 06/03 System Pumping Recons • Page 1 of 1