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Miscellaneous - 135 RALEIGH TAVERN LANE 4/30/2018 (2)
135 RALEIGH TAVERN LANE n Lane - - -- - 210/107.A-0112-0000.0 Q �� �vw IIS — � ' ��d ���'� � �I � a�� � v � � fi� � � �r �. 1- � �, r� _=�'�r - - - - Lot & Street 1�3� 9�el6ll �YCely,,Ir9 Map/Parcel /6 7,4� //-2, CONSTRUCTION APPROVAL Has plan review fee been pai YES NO Permit# Plan Approval: Date: 9 Approved by: Designer: Plan Date: 911,3 Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemic T Date Approved Bacterial Da pproved Bacteria II Date Approve Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: I -,7 SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? - � Type of Construction: NEWREPAIR New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: S NO DWC Permit Paid? ES NO DWC Permit# �/ Installer: J� ✓1 0 CJS Begin Inspection: Y_ES NO Excavation Inspection: Needed: Passed: /�/� By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: By: Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: ��z�/�J� __ _ - /�� CSC is j0F7R9��QgS' North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 135 Raleigh Tavern Lane MAP: 107.A LOT: 0112 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: 8/23/2017 PIPES- pipes from house to tanks, pipe from tank to box replaced — placed T in tank. Michele Grant INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction L Commonwealth of Massachusetts tvtap-Bt°ek-zot 'sem n '� 107.A0112 - ®P ----------------------- G BOARD OF HEALT Permit No North Andover BHP-2017-0534 --------- -- q ... �` P.I. FEE JR4 ; F.I. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-Bate-son to(Construct)an Individual Sewage Disposal System. i at No135 RALEIGH TAVERN LANE ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. 13HP-2017-053 ated ---------------- -- -------- ---------------------------------- Issued On: Aug-21-2017 BOA OF HEALTH fi5 Appticaion for Set1cisposa� Ssterr �--- /��� 7 ` Construction;PertWt - TOWN OF TODAY'S DATE NORTH ANDOVER MA 01845 25aocr—Full Repair $+ 2&.W-Component /7S"ao Apniication isherebymade for a permit to: Q Construct a new on-site sewage disposal system* ❑Repair.or replace an existing onsite sewage disposal system* f A�— r� 2-'Z6epair or replace an existing system component—What? b�,'"✓� l�"�`'^^� T�"�Tom'�'"�_ A. Facility Information Address or Lot# City/rown 2.-*TYPE OF SEPTIC SYSTEM*: ➢ ❑Pump &araviity(choose one) "T pump system,attach copy of electrical pennit to application**'` M Cbmrentionai System (pipe and stone system) ➢ ❑infiltrator or Biodiffuser(GraveQess)(Attach a copy of your certification to install_this type of system_) ➢ ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ 0 Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no further info. needed) 'NO=(installer must specify brand of filter before DWC issuance) What is the Make? WAatis theModcA3 2. Owner Information - "flame /.3S VZ�,-L_ Address(if different from ab ve) _ City/Town State Zip Code t7 /-- ?.39 Tele— pho a Number 3. Installer Information Name Name of Comp n,yy� �ITESON ENTERPRISES,INC. 444 ADM" ' 5 ROAD AddressANDOVER,MA c1810 ©( pry Cityrrown. State Zip Code V r yrs 3 Telephone Number(Cell Phone#if possible please) " 4. Desi . ner1nformation Name Name of Company Address City1rown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 i M i" Ap licat!or�.for.$ ptic Disposal Sys ern - iy•_/ a C©nstrTODTOD-TE uc ion P rmit - TO'C P SND Cwt % M& 01845 $.250.06 T Full Repair �'a �.a•t``6. .. ,�—�— $125.00-Component PAGE 2 OF 2 A. Facility..information continued..., S. Type,of Bufldfn esidentiaLDwellin or Co y mmercial B.Agreement The underslgned agrees to ensure:the construdlon and maintenance of the afore-descrlbe.d on-slte sewage disposal system,ln accordance with the.provisions of Title 5 of the EnvIronMental Code,as well as the Local Subsdrface Disposal Regulat/ons for the Town of North Andover, and not to place.:th* system In operation unt/l a Certlflcate of Compllance has been Issued y this Board of Health. Name _ Date ftloq Approveoard�fHealth'Representative) Q tNm U ' Date Application Disapproved.for the following reasons:" For Office Use Onw• I. 'Pee Attached? Yes v / No 2.• ProjectMariager Obligation Foam Attachcd? Srrstem? Ifso)Attach cojly of .:l��h►i� l p Xes : No 4. Fouad 96OAs-Built?(new co nsfructJonronl}r); (Same scale as approved plan) -<N S. F1oorPLws?(hew consteuctlon only): s No_ ilpplfetfbn'ior.p(sppsal.Systertit: onstrncfieri Pennft Raae 2 rir •,t SF.P'.pIC s.�s'�' '�•�a,�'s�r .�� Srrr'�c3�iG��'Itn�TS As Qio.NgtffiAadover.Iiotsaseti aisiaa fop.tlioUmtxocft-for• h aeptiasyste fotthe-propettyar (Ad4i6ioisgft qg=) AftpLm by xdstiva m thupp of a d•61. ,r�.�,�So/✓ . (ildii r3's Z ama AM dMod Dated VOMTS A Wits ievidam dated' (1,t oled doe) I uacict taad the fonowiv obiigatiasts fats aagetncat of itis ftr*ct: i. Aa the fns I aas.oblig W io abtaia•m0peapits aad'Bowxl cMcAtth Appravcd I a gt to Any woA oa m shr- IMM have thtx Wt� WlV a A�d t }�]] f,-.» ,R,�.. , 3. Asrite iter;.I�ztost tII stay aa=d after ,t£beamn pmjm$t�Aget,or An ot�apar cm not�ocfated wth �xa Y item be � my° P�Fp sad the spsteta is actsacady�thea ' At�u�x Att:.rtt3lripad�hive e y :piia "the appl�bf e i a SS � It fid• , ' _ • st;.: � �--den '• '�� .�I`°��p - sa3�er��s a;' g � • xna # amt a specft 1ptficrea-siothm tob4pltvbn t; 6. c O "(ar ell t� ttftapr chat tis. ftcm rite a�innust -ba ttibiditied•to the 8o*rd ofH&*k aW." ' fora pect{pg Lima I smlter issust prrt<frtr p dt be fesdy Arad Able to . p•to�►or3c s�id" xo�.. ' .' • . C. -�fs�t>iller mast aegearoaalie 'i tl! dingy;fa cmitt I I docs trot have to be .• .'' 4. As-the iasrAltr.:'I that only'? YPc'�etb�rl6a�r I �a rat4p* iaatzeVAton of fife spatrt i s ed �' i r�iired ma�tatiaa:j, . fa df ♦ 4 IS2Izl�f tht-ayat�encd 1 T` nAn%,et mea get Rnolbi �.. AU[IIr_fsat�lle�•Y t1i2�tt7Lt xtrC C�1 * i ptxf fi&mkg comtaa Win: DetasYo thlrt.s5t ' ekr►a: arft&e .: �Sv'bs�etr s�arcliea�- Iaspetafaa ahkell�rrd>:adas eYv awd 'Pia=laapeaax'aalpBofa�t. Taih�sl 'arcaa� _ doe!las3ta aft�k,l�- ,oftM tw&p=p abet t tvsWsratl'otliar 6. As dtt iatttier'I udeixt�.;r tit,f,T'st Abns frit$e it�II �+�+.,t`+1..„�,�tem:R •►t.,. • _ ����I\fo .,n_rH. -�n„��4�t,�flifffl��tr1�.•.a.s+.sMnr•.;a.l� .n ., - ase of � .• �� - i- d�$� a• Uadd Ccauaed[Septic. •• ': (7040 pate ` ,O RTM 7988 OL v • r Town of North Andover HEALTH DEPARTMENT ,s$4CNU`+t4 CHECK#: ,S zo DATE: LOCATION: Z,3 5g 2-;a 7Z � H/O NAME: �U i/') CONTRACTOR NAME: �` ,50/) Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ (�P P pis ❑ Septic-Design Approval $ xSeptic Disposal Works Construction(DWC) s /75— ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ &a6 Agent Initials White-Applicant Yellow-Health Pink-Treasurer �a_ 5 € k 10762 Ps 247 0-15851 Restrictive Coven0 —23-2007 & 01 : 43P Deed Restriction We,Debra and Erik Julin,dated July 28,2006, and recorded with the Essex County Registry of Deed in Book 10308,Page 272,being the owners of the premised identified as 135 Raleigh Tavern Lane,North Andover,Massachusetts,Assessor's map 107.A, Parcel 210/107.A-0112-0000-0,hereby declare a restrictive covenant,a limitation that the dwelling located at said premised shall contain no more the four(4)bedrooms as defined by the 310 CMR 15. Said restriction shall run with the land,but shall automatically terminate in the event said premises is connected into the town sewer system. Said restriction may also be terminated by vote of the Board of Health on the Town of North Andover. Erik G. Julin � Debra A. Julin Commonwealth of Massachusetts Middlesex,ss Date: ud 60 Then personally appeared the above named Debra and Erik Julin and acknowledge the foregoing to be his/her free act and deed,before me. Notary Public: K� My Commission Expires ECC Notary Publk. Commonwealth of I�etls Mp Carrnnission Exptres Od4,2007 BK 10308 PG 272 QUITCLAIM DEED We,Richard A.Mulley and Susan W.Mulley,husband and wife,of 135 Raleigh Tavern Lane, North Andover,Essex County,Massachusetts For consideration paid and in full consideration of Five Hundred Eight-Five Thousand and 00/100 Dollars($585,000.00)grant to Erik Ju fin and Debra A.Julin,husband and wife,as tenants by the entirety,5 Northwood Circle,Woburn,Middlesex County,Massachusetts With QUITCLAIM COVENANTS 0 'C The land with the buildings thereon situated in North Andover,Essex County,Massachusetts, being shown as Lot#25 on a plan of land entitled"Definitive Plan`Raleigh Tavern Estates' North Andover,Mass.,Owner:Old North Andover Realty Trust,Engineer-Hayes Engineering, z Inc.",dated May 15, 1968 and being recorded in Essex North District Registry of Deeds as Plan No.5913,said Lot being more particularly bounded and described as follows: rp"a Northwesterly by Raleigh Tavern Lane,(North)as shown on said pian,168.00 feet; ENortheasterly by Lot#24 as appears on said plan,263.00 feet; N o M co Southeasterly by Lots#37 and#36 as appears on said plan,168.00 feet;and -� ea'^ M Southwesterly by Lot#26 as appears on said plan,263.00 feet. o N Containing 44,184 square feet,more or less. AThe above-described premises are hereby conveyed subject to all encumbrances of record. o Meaning and intending to convey the same premises conveyed to the Grantors herein by deed of P*a aJo-Ann N.Swajian,dated October 14, 1999 and recorded in Book 5580,Page 55. C" a C WITNESS our hands and seals this 28t'day of July 2006. � a a 'chard A.Mnlle''y......///111 Susan W.Mulley —� COMMONWEALTH OF MASSACHUSETTS Essex,ss. July 28,2006 On this 28a'day of July 2006,before me,the undersigned notary public,personally appeared Richard A.Mulley and Susan W.Mulley,proved to me through satisfactory evidence of identification,which were Massachusetts Driver's License(s),to be the person(s)whose name(s) islare signed on the preceding or attached document,and acknowl ged to me that helshe/they signed it voluntarily for its stated purpose. E Notary Public JR,, My Commission Expires: W T M 0` Z M Z JOSEPH T.KEYES m NOTARY PUsuC Commonwedth of Massachusetts p. S✓S��' - My comfWSSIOn Sxp1m on ('t T^ August 7,2009 r • BK 7667 PG 336 EXHIBIT A—LEGAL DESCRIPTION The larnd,thereon situated in North Andover, Essex County, Massachusetts, bounded and described as follows: Northwesterly by Raleigh'Tavern Larne, (North) as shown on said plan, 168.00 feet; Northeasterly by Lot#24 as appears on said plan, 263.00 feet; Southeasterly by sots#37 and 36 as appears on said plan, 168.00 feet; and Southwesterly by Lot#26 as appears on said:plan, 263.00 feet. Containing 44, 184 square feet, more or less. For mortgagor's title, see deed recorded in Book 5580, Page 55. ;. ............,. l Town of North Andover F NORTH p t OFFICE OF �eo 3a �` °•C -0 COMMUNITY DEVELOPMENT AND SERVICES p 27 Charles Street North Andover, Massachusetts 01845 �9q°ATEDyP"icy WILLIAM J. SCOTT SSACHUS� Director (978)688-9531 Fax (978)688-9542 September 24, 1999 Bill Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 135 Raleigh Tavern Lane Dear Bill: This is to confirm you that on September 23, 1999 at their regularly scheduled meeting the North Andover Board of Health considered variances requested for the repair of a septic system at 135 Raleigh Tavern Lane. The following variances were granted by a vote of the Board. 1. Local upgrade approval for setback of soil absorption system to foundation from 20 feet to 15 feet. 2. Local upgrade approval for separation from soil absorption system to estimated seasonal wetlands from 4 feet to 3 feet. 3. Local variance for distance from soil absorption system to wetlands from 100 feet to 80 feet. 4. Local variance to allow a 750 square foot leach field instead of the required 900 square feet. With these variances the plans have been approved. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Please feel free to call the Health Department at 978-688-9540 if you have any questions concerning this action. Sincerely, Sandra Starr,R.S. Health Administrator cc: K Swajian File i Town of North Andover * NORTN OFFICE OF 3�O c`t e o 1OOL COMMUNITY DEVELOPMENT AND SERVICES A t 27 Charles Street North Andover, Massachusetts 01845 ° <� WILLIAM J.SCOTT 9SSAcHUS- Director (978)688-9531 Fax(978)688-9542 September 15, 1999 William Dufresne Merrimack Engineering 66 Park Street Andover,MA 01810 RE: 135 Raleigh Tavern Lane Dear Mr. Dufresne: This is to inform you that the proposed plans for the repair of the septic system located at 135 Raleigh Tavern Lane,North Andover, have been disapproved for the following reasons: • Abutters not listed. (NA 8.02j) • Ends of the distribution lines not connected with solid pipe. (NA 15.01) Please remember that revisions require a$60.00 submittal fee. If you have any questions, please feel free to contact the office at the number below. Sincerely, Sandra Starr,R.S. Health Administrator Cc: R. Swajian File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 MERRIMACK ENGINEERING SERVICES, INC, PROFESSIONAL ENGINEERS • LAND SURVEYORS a PLANNERS 66 PARK STREET•ANDOVER,MASSACHUSETTS 01810•TEL(978)47-c-3555.373-5721 •FAX(978)47Se1448•E-MAIL mamn®000.com September 14, 1499 Ms. Sandra Starr Director of Public Health 27 Charles Street North Andover, MA 01845 RE. 135.Raleigh Tavern Lane Septic Upgrade Dear Ms. Starr- This taraThis office has prepared a subsurface sewage disposal system plan for the above referenced site. As noted on the plan, the design requires several local upgrade approvals and local variances as designed. On behalf of our client, we respectfully request these matters be placed on the next available Board of Health Agenda for consideration of the aforementioned variances. Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufresne Project Manager cd MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS e PLANNERS 66 PARK STREET•ANDOVER,MASSACHUSETTS 01810•TEL(978)475-3555,373-5721 •FAX(978)475-1448•E-MAIL:merreng@aol.com September 14, 1999 Ms. Sandra Starr Director of Public Health 27 Charles Street North Andover, MA 01845 RE: 135 Raleigh Tavern Lane Septic Upgrade Dear Ms. Starr: This office has prepared a subsurface sewage disposal system plan for the above referenced site. As noted on the plan, the design requires several local upgrade approvals and local variances as designed. On behalf of our client, we respectfully request these matters be placed on the next available Board of Health Agenda for consideration of the aforementioned variances. Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufresne Project Manager cd Sep-19-99 .08:05A Paul D_ Turbide, PE/PLS 508-465-0313 P.04 September 10, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover,MA 01845 RE: Title V review for 135 Raleigh Tavern Lane Dear Sandra, Enclosed find the"Checklist for North Andover Septic System Pians" for the above- mentioned site. The following is a list of all the `Problem' areas and deficiencies Port Engineering has found. ❑ Abutters must be shown. NA 8.02j ❑ The ends of the distribution lines must be connected with solid pipe. NA 15.01 ❑ 310 CMR 247(2) states that a minimum of 2" of 118 to 1/2 inch stone is to be placed on the top of the leaching bed. The plan design calls for a layer of untreated building paper to be laid on top this stone. There is no regulation that I could find that allows untreated building paper to be laid over the peastone, and therefore I would recommend that the untreated building paper be removed from the design. If you have any questions or comments please feel free to contact me. Sincerely Carlton A. Brown,PEIPLS Raleightavernl35.doc PORT ENGINEERING Civil Enginerrs& Land Surveyors One Harris Street Newburyport,MA 01950 (978)465-8594 ' FORM 11 - SOIL EVALUATOR FORhI Page 1 Commonwealth of Massachusetts �- , Mess®chusetts foil Suitability Assessmegt for Ort-site Sewaee=lh's=nosal Performed By: ..._.... ................................._.... ............................ witnessed By:..... :: .......................................... .� ..... _.. ::: �:.::: A:::...:...::. ::..::::::..........._............:...........................:." Lot I �H7 l b �} T�kPIaK/ ��`1 fGc�/,�L/Gv /Gc�Grv► or r� New Construction ❑ Repair B Office Review Published Soil Survey Available: No ❑ Yes Cl i ar Published ....1ff/ Publication Scale _.,/. O Soil Map Unit.........Cr. Drainage Class ....... ......... Soil Limitations ............................................................. . ...........__.............CL?s-/.644 Surficial Geologic Report Available: No 3- Yes ❑ Year Published .... Publication Scale GeologicMaterial (Map Unit) ................ .........................................._......._............................_................... Landform 1 . ..........2 '". v................................................................................................................. .... Flood Insurance Rate Map: Above 500 year flood boundary No ❑ Yes Within 500 year flood boundary No Q---- Yes ❑ W ithin 100 year flood boundary No Yes El Wetland Area: National Wetland Inventory Map (map unit) ................................................•.......•..•......_...................••...........•.•.. Wetlands Conservancy Program Map (map unitl...................................................._._........................._............... Current Water Resource Conditions (USGS): Month ..-e Range : Above Normal ❑ Normal El Below Normal Other References Reviewed: rk� ,.. FORM 11 - SOIL EVALUATOR FORM PARC Z Qn. fte Review • i Date: Time:.L�.Vo - Weather Deep Hole Number._r l �,' ��� ___. Location(identify on alta pian( Land Use -� >: --__ �_ Slope 1961 P'! v Surface Stbnea Vegetation�...._...�� �._.. ...__...__._.L� .._._...-......--•• ........_•r__....._....._..-__.._.........._.____._...._.._._.._____._......__ Landform position on landsoaps(sketch on the back) Distanoes from: Open Water Body ZJM� feet Drainage way_'? •f feet, possible Wet Area .9fz�k feet Properly Una 7! ?__ feet Drinking Water Well feet Other .......��- -- DIERP OBSERVATION HOLE LOG papihffts'xfaa tick tiorl:on ramlU M e i ea IAnt111n0 18 ,pq . tlnve v �Ht f& Y Lia a parent Material(geologic( ._.--.......-_............. Depth to Bedrock: Qw1hh tQ Groundwater: Standing Water in the Hole: ..P!� Weeping from Pit Face: ... l Estimated Seasonal High Ground Water: .... FORM 11 - SOIL EVALUATOR ftM Page Z On-site Review ' s Deep Hole Number Weather , Location lldendfy an site plan! Land Use - 'sQ-.- ____. Slope(%I enz.. Surface Stones .... Landform position on landscape a!sketch on the back! -- S' ..........—------.. .. oe Oistan s from: , Open Water Body feet Drainage wey..2:1w_. feet, Posslbla Wet Area _1API feet Property Une._.la..�k feet Drinking Water WONT ..` feet Other -.�--•••w---..--- -� DEEP SERVATION ROLIE LOCY D.pq tf surra sos tiori:on 6ogVMA• i�C 24 Sol IAatdY+a (SMUft ►,p.q 8 QoMA�n, �r VO Parent Material lgeologlcl Depth to Bedrock: --, Death to Groundwater: Standing Water in the Hole: ..- ! Weeping from Pit Face: ....AJM✓f Estimated Seasonal High Ground Water: ..... ! ' FORM It - SOIL EVALUATOR FORM , r Page 3 n+dminn on for Seasonal HM Mk Tactile ❑ Depth observed standing In observation hole inches ❑ Depth weeping from side of-observation hole. w Inches , lot- r-,/Depth to soil mottles . t. Inches � -s�T z (9 / ❑ Ground water adjustment .,..--- feet Index Well Number Reading.Data . _ Index well level Adjustment factor Adjusted ground water level M oh ofr iv Occurring Perytous Mate[ Does at least four feet of naturally occurring pervious material exist In.ell areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? I certify that on �� ��� Idetel I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 16.017. Signature :7 FORM 12 - PERCOLATION TEST r COMMONWEALTH OF MASSACHUSETTS Massachusetts Pemolatfon Test Date: ...a- ..f, . .. Time: .................................... Observation Hole # Depth of Pero ti Start Pre-soak End Pre-soak ' Time at 12" Time at 9" Time at 6" Time 19"-6`1 /O Rate Min./Inch Site Passed El-""site Failed ❑ Performed BV: ----)3 12, �u Witnessed By: - / L"7Z-0 Comments: ....................................................... ............................................................................................................................................................. PAGE 1 OF 5 Commonwealth of Massachusetts Application for Local ,grade pproval Title 5, 310 CMR 15.000 DEP Approved form required by 310 CMR 15.403(1) To 'ne submitted to L l A wrptvi g horijy/Board of Health: For the upgrade of a failed or nonconforming system with a design flow of <10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade g ude made of af a e stateor nor federal�facgilitys wheretem with full design flow of 10,000 up to 15,000 gpd and/or pg compliance, as defined in 310 CMR 15.404(1), is'not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design now to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 tMR 15.000. 1) Facility/system owner y NameIAIN Address I,Zz!!j 161-1 T.���►z►) rc-� Phone # 6,6 7-2-ice Address of facility I77 UA 116 d LA`610 N=J 2) Applicant'(if different from above) Name N Address Phone # 3) Type of facil' . idential _commercial —school institutional (Specify) DFP AMOVBD r02M-UWM Ry PAGE 2 OF 5 4) Type of existing system /Conventional oo1(s) �/ system _ cessprivy P Other (describe) Type of soil absorption system (trenches, chambers, pits,etc.) 0,3 A19 5) Design flow based on 310 CMR 15.203 .Lqa) Design flow of existing system 04 gpd Approved? _yes approval date no why? b) Design flow of proposedu graded system gpd c) Design flow of facilitygpd 6) Proposed upg de of existing system is a) Voluntary Required by order, letter, etc. (attach copy) Required following inspection required by 310 CMR 15.301 (provide date inspecori .date) tion form was submitted to the approving authority) ( b) .Describe the proposed upgrade e to the system Td "7rx� c) Which of the following are applicable to the proposed upgrade? ✓ Reduction of setbacks) (list setbacks to be reduced with proposed setback distances) N,k Percolation rate of 30-60 minutes per.inch (state actual perc rate) IDU A eRov®MM-i2Mea PAGE 3 OF 5 Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) #fA Relocation of water supply well (identify well, describe relocation) Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) gA Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the Code) System upgrades that cannot be performed in accordance with 310 CMR 15.404 & 15.405, or In full compliance with the requirements of 310-CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves.a reduction in the required separation between the bottom of the soil absorption system and the-high groundwater elevation, an Approved Soil Evaluator must determine the.high ground water elevation pursuant to 310 CMR 15.405(1)(i)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater feet As determined by: Evaluator's name �J �- Evaluator's signature Date of evaluation e-V5 DEP AFMOVW FORM-121VI95 PAGE 4 OF 5 8) Notice to Abutters No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property or well is affected by certified mail at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the Department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the Department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. List of affected Abutters: Abutter Name Date notified Address i Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible: �-I M N'grD s Fkz0 1-+r ?'O t'--P'64 vJ TL�cl1��5 Al,4. b) an alternativey pp system approved-pursuant to 310 CMR 15.283.15.288 is not feasible: DEP APPROVED FORM-IV07/15 PAGE 5 OF 5 AAc) a shared system is not feasible: AA d) connection to a sewer is not feasible: 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evalu "tion forms), must accompany this application. Is the DSCP application attached? yes no 11) Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." J" 'Ad so Fa ' owner's signs re dare o�kN l� `7uy A- L IAJ Print Name I LA Name of.preparer rDate Telephone # & address of preparer NOTE: Title 5, 310 CMR 15.403(4), requires,the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. WM eereoM row►+-mans SEPTIC PLAN SUBNHTTAL FORM LOCATION: / 7,5,5 C.04-x' NEW PLANS: $125.00/Plan ✓ REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: <nj!4P NO DATE: e7-7 ' DESIGN ENGINEER: :zCe'eyotwielG 44I&96U1fg�� DATE TO CONSULTANT: *If you want your plans expedited,please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place,route to the Health Secretary. 1 �� Town of North Andover, Massachusetts Form No.2 o� NooTti� BOARD OF HEALTH 9147° 19 . DESIGN APPROVAL FOR ,SSACMUSEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. Site Location Reference Plans and Specs. 143 ENGINEER DE IGN DATE a "> Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CH IRMAN,BOARD OF HEALTH , y 169c?— : Fee /�c�� Site System Permit No. TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 10/13/99 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by John Soucy at 135 Raleigh Tavern Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit# 1098 dated 9/27/99. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. of Board of Health Inspector TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION Therindersigned hereby certify that the Sewage Disposal System( ) constructed; (�repaired: by ..I o1-+0 located at IZAk_,EiE: Tav c Z_N_) L� was installed in conformance with the North Andover Board of Health approved plan, System Design Permit#Iefj�( dated , with an approved design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: Engineer Representative Final inspection d e: Engineer Representative Installer: Lic.#: — Date: /0 /3 Design En ' eer: ��—� Date: . AS-BUILT CIIECK1. IST r LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM. INCLUDING RESERVE TIES TO LOT LINES& DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA { LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER, GA$, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK B_OX=------------ STAMP& SIGNATURE - 1, IMPERVIOUS AREAS -DRIVEWAYS, ETC. 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I ` '!' . , ,,-1";,.I, 1 ". : � .1.1 ,,7��j!,�Ii 7t,1 1�i, 't.%;. i;q — IllUlllll Form No.3 .t ,1 1 ,,�-�j�'�:.",:�di�:,i;_.;'�I,�'ii V l'i"'r I'."'I 1..11 . �i;:It:ll�'. I,!!� :I ,_,�""... ...", ,., �!- i:-,., .-� I. 1�1,;U?_,-i..;, iT;T,q.,I,: . F�,� ��i�'����'�.,��11.� Iil :; ��,;,� -�;. h Andover, Massachusetts ...- � ��, � .. Town of North I K� ,. 'V. i ,�fj;:i-�,::,�,'. ��','.,I�;,�-"'!;",,'�-�i"li,, 1 ,. Zlj," ,1-� 11� 'I!.!�'I,ii', . si ',:_�. .........�,lj ,I.j.,_ ,t . `, . . BOARD OF HEALTH . % (/y} � j. . IV.." I? . . . . I'l,, �iti,,, 1 _� z,�S,,��,,ii�!,�t,,,,1. . .......21,tt..,.,�%Ij�-,�,�[,'7!t; 14ORTFI ,,-2-?— � , - i�III I- t�"_il -,t-li, � 'j , . I . - -1 . i �j� , "L41.;j. � ?A,I,I.��,;4 0 ". 16 1 / -11 -... _. . . . I . : 4� It� f • �-,i,; - . ',-,'A'i:I�!A!� .1, : �II,.V,.�jf? j;,!i,';!:t;, . I �t;'I,I_� I, P.-, - 4-,"'- . t�,":,tic,�ii.tfi. -i. . .,it; ;o,,.;, 4 If I c u, I.- ."t" 1-." - � ... ...I q F;;. .-7:,_,�,�-I:,p" �,..:!: .�ifi ; ii * j,'�:I. I'll PERMIT : .. . ONSTRUCTION PE 6,i �,1, �i'i'I — . • * . -I , .��;I,;,I�"',,��- �,�III � ... .- - I 4 , -- .* �.�,..;_- DISPOSAL WORKS C 1p. � ,,!�,;�.��'q'�.15 .. , 1, � . .�I;%�.::t;�:,ui�,tIU;- g.-��4,-,eli����'.'�,�:::�'i��!"zI ."j.".t1-j'�. .� I . . I- - - -, . � ���,,,, �I%1U; , , .'�, I!v.i: ,�',q'��,,' I -SS .It�t_-,!�,;f i ,z q ij.;3::.�,�.�zit -.��,,'�;�'. HUS I ,'� ii,;,.i_� -1-...;,, I i - — ✓ �;�� I . I .. - 4.,�;�-,i�;�i;'-,,'������4,�;�,;."".�,,�".�!�-�,�, I . I . .. , . . ,, .. . ;,.�-1.�,6,13-,.�,,T�;-.�i.-.'�,'�',,.-L,.`1-%�.. ' , ' ;,- . -�.%... � . ., , . . ",,.r,,..,i,,._ �".1_,,._ �4,�. I �,W;i- t. - - �-_ ,- _ _ ,.,., 6 ,.i�.,� ;i.,i,.i.�1�';,_C11;1 I,11�-L,IV -, . .1 I I ti- _.I . IiVI.:4v,i,. '�V ., -",�� �.;i �,�E",;s"����, P,• .. I.I .. . i4,,I'1i;4,.�I4q Ij�- , , **,- 5?_�il�i-�.TI,T",,,* ! TELEPHONE , � ,�.t�. ,.-: , . ': ,I. �1 . ,tt , ".,,, .,,F q-�r,,�N''. „,.�,�,4'f�.-, . :. :, : :. :�� , 11:1`_"!:*�11”,,�i��!,I�_-i""V I,,.,,,,J,h�,'to , r � : � -- ..i � ,, " I . I I - - I.. I it I," i I I:-... I.- �, �i-1- DRES � � ,t� 141tiif'. I,� i�-I-�,�V,I�z jflft,R Gd . �,�, ... ll'll., j - I- , � , t , � . . .+, , ,:�7.�;r":,I,7�"I,-1�-it;�`-5,�",i,!;I�Sj- , 12; , , Applicant " -��","I��ti"t,��i,,4,i'�.f���..',.,, '! , -a .::ij � I "',"-: . . _1 I-1 -t..; '� ME �41 �, ,,. � I % , i i F.,I,�.T";r.,V%1'i t� ..;:��-i Ii�i.,1k���:, i�i it,-,I'* ��. , 1.z. ".,.t .�;,"a�`,Ov,r,-��I,'ij!'I;c* . � , I I r,'I1,%fi_,�: '�Iil � ;"--i,.'4 I.- .-",'. i - t t. ,�; I i.-1,,�, .1,;., � I 1. I �--�,,-tliti $I�-r .?,�,N ,:;�t,t I . . - - .,. . �,�--��p.! '�, -�IE'ii�i�'t��� .1.11,-�'. ,,:.,� . -. . '-f1,' - ,. ., � ,, - ii,f_ - ii Ij -, - �__ - � � I.11.1:. - - , I ��,�- , ,", -.1i-I'", ,- '. j-$' 1-I-i , , ", i Site Location . ,�llg ,' l�. _r,�;,�- --.f �,tt. . it. I ;1 If. , ,Ii,t.1;'A,,,,I� 't", �,,�I,K�,, .I,---, . J"t-plig -?. , � '-fte t�j, _ I;.,1,'I-, . i - - -, t,l�,��-�i�l�""Alt.,I,�E.�,--�����,,,.I-�qj Y.� , : - , - . . I I " 7 ... . � . 2 I.i 1'..'.."'it ,;�,;. .-�,.,� . � . � . " . , ,V , 'A --t,!,�, ,J;,,, ,-, . . 1. 1. 11... 4 aM , " �- - � . . I. � ,.. ii , �. Iif�1, -4,- ,7� �r-- . � ,,, qgi ,,f .1 1--, L, . . . I ::t:, � : ��,,' ' .R��.', I, �l g, -, lit: I_.-, `_.�_, I, I itt.i. . , :-. I- , ,t,I . - s 1i_�I!,I, . � 1p"f'. . , soil Absorption . '' i�, .i", - .I . i -- . , 1.11"-J-11- � I . � I - " �;�".�, �� ii : * Individual . I .1. . , '!�, 'i�.;; .- .� . "'. I f,4 ."i� � ��,- -��: i , ; ...,..I I. . x"!tV I�;i` . .�.._t'I.i� jl,!"�;��. .*. r Repair W an In . . , I I ., - 4� liz , ---��iI , "A I �- . . nted to C�nstruct ( ) 0 ",.,,�`l j11�it,:i4:, - � ,- i., .. i...11.'! ,�� J . I - ., ,� :i,t'I'�, " r ,* ,I;,-!i1:I1_ ,:, , , Permission is hereby gra 0 ,?C?- �",;J,�411.: .�z t / ,T ,1,,�.'I,1,1':." ;,I S.S. No. ' �:i,- �.- " � " i. " . -� . � . , . . , fl `k as shown on the Design Approval S-S , � j'�_ I,. ,il, ,.. ,., t �'� _ . �I,�,� ;. ,k��I,iqil"i�il"-I' , 11 . I I .1 I � Sewage Disposal System W, � .1 - : Sewa - , - ii i. ., I . , , �. , . . -4 I..'' , : , , _ .- ;izIi,!r-,`.t.,_ , - ,- ._I- I - j" .. *;,:.- - ,iXIim w"I j �,- ,FI,-if"'w�' I I _� �, i�� I�; /0,0�_`t , �4 -It,*�,,�w,i:ila,!q",'' - . 11 tt� 1.:iil'�:�,�,�. I t7 i, � it � �� 11 .. I_IWq'1q -11 I. k.�'., :�""12,rrl , , , ; . 11� I!.,*;,�, t; � I - . 4, N�,'-K 44�"., -f�.t t:�'i,: ,;�� . !It., ,:, ,!.�� �,t�.,,,�. 't.-1, . . ..: . . . ,"i, 4j" , "..". ... , . —HEALTH iNj.,*JM'-INI��t,� I. - Z - i .....CHAIRMAN,....''' ' .... .... —BOARD OF �J��,�if j ,.f , : - ,;--, -�, I 'I. —, , ' . I �:i", " ,;�' � . I ',,�,;�:I ; ;I ;I"�.i'- . I.11 ,.%. .� . . i A, �! �, . _,: � i, I 1. I, I , tv, .... I . "i�..., .� . 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I� �.:A --:,.�� ..-i�,,-..---,-�,,.��-_, :'.,:.::1 J11 * , �, -: . : , . -z , - ,�.f APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTAL o c,� SIGNATURE: TELE ONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 575.00 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: Ila Y TOWN OF NORTH ANDOVER/ SEP 2 8 I109a K COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS b DEPARTMENT OF ENVIRONMENTAL PROTECTION r a�0 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 135 Ralleigh Tavern Road --Ila e�l ze4/L North Andover,MA 01845 MAY 3 12006 Owner's Name: Susan Mulley Owner's Address: Same TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Date of Inspection: 05-04-2006 Name of Inspector:(please print)John Soucy Company Name: Soucy Sewer Service,Inc. Mailing Address: 830 Livingston Street Tewksbury,MA 01876 Telephone Number: 978-851-8839 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai&AP Inspector's Signature: Date: —�- — The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic system. t Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 135 Ralleiah Tavern Road North Andover,MA 01845 Owner's Name: Susan Mulley Date of Inspection: 05-04-2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: , Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 135 Ralleizh Tavern Road North Andover,MA 01845 Owner's Name: Susan Mulley Date of Inspection: 05-04-2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. —The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. —The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 135 Ralleiah Tavern Road North Andover,MA 01845 Owner's Name: Susan Mulley Date of Inspection: 05-04-2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _the system is within 200 feet of a tributary to a surface drinking water supply _the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 135 Ralleieh Tavern Road North Andover,MA 01845 Owner's Name: Susan Mullev Date of Inspection: 05-04-2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x ` Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x _ Has the system received normal flows in the previous two Week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? x Were as built plans of the system obtained and examined?(If they were not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x _ Were all system components,excluding the SAS,located on site? x _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? x Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No x — Existing information.For example,a plan at the Board of Health. x _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 135 Ralleigh Tavern Road North Andover,MA 01845 Owner's Name: Susan Mulley Date of Inspection: 05-04-2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 5 Does residence have a garbage grinder(yes or no):yes Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): no Water meter readings,if available(last 2 years usage(gpd)): See Attached. Sump pump(yes or no): no Last date of occupancy: recent COMMERCIAUUNDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes of no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Home Owner Was system pumped as part of the inspection(yes or no): e�s If yes,volume pumped: 1500 gallons--How was quantity pumped determined?Gage on truck Reason for pumping:Maintenance and Inspection. TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 6 Years Old Were sewage odors detected when arriving at the site(yes or no):No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 Rallei¢h Tavern Road North Andover,MA 01845 Owner's Name: Susan Mulley Date of Inspection: 05-04-2006 BUILDING SEWER(locate on site plan) Depth below grade: 28" Materials of construction: X cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 8" Material of construction: X concrete_metal_fiberglass_polyethylene_other (explain) If tank is metal list age:_Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5'x 6' Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 38" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Tape&Sludge Tool Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Garbage disposal NOT ALLOWED states in design plan,also when system installed the Town was checking inside for disposals and not insuring a cert.unless removed. GREASE TRAP:_(locate on site plan) N/A Depth below grade:_ Material of construction: concrete metal_fiberglass_polyethylene_other(explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,� ,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 Rallei¢h Tavern Road North Andover,MA 01845 Owner's Name: Susan Mulley Date of Inspection: 05-04-2006 TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)N/A Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:___etc ual Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-Box-solids carry over and in lines (Corrective action took:cleaned lines and flow tested D-Box.) PUMP CHAMBER:_(locate on site plan)N/A Pumps in working order(yes or no):_ Alarms in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 Ralleizh Tavern Road North Andover,MA 01845 Owner's Name: Susan Mulley Date of Inspection: 05-04-2006 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: X leaching fields,number,dimensions: 15'x50' overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): No Siffi of Hydraulic Failure. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)N/A Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding;condition of vegetation,etc.): PRIVY: (locate on site plan)N/A Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 135 Ralleigh Tavern Road North Andover,MA 01845 Owner's Name: Susan Mullev Date of Inspection: 05-04-2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. + EtJ s �.�'-�K_,�,-•+�G,ij! `t`iNE NRK. ,.t u 19—(1 SoAr ._. t7• O –� s –•_ I—140616-A TA Jic t oc- Qb.vt i i 9 � � I �Y "em"a I,JG. qy Q N Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINT PART C SYSTEM INFORMATION(continued) Property Address: 135 Rallei¢h Tavern Road North Andover,MA 01845 Owner's Name: Susan Mullev Date of Inspection: 05-04-2006 SITE EXAM Slope Surface water Check cellar x Shallow wells Estimated depth to ground water None Please indicate(check)all methods used to determine the high ground water elevation: x Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Obtained from design plans 08-25-1999. J�•.� 4� �V 4J i� P. v j r sommar*rc,ord Card gnr:eratA on*5:—,'?r.G.6 2:7-:36 PV'-y:Js-z Warren Town of North Andover r : Tax Map # 210-107.A-01 12-0000.0 136 RALEIGH TAVERN LANE MULLEY, SUSAN & RICHARD 135 RALEIGH TAVERN LANE N. ANDOVER, MA Class IU1 ain0!8ramity Prstw-w '1aPr3 Size Total 1.0 1 Acres Fy' 2000 US Mailing Index NamoiAddress Type Lean Number Active1nact. From l,tntil MU-LU, 5ll5AN 1; RICHARD Payor' 135 RALEIGH TAVERN LANE N. ANDO'3Eri, MA 01845 UB Account Maint. Account No� _� Cyrcia Occupant Nssms Aciroe/tn rc?ivr 3Ed9 Id, 13222.0 135 RALEIGH TAVERN LANE Last gTing Late ii l.' Uc1ti ?100'22 02 CyvIc 02 Active LCB SBrvices Maint. Service Code Rete charge 11 citlplier;6lser, MISC:FFE AIMAIN FEE 0.53 518 7.52 1! VJTR V.j ATER 0- ALL!V'1- T-E i SILL US Meter Maintenance Serie!No $ratus Location F3rand Tv,,,) Size yri'i Cons 1633564=+- a Active LU NP.cTE MET= p.'-W,; cr 0.x33 C.+.'v3 0 Data Reading Code Consumption Posted Dat; Variance 2;2!2006 584 a At;wa! 30 3/13,2006 5` 1111!1005 564 e[uai 78 11.,`14;2005 13(2/2005 526 a Acw.l 29 9!'12..'2005 1 'o 513(2005 497 a Artua1 27 6%$12005 t% 2/3x'2005 470 a Actual 31 3/15120CQ6 9`.0 11/512004 439 a:��tua! 26 12,1",,200•t. 1'1=:ro 8!10/2004 413 a Anrual 24 9!2012004 14°/a 5x13/2004 389 £+A,ctual r.7 6/1412004 5 211W2004 352 a Actual 3u 4i16 2004 111612003 332 n New Il^et r 0 ?t 1612003 7"!0 BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: LOCATION OF SOIL TESTS: 05 ✓t Le- � Assessor's map & parcel number: 10"7 A OWNER:JOAP%Ytz- 5wA. i4WTEL. NO.: ADDRESS: 1315 rZwl ,Gh —au ENGINEER: rTEL. NO.: 4,1 S-3 5 CERTIFIED SOIL EVALUATOR:Ei ki,, Inten land: .esidential subdivision, single family home, commercial Rair stin Undeveloped lot testing t� N. A. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evalLr,.at on*Forms shall be submitte W or wcR��H ANDOV PQ.�>Rt�or:;�R� i I � FL.� UL2 8 1999 � �� 1 i Tr) 'INN r ,. ��' ";. G?d�. ?'"� � q ,n llRRFFI ,✓ar frf R��"°A! ' � ,�{:�E dl � _��' �' J �,. M f.�� 3 . t 3" - �h•L4' !�iy �`„�C �� I.H�k , .` ,• y..� vy'�'F' kk'.'� k�,.x f ° �:-� ,. ” ,,, r. k w�l t;»i `.��q .SC"�J.Ir.,�s;,'� ,f'i T,y.¢.. ^ 4 r ;•w �r xf s tt 8°'r �, � ��' 4 � �' ., .- ,.�; .,�' .�,..� t "�.S�d r yy� „ t� tC�iS�. E ,.`n•f:, "^ Et s� a k, i» <«�.... rx�tr. ta:g: 't1 '" 'i�I,.� &J-�J}3�.�r•�� . r �" ... (�k.i fide, . � .. - ,.. � .i€ ..d � t. } '.P. �ks d i,":. , .,�, �' .r{� .d,k�°"s � �.. a .� �'' 1�l�Pelr� ��^ ..' � '•.�� «., ., #s �1?a`e•. 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" kag a r :,r " ��rain.k�Ar... 5 to x �: ai_r °!r. .r"• , I :r` a £. c a r s r 3r -�� ` r .4 `2 �. z}ffr. ti -C" 1" �"� '�•1I {=I} � t C. � a..� Sr��.:, ; 1f y�r:k S� ].4:t�'} 'S'o"F}.. i „#Y,C`'i�A ;x1"� s t c rx x rF _ar ea rte " t• +``r,.^�1°a� rr a t r ..,�b 1 I. y x.d "�.' -tn' Eaf rs I r °f sy.. • .�„.r L- L AI'EH: LOC ATI 0 N: `NLINE E Eu vv ITN E'S PEI=C i^TION TEST = E0 TT 0M D I Or PEER I 9 IM` GF C�,i�.. a' 4p )CIC) — o — — I I>viE CL NIGHT X0.2-K I I IMI C E ,^.iy I = E: - I iL, I iNiE A I r Town of North Andover' Massachusetts Form No. 1 r1ORTH BOARD OFflEALTH •p-/� 3�Oy Ss eo '6 Z. 6 `J' 19 * °R APPLICATION FOR SITE TESTING/INSPECTION �9SSACHUSE��� Applicant • NAME ADDRESS TELEPHONE Site Location - 09L'0"� Engineer . NAME ADDRE TELEPHONE Test/Inspection Date and Time t% eJ-29 C2 e CHAIRMAN,BOARD OF HEALTH Feed Test No. S.S. Permit No. �ZD.W.C. No.-A-13 C.C. Date Plbg. Permit No. a r APPLICATION FOR SEWAGE DISPOSAL INSTALLATION ` HEALTH DEPARTMENT - NORTH :ANDOVER, MASS. I hereby makeapplicationfor a per for ay sewage disposal installation at e�-- /,���c}�� / I will install this system in ac- cordance with all the la-A of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum .diameter being 4 inches, and will maintain a minimum grade ,of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%.- - 1 will install a con- crete septic tank of in size. A manhole ('s) permitting easy cleaning will be provided with removable cover (s) of iron or conerete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum oflineal' (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia. ) and the pipes. w ll'be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling,".the. trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will .be placed ,," .the course gravel or stone. The disposal field will be installed at a grade.of 4 td' inches/100 feet. No single tile line will exceed 100 feet, in length;and ' n any `.'ca's.e, two lines of tile will be install A ed. minimum of b feet will be- mantained�^b'e'tween the center lines of the disposal field trenches and the average =depth of treAie shall not exceed 36 inches. No part of the installation will be.-less tPan `100 feet,: from.an private water supply, ,�.._.. y P pP y, 25 feet from any stream, 20 feet from.. any dwelling or 10 feet from any property line. I further agree-not-to cover any portion of this installation until approved by the inspection officer, as. provided below, and'to incorporate any additional requirements that may be attached to the. permit., Plot Pians must be submitted with application. DATE /92 - F signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as describ d. DATE c Signaturd J6f Inspecting OflUer Percolation Test ����7 Garbage Grinder •'1 f BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. i 1. NAME LG�1�'` DATE e 2. ADDRESS i 0/ 2�L -fatil- LOT NO. TEL. 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDERYES NO f 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 1 x 1. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. I BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS SEWAGE DISPOSAL DATE 31 G NAME OF APPLICANT LOCATION Addre of lot no, BUILDING: Dwelling Other SYSTEM: NewK Repair J GENERAL DESCRIPTION OF LAND SUBSOIL: Clay avel Sand PERCOLATION TEST 7 minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK ) p- -p gallon capacity. LEACH FIELD ' lineal feet of drain piped OA William J, Dri c ll , Engineer Board of Healt