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Miscellaneous - 1367 GREAT POND ROAD 4/30/2018
/ 1367 GREAT POND ROAD 210/090.0-002¢0000.0 ID ROAD x s i k i i I I Jae, t? 'Ej HlIZ- in, << s -Ar N e ,p�w•� — w.l yr C�© 1367 GREAT POND ROAD JS-2003-0759 Proiect Detail Report Printed On:Tue Apr 27,2004 Project Name: GIS#: 4791 Project No: JS-2003-0759 Owner of Record WEBB,CHARLES L&ALLYSON Map: 090.0 Date Submitted: Apr-04-2003 1367 GREAT POND ROAD Block: 0024 Status: Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 1367 GREAT POND ROAD Zoning: Proposed Use: District: land Use: 101 Proposed Use Detail Subdivision Description Soil Testing Comments: of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2003-0057 4/16/04-Revised septic system as-built plan received from NEES. Okay for COC per Susan. 10/31/03-See Document link letter 6/20/03-Tues.-George brought in his certification form from Infiltrator Systems,Inc.(860) 4 577-7000. Took permit,receipt and copy of plan. File back in active drawer.--p.d. Mon.6/16/03-G.Henderson,installer,needs to be certified to do special type of septic installation. Certification person will be certifying George on Friday,6/20. DWC permit is signed,but is being held until certification complete. PDR and file in active file drawer.--p.d. Thurs.6/12/03-DWC application submitted and passed on to Sandy's DWC inbox. Previous applications from 2002 for site testing in file,but an assigned date was never written on the permit form. However,it appears that soils and peres were done in July and August of 2002. Design plan submitted in April 2003 was approved on 4/18/03. Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: Design Approval-Plans BHP-2003-0129 Jun-12-2003 SIGNED OFF JS-2003-0759 Septic Design Repair Soil Tests BHP-2003-0130 Jun-12-2003 SIGNED OFF JS-2003-0759 Soil Testing Septic System BHP-2003-0131 Jun-12-2003 SIGNED OFF JS-2003-0759 GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 I e r r li u I I I I r. t � -7 f I r a k 06/29/2007 09:20 FAX 6033780610 ASAP Qj001 } .y! AII'State Abatement Professionals, inc. 4 Wilder Drive, Suite 12 866-565-ASAP ' Plaistow, NH 03865 Fax:603-378.0610 FAX Date: �j l Number of pages includuag cover sheet: d/ To. / From: D 4 All State Abatemem Professionals,Inc. O a�'C.t' o->/' Aeoa Scott Curley Phone: Phone: (603)378-0600 Fax phone: 9 � $- (� j `62 _ Fax phone: (603)378-0610 i CC; RCM RM: ❑ Urgent ® For your review ❑ Reply ASAP ❑ Please comment Asbestos-Masonry Cieaning =Selective Demolition•Shot/Sand Blasting• Mold Remediation RE �{ `Commonwealth of Massachusetts u l W City/Town of North Andover JUN 014 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT �H DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System 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 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 1367 Great Pond Rd key to move your Address cursor-do not North Andover MA use the return key. City/Town State Zip Code 2. System Owner: r� Webb Name rertun Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 5/8/2014 2. Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? ® Yes ❑ No 5. Condition of System: Good 6. System Pumped By: Thomas Murray jr M79-896 (BHP-2014-0136) Name Vehicle License Number Wayne's Drains Company 7. Location where contents were disposed: Lowell Regional Waste Water 5/8/2014 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 NEW ENGLAND ENGINEERING SERVICES INC April 16, 2004 Susan Sawyer North Andover Board of Health 27 Charles Street - _ - --z uhf`"a:w OF N©21'N ANUG tt North Andover, MA 01845 RQ,er=n, OF HEAUN Re: 1367 Great Pond Road, As-Built Septic System APR 16 L Dear Susan: . Enclosed are 3 copies of the revised septic system as-built plan for the above referenced property. Per the request of Brian LaGrasse,New England Engineering Services performed a survey to determine the actual location of the segmental block retaining wall. The only changes in this revision pertain to the location of the segmental block retaining wall. No changes were made to the system ties or invert elevations. Please feel free to contact me with any questions or concerns. Sincerely, Thomas Hector, EIT New England Engineering Services, Inc. Enclosures (3) 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 i Page 1 of 1 f DelleChiaie, Pamela From: Dan Ottenheimer[info@milldverconsulfing.com] Sent: Tuesday, November 25, 2003 8:45 AM To: Heidi Griffin; Brian LaGrasse; Pamela Dellechiaie Subject: 1367 Great Pond Road Heidi, Brian and Pam, Attached please find the construction inspection report for the septic system built by George Henderson at 1367 Great Pond Road. The contractor should be calling your office to arrange for an inspection of the retaining wall which was not constructed at the time of our inspection, along with the final grading over the leach field. If you have an opportunity you may wish to check with the Town's Electrical Inspector to confirm that the alarm and pump were actually on separate circuits as required in Title 5. Dan Daniel Ottenheimer, President Mil[ River Consulting Septic System Management Services 5 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 w_ww.millriverconsulfng.com info@millriverconsuIting.com 11/25/2003 MILL RIVER CONSULTING Septic System Management Services TOWN OF NORTH ANDOVER SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS: 1367 Great Pond Road MAP: 90 LOT: 24 INSTALLER: George Henderson DESIGNER: New England Engineering Services PLAN DATE: 11/25/02 BOH APPROVAL DATE ON PLAN: 4/18/03 DATE OF BOTTOM OF BED INSPECTION: 10/31/03 & 11/04/03 DATE OF FINAL CONSTRUCITON INSPECITON: 11/14/03 DATE OF FINAL GRADING INSPECTION: SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION X PRESSURE DOSING HOLDING TANK ADVANCED TREATMENT OTHER COMPONENT SUMMARY FROM PLAN GALLON TANK = 1,500 LOADING OF SEPTIC TANK = n/a GALLON PUMP CHAMBER = 1,000 LOADING OF PUMP CHAMBER = n/a TYPE OF SAS = Field DIMENSIONS AND DETAILS OF SAS: 15' X 49' SITE CONDITIONS Inspections 0 Existing septic tank properly abandoned O Internal plumbing all to one building sewer 0 Topography not appreciably altered Comments: 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com Page 1 of 4 MILL RIVER CONSULTING Septic System Management Services SEPTIC TANK 0 Bottom of tank hole has 6" stone base 0 Weep hole plugged O 1,500 gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) 0 Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) 0 Inlet tee installed, over access port 0 Outlet tee (gas baffle or effluent filter) installed, over access port 0 24 inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present O Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER 0 Bottom of tank hole has 6" stone base 0 Weep hole plugged 0 1,000 gallon Pump Chamber installed (H-10 or H-20) (monolithic or 2 piece) 0 Inlet tee installed, over access port 0 Pump(s) installed on stable base 0 Alarm float working 0 Pump On/Off float working 0 Drain hole in pressure line 0 20 inch cover to within 6" of final grade installed over one access port 0 Water tightness of tank has been achieved Visual or Vacuum Test or Water held for 24 hrs 0 Hydraulic cement around inlet & outlet Comments: 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282. 0014 info@millriverconsulting.com Page 2 of 4 4" MILL RIVER CONSULTING Septic System Management Services D-BOX 0 Installed on stable stone base 0 Inlet tee (if pumped or >0.08'/foot) D Hydraulic cement around inlet & outlets O Observed even distribution D Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM 0 Bottom of SAS excavated down to. C soil layer, as provided on plan El Size of SAS excavated as per plan 0 Title 5 sand installed, if specified on plan D 3/4-1 %" double washed stone installed O 1/8-1/2" (peastone) double washed stone installed O laterals installed and ends connected to header (and vented if impervious material above) D Orifices @ 5 & 7 o'clock positions ❑ Gravelless disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan D 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Leach field not excavated to proper size. 3' narrower than needed based upon verbal discussion with George Henderson. Plan not on site. 10/31/03. Field size properly excavated 11/14/03. CONTROL PANEL ❑ Alarm & Pump are on separate circuits O Alarm sounds when float is tripped O Location of control panel: Basement ❑ Rated for exterior if placed outside Comments: Visual inspection 11/14/03 indicates apparent placement of pump and alarm on same circuit. Telephone consultation with George Henderson on 11/21/03 indicates he had Electrical Inspector visit site who confirmed they were on separate circuits. 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282. 0014 info@millriverconsulting.com Page 3 of 4 l' MILL RIVER CONSULTING Septic System Management Services SYSTEM ELEVATIONS Benchmark: 100.00 Rod at Benchmark: 1.95 Height of Instrument: 101.95 INVERT ON DESIGN PLAN ELEV Cad TOP OF PIPE INVERT ELEVATION Building Sewer OUT 98.00 Septic Tank IN 97.80 4.30 97.32 Septic Tank OUT 97.55 4.62 97.00 Pump Chamber IN 97.50 4.65 96.97 Pump Chamber OUT 97.25 Distribution Box IN 9997 1.81 99.81 Distribution Box OUT 99.80 Lateral 1 HIGH 99.72 1.86 99.76 Lateral 1 LOW 99.47 2.05 99.57 Lateral 2 HIGH 9972 1.82 99.80 Lateral 2 LOW 99.47 2.04 99.58 Lateral 3 HIGH 9972 1.83 99.76 Lateral 3 LOW 9942 2.03 99.59 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282. 0014 info@millriverconsulting.com Page 4 of 4 n � TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( j constructed; repaired; by Cc,:,, located at was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# ,plan dated ,with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310 CMR 15.000,Title 5 and local regulations,and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: `c Engineer Representative Final inspection date: Engineer Representative Installer: Lic.# 0 .g-? Date: . 2- L — G 3 Engineer: Date: G ' NEW ENGLAND ENGINEERING SERVICES lk INC December 10, 2003 George Henderson 280 Chandler Road `l� 12 Andover, MA 01810 _ 1 s Re: 1367 Great Pond road,North Andover Dear George: Enclosed are four copies of the as built plan for the above referenced property and the original certification document. You need to sign the certification document and deliver three copies of the plan with the certification document to the town for their approval. If you have any questions please don't hesitate to contact this office. Sincerely, Benjamin C. Osg d, Jr., EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 Page 1 of 1 DelleChiaie, Pamela From: Dan Ottenheimer[info@millriverconsulting.com] Sent: Friday, October 31,2003 11:31 AM To: Heidi Griffin; Brian LaGrasse; Pamela Dellechiaie Subject: 1367 Great Pond Road Heidi, Brian and Pam, Attached please find the construction inspection form for the property at 1367 Great Pond Road. The contractor did not have the design plan on the site but based on what he said the size of the leach field was, his excavation was 3' too narrow. He was going to check this, likely re-excavate the field, and then call for another inspection. He was sort of embarrassed by this error, and I felt bad for the guy. He said his nephew was doing the excavating not him. Dan MITI River Consulting Septic System Management Services 5 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 info@millriverconsulting.com 10/31/2003 i V MILL RIVER CONSULTING Septic System Management Services TOWN OF NORTH ANDOVER SEPTIC SYSTEM CONSTRUCTION NOTES ADDRESS: 1367 Great Pond Road MAP: LOT: INSTALLER: George Henderson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: SELECT SYSTEM TYPE GRAVITY DISTRIBUTION PRESSURE DISTRIBUTION X PRESSURE DOSING HOLDING TANK ADVANCED TREATMENT OTHER COMPONENT SUMMARY FROM PLAN GALLON TANK = LOADING OF SEPTIC TANK= GALLON PUMP CHAMBER = LOADING OF PUMP CHAMBER = TYPE OF SAS = DIMENSIONS AND DETAILS OF SAS: SITE CONDITIONS Date & Initials Inspections ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com Page 1 of 5 w- MILL RIVER CONSULTING Septic System Management Services SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, over access port ❑ Outlet tee (gas baffle or effluent filter) installed, over access port ❑ inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon Pump Chamber installed (H-10 or H-20) (monolithic or 2 piece) ❑ Inlet tee installed, over access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off float working ❑ Drain hole in pressure line ❑ inch cover to within 6" of final grade installed over one access port ❑ Water tightness of tank has been achieved Visual or Vacuum Test or Water held for 24 hrs ❑ Hydraulic cement around inlet & outlet Comments: 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com Page 2 of 5 MILL RIVER CONSULTING Septic System Management Services ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: D-BOX ❑ Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM 10/31/03 MRC El 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 ❑ 3/4-11/2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ laterals installed and ends connected to header (and vented if impervious material above) ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravelless disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Leach field not excavated to proper size. 3' narrower than needed based upon verbal discussion with George Henderson. Plan not on site. 10/31/03. 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com Page 3 of 5 MILL RIVER CONSULTING Septic System Management Services PRESSURE DISTRIBUTION ❑ inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282. 0014 info@millriverconsulting.com Page 4 of 5 e MILL RIVER CONSULTING Septic System Management Services SYSTEM ELEVATIONS Benchmark: Rod at Benchmark: Height of Instrument: INVERT ON DESIGN PLAN ELEV ,j TOP OF PIPE INVERT ELEVATION Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Manifold Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW 5 Blackburn Center, Gloucester, Massachusetts 01930-2259 toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com Page 5 of 5 TOWN OF NORTH ANDOVER BOARD OF HEALTH Location / � -ncn to D «*• ro �wti Permit # x 4 cD CD .+ ,�+o�w, o Food Service $ r c9 C) = 2 01;., 0 1 1/ O a ��a j' ;'� Retail Food $ v,' � '= �'•;�..., ooh o �„ 0 **„ n�'` Limited Retail $ h w CD z' Seasonal $ h; CD a � 3 b m Disposal Works Installers $ 3 v �/ w Disposal Works Construction"--$/ onstruction o a Soil Testing $ D � o ( r o Design Approval Permit $ 0 0 y0O W z N o Dumpster Permit $ _ D 70 D Burial Permit $ O y Z n o Swimming Pool Permit $ �D o m Animal Permit $ D ` nRecreational Camp Permit $ M.. w p, y c Well Construction Permit $ A v� z r- 3 'v co Funeral Directors Permit $ D z w \� m N Massage Establishment License $ O 1� _ U Massage Practice License $ z w Suntanning Establishment $ o = M N D p , Offal/Trash Hauler $ r -I " �D Other $ 0 r T \ k - 3 z ° 6952 • j m w � Health Agent 1 TOWN OF NORTH ANQOVE BOARD OF HEALTH Location �.J?6•/ 4,1" Permit # Food Service $ Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers �$ / Disposal Works Constructions $ Soil Testing $ Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ _ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ offal/Trash Hauler $ Other $ 6952. Health Agent White - Applicant Yellow - Dept. Pink - Treasurer a V , TOWN OF NORTH ANDOVER/ BOARD OF HEALTH 1 Location Permit Food Service $ Retail Food $ iLimited Retail $ Seasonal $ Disposal Works Installers �$ Disposal Works Construction,/'$ Soil Testing $ f Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ Offal/Trash Hauler $ Other $ 695 Health Agent M- ite - Applicant Yellow - Dept. Pink - Treasurer i f . APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: L j z —0.3 CURRENT INSTALLER'S LICENSE# LOCATION: / 36? � r�c �`` �®n 9d, LICENSED INSTALLER: L9 Alea SIGNATURE: / TELEPHONE# °��v �' s 9,5'- CHECK �CHECK ONE: REPAIR: f/� NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $175.00 Fee Attached? Yes t/ No Foundation As-built? Yes No Floor plans on file? Yes le'51�C_ No Approval Date: 2003 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North.Andover licensed installer for the construction of the septic system for the property at 13 7 [� r� �i r, d) G A? relative to the application of 4 449 dated f�- o Z for-plans by.h e w I' and �Nc,vrrvF�Mrg -eY/>/C e S dated with revisions dated f/ d I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,. without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the, system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. , 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer Date:_ G!2�--,e 3 Disposal Works Construction Permit# JUI 1 2 2003 Town of North Andover, Massachusetts Form No.2 '. 01 MOR7h, BOARD OF HEALTH ' " o C16 a3� DESIGN APPROVAL FOR ass"CHUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant /� / �`�= Test No. : Site Location Reference Plans and Specs.v/ G' �✓�� `���`� - �'' • ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. C AIRMAN,BOARD OF HEALTH • � n Fee /� Site System Permit No. ��D� rw Town of North Andover, Massachusetts Form No.2 BOARD OF HEALTH 0 0 40— DESIGN APPROVAL FOR VSs"C SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM K Test NO Applicant n.— -7 Site Location Reference Plans and Specs. ENGINEER DESIGN Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CWAIRMAN,BOARD OF HEALTH Fee Site System Perrnit No. /11140 • TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET ", NORTH ANDOVER MASSACHUSETTS 01845 ssaCHU51 Sandra Starr,R.S., C.H.O. Telephone(978)688-9540 Public Health Director FAX(978)688-9542 FAX Benjamin C.Osgood,Jr.,EIT From: Pamela for Sandra Starr TO: NEW ENGLAND ENGINEERING ' SERVICES,INC. 60 Beechwood Drive North Andover,MA 01845 978-685-1099 Pages: 2 Faic 978-686-1768 Date: Thursday,April 03,2003 Phones Septic Plan Response CC: Sandra Staff, R.S.,C.H.O. Re: Health Director O Urgent X For Review ❑Please Comment 13 Please Reply 11 Please Recycle •Comments: Attached is the response from Sandra Starr regarding Septic Plans for the following property: A co has also been mailed to the homeowner. mewvner. Please call 978-688-9540 for assistance with any questions. Thank you. Xc: ;/Address File Chrono File f %ORTH 1 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 SACHUSt Sandra Starr Telephone(978)6889540 Public Health Director FAX(978)688-9542 April 2, 2003 Ben Osgood, Jr. New England Engineering Services, Inc. 60 Beechwood Drive North Andover, MA 01845 Re: 1367 Great Pond Road Dear Mr. Osgood: This is to notify you that the proposed plans dated November 25, 2002 for the repair of the septic system at the site referenced above are essentially approved. There are two items only that should be added to the plan; a note about protection of the vent from animals and weather, and a thrust block at the eastern end of the force main. If you have any questions, please call the office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: BOH Homeowner File NEW ENGLAND ENGIIc EERING SERVICES lk April 7, 2003 Sandra Starr,Administrator North Andover Health Department Town Hall Annex9 2003 27 Charles Street North Andover,MA 01845 `! Re: 1367 Great Pond Road,North Andover, Septic system designu �` � Dear Sandra: Enclosed are 5 copies of revised septic system design plans, one with an original stamp for the above referenced property. The following corrections were made to the plan. 1. The vent detail has been revised to indicate the installation of a charcoal filter/animal screen. 2. A thrust block detail has been added. 3. A note indicating that thrust blocks shall be installed at all force main bends has been added. This plan is being submitted for approval. If you have any questions regarding the information submitted,please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood .,EIT President Cc Owner 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 M ? 4 CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS Job The following is a checklist that incorporates all Title 5 and local regulations for septic plans. Name of Appli t: � �� � �6 P P Alz-:Name of Designer: E'5 f J Plan Date: 6 l5 L� Revision Date: Date of Review: 7 Property Address: J 3!y 7- Map: Lot: BOH Reviewer: Type of Plan(new or upgrade): Number of Bedrooms: -Ah gpd) Garbage Disposal Allowed: General Information: N.A.=North Andover Septic Regulations Other numbers refer to Title 5 OK roblem N/A Street number and map/lot-220(4)(u) Maximum scale of 1 —40 -for plot plan 220(4) Maximum scale of 1 "=20'for profile and component details-220(4) Legal boundaries of the facility being served-220(4)(a) Names of abutters from recent tax map- NA 8.02j Number of bedrooms,design calcs.,-NA 8.02i Name&address of record owner&applicant- NA 8.02k Name&address of designer-NA 8.021 Holder and location of all easements-220(4)(b) Date plan drawn&any revision date- NA 8.02m ✓_� All dwellings and buildings,existing and proposed-220(4)(c) Location of all existing or proposed impervious areas-220(4)(d) �- All distances on site plan—NA 8.03a-c Elevation of proposed driveway NA 8.02t ✓ Location and elevation of foundation drain-NA 8.02y ✓ Location and dimensions of the system incl.reserve(new const.)-220(4)(e) Limits of excavation of leach area on site plan-NA 8.02z Locus plan-220(4)(t) (Not to scale) North arrow-220(4)(g) ✓ Existing and proposed contours-220(4)(g) ✓ Locations and logs of deep holes-220(4)(h) Locations and logs of percolation tests-220(4)(i) Date(s)of soil testing-220(4)(h)&(i) Existing grade elevation of each deep hole-220(4)(h) ✓ Elevation of percolation tests—N.A. 8.02n ✓" Name of approving authority representative-220(4)(h)&(i) ✓ Name of soil evaluator-220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines,drains,and subsurface utilities-220(4)(m) ✓ Observed and adjusted g.w.elevation in the vicinity of the system-220(4)(n) Complete profile of the system to scale-220(4)(o),NA 8.02c Cross section of leaching facility-NA 8.02w (Not to scale) ✓ Location of benchmark(s)within 50-75 feet of facility-220(4)(q) Note listing all variance requests with proper citations-220(4)(p) Local upgrade approval request form submitted-403(1) a 2 Original R.S./P.E. stamp,signature&date-220(1)&(2) -P-E-,-discipffne specified7w-ittiii s`t ma p. MGL C. 112 s. 81M sfc. supplies(w/in 400'),pub.wells(w/in 250'),pvt.wells(w/in 150')-220(4)( _AL' Location of watercourses,wetlands,wells,etc.Win 150'of system-NA 8.02r Wetland disclaimer-NA 8.02s RLS plan reference&certification required(prop line setbacks)-220(3) Plan contains designer's certification statement Use approvals/standards checked for I/A system-DEP docs., i✓ Perc rate>30 MPI-not allowed for new,LUA for upgrade-245(1)&('3) 1✓ Perc rate> 60 MPI-must use modified tight tank or VA technology-245(4) ✓ Proposed system qualifies as"shared"system-002(definitions) ,✓ Flow is over 2,000 gpd-No R.S.allowed-220(1) Design flow was set in accordance with code-203 Existing system location and note on proper abandonment-354 Leaching facility at least I' above Base Flood elevation-NA 9.05 t/ All piping Sch 40 minimum-NA 10.01 Basement floor minimum 1'above groundwater elevation-NA 5.04 Foundation drain present with elevation-NA 8.02y On-site Soil and Groundwater Review OK Problem N/A +� Proper deep observation hole logs on plan-220(4)(h) ✓ All deep holes and peres shown,including aborted tests-NA 8.02n t/ Soil evaluation forms submitted within 60 days of field work-018(2) Proper percolation test log-220(4)(i) Ample deep observation holes in primary disposal area(minimum 2)- 102(2) Ample deep observation holes in secondary disposal area(minimum 2)- 102(2) ✓ Ample perc testing(one in each disposal area,3 in prim.>2,000 gpd)- 104(4) Deep hole testing conducted within two years-NA 7.05 Hole Identification Numbers: � / Z2�& ground elevation el. AW •!// W-$z � acceptable soil el. �ga 7 ' Leach facility invert el. / y 7 ground water el. � refusal el. / bottom of leach facility el. 99, VY thickness of acceptable soil �7 [o� 211"16 before&after soil R&R separation to groundwater separation to refusal soil class 2 • 3 i perc rate loading rate — septic tank below g.w.table (yes or no) pump tank below g.w. table (yes or no) 11 in fill -41 -255(l) Setback Distances(Given in feet) 15.21 1 YES NO Is the lot in the Lake Cochiewick Watershed? NA 6.00&5.02 OK Problem N/A Septic Tank Leach Facility VCx. r. Property line 10 10 Cellar wall 10 20 i�Inground pool 10 20 Slab foundation 10 10 Deck,on footings,etc. 5 10 Waterline 10 10 Private drinking well 75 100 r Irrigation well 75 100 f Wetlands 75 100 Public well 400 400 L/ Wetlands bordering surface 150 150 water Supply or trib. / (in Watershed) v Trib. To Surface Water supply 325 325 i/ Reservoirs 400 400 Tributaries to reservoirs 200 200 Drains(wat. supply/trib.) 50 100 Drains(intercept g.w.) 25 50 l� Foundation drains 10 20 Drains(Other) 5 10 L/ Drywells 20 25 y Downhill slope 15'to 3:1 slope 3 4 w/o barrier Building Sewer OK Problem N/A Grease trap required for certain uses(check 230 for details) Pipe diameter listed(4"minimum)-222(1) Pipe schedule listed-222(3) Pipe cast iron or Sch 40 PVC—NA 11.02 / Watertight joints specified-222(3)&(4) Pipe laid on compact,fin base-222(5) Pipe laid on continuous grade in straight line-222(7)@ Cleanouts precede all changes in alignment and grade-222(8) L,..-' Cleanout provided every 100 feet-222(8) Lf Manhole at any 90 degree alignment cha ge-222(8) ✓ Invert elevation at building: Invert elevation at s tic tank: q 7, Q Length of run: Slope: d -D `4,- (minimum of 0.01 -0.02 desired)-222(6) c/ 10'offset to private well or suction line-222(2) Septic Tank OK Problem N/A Tank is accessible-228(3) No structures above tank—(228(3) Tank can accommodate both primary&reserve—NA 9.04 200%of flow(required&provided given. 1500 min.)-220(4)(f)&223)(1)(a) V_ Minimum 2-3"drop from inlet to outlet-227(5) Minimum of 4'liquid depth-223(2) 3"air space above tees/baffles(minimum)-227(4) ✓ 9"air space above flow line(minimum)-227(4) Tees are not to be replaced by baffles-227(1) c/ Tees extend 6"above flow line-227(1) Inlet tee extends 10"below flow line(minimum)-227(6) Outlet tee extends 14"below flow line(more for deeper tanks)-227(6) Gas baffle installed on outlet-227(4) Access manhole cover above center of tank&each tee(except 2 compart) 228(2) 3-20"manholes-228(2) 1,7- 1 childproof;24"riser/manhole w/in 6"of final grade if<1000gpd-228(2) Inlet and outlet tees on center line-227(1) Soil compaction below tank specified(if soil is non-native)-221(2) ✓ 6"of<=3/4"stone beneath tank specified-221(2)&22 8(1) If> 1,000 gpd AND not a single fam.dwell.must be 2 tks or 2 comp.-223(1)(b) If plan specifies disposal must be 2 tanks in series or 2 compart.tank-223(1)(c) Buoyancy calcs.required if tank at or below water table-221(8) 7 Tank is watertight-221 (1) 9"of cover over tank(minimum)-228(1) / H- 10 loading(min.)-H-20 if traffic-226(3) ✓ Top of tank<=36"below grade-221(7) ✓ All pumping to tank(if applies)in accordance with-229 Tank is set to keep old system in service during install if possible 4 5 Tight Tank(Check here if not present: � )' OK Problem N/A 500%of design flow or 2000 gallons provided—260(2)(a) 3-20"manholes—228(2) Soil compaction below tank specified(if soil non-native)—221(2) 6"of<=3/4"stone beneath tank specified—221(2)&228(1) Buoyancy calcs.Required if tank at or below water table—221(8) Tank is watertight—221(1) 9"of cover over tank specified(minimum)—228(1) H-10 loading(min.)—H-20 if traffic—226(3) Top of tank<=36"below grade—221(7) All pumping to tank(if applies)in accordance with—229 AN alarm set at 3/5 tank capacity—260(2)(c) Min. 1-24"frame w/cover at finished grade—228(2)(f) Year round access for pumping—228(2)(g) Distribution Bog(Check here if not present: ) OK Problem N/A Inlet elevation: 7 Outlet elevation: 7 0.17'drop from inlet to outlet(minimum)-232(3)(b) 6"sump(minimum)-232(3)(e) All outlets at same elevation-232(3)(b) Outlet pipes laid level for first 2 ft. -232(3)(c) Pipe Sch 40-NA✓ 10.0 Number of outlets: (p Number of laterals: 3 Size of outlets: i/— Inlet baffle/tee min. 1"over outlet invert for all d-boxes-232(3)(a), Soil compaction below distribution box specified(if soil is non-native)-221(2) 6"of stone beneath distribution box specified-221(2) Box is watertight-221 (1) Top of box<=36"below grade-221(7) ✓ Buoyancy calculations required if box is at or below water table-221(8) Pump Chamber(Check here if not present: ) OK Problem N/A Volume specified: 100 1220(4)(r) Pump on elevation- W9,3 3 220(4)(r) Pump off elevation: 7 220(4)(r) Alarm on elevation: 220(4)(r) Number of cycles per day-220(4)(r)(also 254(1)(d)if gravity from d-box) Minimum 2"delivery line to d-box if gravity-254(1)(c) ii Pressure dosed Lf if flow>=2,000 gpd-254(1)(a)&254(2)(a) Cycles per day is consistent with chamber volume-23 1 Volume calculations include flowback volume-2') 1(2) 5 6 24 hour storage capacity above pump on elevation-231(2) Number of pumps: 2 if system serves>2 dwelling units-231(6) !/ Capacity of pump(s)- /pZ gpm @ 9' 'TDH-220(4)(r) Pump can pass 1 1/4 "solids(minimum)-231(7) Pump controls specified-220(4)(r) Alarm equipment specified-231(2) Alarm is in building and powered on separate circuit from pump-2') 1(9) l . Pump sequence correct(off-lead on-lag on-alan-n on)-231(8) Pump performance curves included-220(4)(r) Manual operating switch-NA 12.01 Check valve,bleeder hole-NA 12.01 1 childproof,24"riser/manhole to final grade-2'31(5), Soil compaction beneath pump chamber specified(if soil is non-native)-221(2) 6"of<=3/4"stone beneath chmbr.specified-221(2)&228(1), Buoyancy calculations if chamber is at or below water table-221(8)@ 9"of cover over chamber(minimum)-228(1) H- 10 loading(min.)-H-20 if traffic-226(')), Chamber is watertight-221 (1) Top of chamber<=36"below grade-221(7) Leaching Facility(general-complete for all designs) OK Problem N/A/ ✓ 50%larger if garbage disposal-240(4) Trenches to be used whenever possible-240(6) No vehicle or imperv. area above 11 unless unavoidable-240(7);NA 13.02 Vented if under impervious cover-241 (1) Vented through same pipes as distribution system-241 (1)(a) Vent protected from precipitation/animal entry-241 (1)(b) 7 Vent is placed beyond traffic or impervious area-24 1 (1)(c) All lines connected to vent if bed or trenches-241(1)(d) +/ 9"cover over peastone-240(9) ��Reserve area provided(new construction)-248(1) Reserve 4' from primary leach area—NA 9.04 VQr. 4'(5'if perc rate<=2 MPI)separation to g.w. -212(a)&(b) C/ 4'(down to 2'with variance or I/A-upgrades only)of natural soil under Lf GW separation is adjusted to highest existing grade if facility cuts into a hillside Pipe slope minimum of 0.005-251(9) �[ Require 5'removal and replacement if in fill-255(5) Top of leach facility<=36"below grade-221(7) Final grade over 11.minimum 0.02 ft/ft-240(10) ✓ Surface&subsurface drainage away from l.f. -240(1 1)&245(5) Minimum design flow 440 gpd without deed restriction—NA 13.01 3:1 slope where grading required-255(2) Toe of fill slope stops 5'from property line or swale installed-255(2) Impermeable barrier if<3:1 slope or< 15 feet to—3:1slope-255(2) Impermeable barrier/retaining wall —NA 9.02 S / Retaining wall stamped by P.E. -255(2)(b) Top of retaining wall>=top of peastone elevation-255(2)(f) — 10'offset from edge of leach facility to edge of ret.wail-255(2)(g) ✓F Perc test(s)done in most restrictive layer- 104(2) Perc test 4' below leaching elevation—NA 7.06 Design flow listed and required/provided leach area given-220(4)(f) Leach pipes SCH40 PVC—NA 10.01 Leach pipes minimum 4"diameter except for dosed system—NA 14.04 6 Leach lines capped,vented,or connected together-251(9) Pressure dosing guidance followed if pressure distribution-254(2)(c), s/ Pressure dosing required over 2,000 gpd or with I/A remedial use-231(1) Leaching Trenches(Check here if not present: `� ) OK Problem N/A Number of trenches: Minimum of 2 trenches-NA 9.01(2) Depth of trenches(max eff.2'): -247(l) Width of trenches(2'min.,4'max.): -251 (1)(b) Length of trenches(100'max.): -25 1 (1)(a) Trenches are vented(when>50')-251 (11) Trenches follow contour lines-251(2) Trench spacing 3 times effective width or depth minimum-251 (1)(d) In fill or reserve between trenches, 10'min. -NA 14.01& 14.03 Available leach area given(Min. 500 s.f.)-NA 9.01(2) Bottom=L x W x# = s.f. Sidewall=L x x# x2= s. f. Effective leach area given Loading factor: Effective area=total area s.f.x LTAR = g/day Effective area is>=design flow of facility being served 2"of 1/8"- 1/2"2x washed peastone.-247(2) Trench depth of 3/4"to 1 1/2"double washed stone-247(1) Leaching Pits(Check here if not present: ) OK Problem N/A #ofpitstpit systems: (dosing chamber if>1,231 (1)) Dimensions of each pit or system:L W D Depth of pits(max eff. 2'): -253(1)(a) Available leach area given Bottom=L x W x#of systems= s.f. Sidewall=L+W x D x 2 x#of systems= s.f. Total area=bottom +sidewall = s.f. Effective leach area given Loading factor: Effective area=total area s.f.x LTAR = g/day Effective area is>=design flow of facility being served Minimum of 2 pits at least 13'X16'—NA 9.01(3) Distribution for galleries/chmbrs. in trench config. -pipe every 20'-253(6) Distribution for galleries/chmbrs. in bed config.-ea.pipe serves<=40 s.f.-253(6) Spacing-2 times the effective width or depth(the greater)-253(1)(c) 2"of 1/8"- 1 /2"2x washed peastone.-247(2) 3/4"to 1 1/2"double washed stone-247(1) Each pit has at least one 20"access cover.24"Cl to grade over 2,000 gpd -253(3) Surrounding aggregate thickness between 1'(min.)and 4'(max.)-253(1)(b) Vents,if necessary,extend under covers of pit(s)-241 (e) Leach Fields(Check here if not present: ) OK Problem N/A Number of fields:_ (need dosing chamber if> 1,231 (1)) 7 . 8 ,. ✓ Length(100'max.): -252(2)(b) 1/ Width: f'5 Total area:L�x W _ r f. ✓ �� Minimum 900 square feet-NA 9.01(1) Distribution lines connected with solid pipe—NA 15.01 ~� Effective leach area given -.;7 Loading factor: / // Effective area=total area �J' s.f x LTAR -lO = �y/ g/dav Effective area is>=design flow of facility being served Minimum of two distribution lines-252(2)(a) 6'line separation(max.)-252(2)(d) s� 4'maximum separation from edge of field to line 252(2)(e) 10'minimum separation between adjacent leach fields-252(2)(f) �f Between 6"and 12"of 3/4- 1 1/2"stone beneath field-252(2)(g)&247(2) 2"of 1/8"-1/2"2x washed peastone.-247(2) Final Grading OK Problem N/A '/' Slope over leach area minimum of 0.02 feet/foot—240(10) Grading shall divert drainage away from leach area—240(l 1) Grading slopes away from dwelling 5/24/01 8 NEW ENGLAND ENGINEERING SERVICES lk INC December 2, 2002 Sandra Starr,Administrator North Andover Health Department Town Hall Annex DEC ` 4 2002 27 Charles Street North Andover, MA 01845 - _.--- Re: —Re: 1367 Great Pond Road,North Andover, Septic system design Dear Sandra: Enclosed are the following documents for the above referenced property. 1. 5 copies of design plans, one with an original stamp. 2. Soil evaluator sheets. 3. Form 9A request for local upgrade approval. 4. Application for approval and required fee. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, Benjami i C. Osgoo , Jr., EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 SEPTIC PLAN SUBMITTAL FORM LOCATION: 1 3(6 7 IZ.o a v NEW PLANS: Q $160.00/Plan REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: NO DATE: DESIGN ENGINEER: Fri G-L.A-A,a E NFj;,,c- DATE TO CONSULTANT: t DEC - 4 2002 When the submission is all in place, route to the Health Secretary. cx` Town of North Andover, Massachusetts Form No. 1 NORTH P BOARD OF HEALTH //J } 3 0 1� o m APPLICATION FOR SITE TESTING/INSPECTION SACHUSE��h , ApplicantA.��� NAME ADDRESS TELEPHONE Site Location / !? 40 ER —,—POIV Engineer dJ'L:%-V 0,56 co b NAME ADDRESS TELEPHONE Test/Inspection Date and Time --,1 CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. ` 1 �T_gwn of North Andover, Massachusetts Form No. 1 pIORTH ♦ "BOARD OF HEALTH Jj �LMy 3�O��SIED l6�'YOL -5-130 6 I 0 t6 Q Y •yy1' In F � `3ti <o<:,.:w,<. * APPLICATION FOR SITE TESTING/-INSPECTION SACHUSE��y _ Applicant a� eLCS 1'04466 NAME ADDRESS TELEPHONE Site Location 67 GRE97_ __FOW� EngineerN 056' CO L>�_R NAME ADDRESS TELEPHONE Test/Inspection Date and Time -- C__ _ CHAIRMAN,BOARD OF HEALTH Fee - Test No. S.S. Permit No. D.W.C. No. C.C. Date .. Plbg. Permit No. PH®11lE CALL FOR (1 DATE TIME + ��/ P. M li C�!• '�.. �2� OF PHONED RETURNED PHONE !) YOUR CALL AREA CODE NUMBER XTEN SIO" MESSAGE lr'2 q ( (1 I \"fe PLEASE CALL + WILL CALL RlqnAGAIN CAME TO SEE YOU WANTS TO SEE YOU SIGNED �niversal 48003 NOTES t Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH NORTN • •- �O5 SS LEo /6�•r 0 i � L ,. A 9 -. APPLICATION FOR SITE TESTING/INSPECTION A�AATE�PPP' '�y ��SSAGHl15�S nie8 Applicant ADDRESS TELEPHONE t, NAME z Site Location �� Cn Q ERT -PIV SIV �`SU� �` TELEPHONE NAME r Engineer ADDRESS Test/Inspection Date and Time f, r. CHAIRMAN,BOARD OF HEALTH Test No. _.- Fee S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. 9 ' Pj 0-t O'-111 E.CA L L FOR (1 DATE r TIME +t b P. M Q t,S L3e, 77 O F PHONED 1 / RETL)RIIED PHONE 191r SSR AREA CODE NUMBER XT NSION -r. MESSAGE W##1 CALL ; qAGAaN,.. � . CANtE 'ti ;'. S£E WANTS TO SEE YOLI;: S I G N E D �nIVE?fSOI 48003 BOARD OF HEALTH . Ra NORTH ANDOVER, MA 01845 . 978-688-9540 APPLICATION FOR SOIL TESTS DATE: Z MAP &PARCEL: 10c - 2 LOCATION OF SOIL TESTS: 1 '3(.-7 c:,'2�4'a Po f -D OWNER: (SVc,2 LL 5 W E+3 B TEL.NO.: 17,9- ADDRESS: 7,9-ADDRESS: ?, (,7 ENGINEER: &,44;,ee P-4 !27 TEL.NO.: q7 43- SSC, -l76-3 CERTIFIED SOIL EVALUATOR: Intended Use of Land: Residential Subdivision Single Family Hom Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$200.00 per lot for repairs or up ades. (If time is not critical, fee for repairs is$75.00) GENERAL INFORMATION I. 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 I"A 00') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: . 6 / Date Received: Check Amount: Check Date: low x`40 M - 40 VIM BOARD OF HEALTH . NORTH ANDOVER, MA 01845 978-688-9540r APPLICATION FOR SOIL TESTS DATE: MAP &PARCEL: 10 C — 2 I LOCATION OF SOIL TESTS: 13G-7 OWNER: �1^c,2 !,L 5 `-v E+3 B TEL. NO.: ADDRESS: ENGINEER:_NiIA-1T4 P-"" ee,0, !27 TEL. NO.: q7 f3— GS(�; �176.3 1-1 CERTIFIED SOIL EVALUATOR: 10 J Intended Use of Land: Residential Subdivision Single Family Hom Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No__X THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) S 2. Plot plan & Location of Testing 3. Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$200.00 per lot for repairs or up ades. (If time is not critical, fee for repairs is$75.00) 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"A 001) shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: r y I� T ' . M / FORM 11 - SOIL EVALUATOR FOR,,N ' Page 1 of . No. ( Z-- Date: Commonwealth of of Massachusetts Massachusetts SoilSuitability Assessment� r On-site Sewage Disposal o�— Performed B ` ' Date:7�� WitnessedB .... ..................... ....... (acaiion Address a �L%�' �P Fes` 0—er's Name. �-�•j �f/.� Www Address,and �7 � D ey Tdeplarc/ ,x New Construction ❑ Repair _Office Review Published Soil Survey Available: No ❑ Yes Year Published I �................. Publication Scale Soil Map Unit �9"" g� Drainage Class 0';-4A—.......... Soil Limitations .................................................................. Surficial Geologic Report Available: No Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) .................................................................................................................. ... ..... ...... ......... Landform _.. _....- Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No El Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) -................. --.... - ................................... Wetlands Conservancy Program Map (map unit) ................................... Current Water Resource Conditions (USGS): Month J4/4--7/ Range :Above Normal ❑Normal ❑Belcw Normal Other References Reviewed: DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FOKI1 Page 2of3 Location Address or Lot No. 3�7 � ��.Uy •�" �'' �kv�G On-site Review / r o Deep Hole Number .:.:: Date:.71WO-171 Time:. O 9.r-'-a Weathe ��� .� .: Location (identify on site plan) Land Use Slope o Z .:::::.:.:...: ..::...:..:....tA�l;l9�.... . (%) .....:.:.:... . Surface Stones '–" Vegetation .. !mom. .....:::. Landform Position on landscape (sketch on the back) Distances from: Open Water Body,< feet Drainage way .2!5, ..:. feet Possible Wet Area �� b 2. .. ..... feet Property Line .. �..::.....:. feet Drinking Water Well�>4�... feet Other .......:...... DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) o o amu, L �'S .Jy ilk 3 1rl'ye ED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) 6G f!�ii �L C— DepthtoBedrock: `— Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: .r _ Estimated Seasonal High Ground Water: DEP APPROVED FORh1• 12107/95 FORM 11 • SOIL EVALUATOR FORM Page 2 of'3 Location Address or Lot No. �3�� 1` �1� ��� �• ���� '�- On-site Review d Deep Hole Number _::Z Date: /�Z' Time: .':3� Weather Location (identify on.site plan) Land Use .::.:/ '�r�� xilT _L. Slope M : :. . Surface Stones Vegetation . .:...::::::.:::.:..:::...:..:. . Landform .::.::.::.�opr..tJD:::.. .I✓��lJ (E Position on landscape (sketch on the back) oto Distances from: Open Water Body feet Drainage wayFz� _:. feet Possible Wet Area 2 ©:.. feet Property Line .2�.:.... feet Drinking Water Weller®._ feet Other ........,. DEEP OBSERVATION HOLE LOG` Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, % Gravel) YAP O yR 416 014 ,s 6iy YCIZ . ,q� .- q�j y 5 +iOLES REQUIRED-AT-EVERTM0POSED DISPOSAL AREA Parent Material(geologic) 45�"jV_<= 7T4-G C.-- DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: / Weeping from Pit Face: _ �p t Estimated Seasonal High Ground Water: ---- DEP APPROVED FORh1- 12/07/95 v FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. � � � r� � � N• � b��7cC. Determination for Seasonal High Water Table s. Method Used: ❑ Depth observed standing in observation hole................... inches ❑ Depth weeping from side of observation hol ................... inches QDepth to soil mottles ...,.....:....finches � Cld Grounwater adjustment .................... feet Index Well Number .................. Reading Date ................... Index well level ................... Adjustment factor ................... Adjusted groundwater level ........................................................ Depth of Naturally Occurring Pervious Material Does at least.four feet of naturally occurring pervious material exist inIt areas observed throughout the area proposed for the soil absorption system? . .I If not, what is the depth of naturally occurring pervious material?. --- Certification I certify that on�l ��-(date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signatur ° Date DEP APPROVED FORM-12/07/95 M CIA 0 CA.71-)C N. o' ----------' /V IT N ' cE OL i 1 C N i ES i .= ' =C' ►1—i Oltil mac, ;: CIS -:C i i• �� • �C�� f S�� i L iHME , =- Ni LOC, ------------- ^COL i ION i WE T i Itil� .�.��•, t L O�.'�=NSG^ 1 =. T IN/IE S .. .r^.^.. PvI_ . . I 1 ;Iv1 . y Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health For the upgrade of a failed or non-conforming system with a design flow of<10,000 gpd, where full compliance, as defined in 310-CUR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non-conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: c gffR j-t s w t 3 i3 Address: �3C,7 Cs R E Ami Fo N P-b No 2TN NN ilo t,2 Phone#: q7 g 6 E36-SSS G Address of facility: l36'7 2) Applicant (if different from above) Name: S r Address: Phone#: 3) Type of Facility: ✓1lesidential Commercial School Institutional (specify) _-'s Lo1,-- Page 2 of 5 4) Type of Existing System: _privy cesspools) ; _ conventional system other(describe) Type of soil absorption system(trenches, chambers, pits, etc.) 5) Design Flow Based on 310 CMR 15.203: a) Design.flow of existing system ? gpd Approved: ?es Approval date: ? no Why: b) Design flow of proposed upgraded system Yp gpd Why_j c) Design flow of facility `V LI o gpd 6) Proposed upgrade of existing system is: a) ✓Voluntary required by order, letter,etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: 2-1iAi-c . 1E -rAn,)A, A P1111 An» 2-cf1{(4 j=/6CI c) Which of the following are applicable to the proposed upgrade? ✓Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) j-eaLR - rt Fav -fu P a.o? W N b If2o M 10` -1-0 6 Percolation rate of 30-60 minutes per inch(state actual perc rate) Up to 25% reduction in subsurface disposal area design requirements (state required& proposed size) Relocation of water supply well (identify well, describe relocation) VReduction of required separation between bottom of SAS & high groundwater(specify proposed reduction & perc rate) /J rn(V? f iAt(kf Page 3 of 5 _ Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) if the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater 3 feet As determined by: Evaluator's name: ti 2,4 5-TA�L,Z Evaluator's Signature: Date of evaluation: 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda: Such notice shall include the date, time and place where the upgrade approval will be discussed. If the department is the approving authority,then such notice toabutters 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. • I Page 4 of 5 List of affected abutters: i Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9)' Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: G-o T e S •7�� .�-t.ate� b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. _ 'n57- i s JlLo/1e,9- 0-77oc c) A shared system is not feasible. J- , rs �o ffD J.9 cE�v AN�i o i��ry�r3bLe Lne#N 0 d) Connection to a sewer is not feasible. —/HI A,' X-1i;lso""'-64C �iSi�NGL� 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications,site evaluation forms),.must accompany this application. Is the DSCP application attached? yes no Page 5 of 5 11) Certification ; "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true,accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." Facili Owner's SiO tore Date e�; Gcv� n G Print Name z zo z Name of Preparer Date Telephone No. &Address of Preparer NOTE: Title 5,310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. STATEMENT DANIEL A. GIARD 130A Appleton Street NORTH ANDOVER, MA 01845 DATE Phone 686-7653 ....... .....--... ...................... . .......... ............ 7 19� 12,0 TERMS: PLEASE DETACH AND RETURN WITH YOUR REMITTANCE $ 13c -z-_ DATE I INVOICE NUMBER DESCRIPTION CHARGES CREDITS ANFe BALANCE FORWARD Ell ?'-ZL7 ................. .................... .......... .......... ............................ t .................... .......... .......... ........... ........... ...........................-.................................................... ......................... 341 ................ .............. ......................... ................................ ........................................-...................................................... ........................................................................ ................... ...................... ....................... .................. ............... .......... ............... ....................... ........................................ ............... ........................................... .......................... ..............- ............ ............... .................. ......................... ................ ..................... ...........................- ........---------- ............................. ..................... ................................ .............. ......... .........................................---....... 1139",1 PAY LAST AMOUNT DANIEL A. GIARD IN THIS COLUMN PRO()=1*2�Ajim..rroim.man 01111.10 Order PHONE LOLL FREE I-MVSM 2. Street Address 0& &RF-PT POOJD P-04b ) 3. How many members are in your household? 4. What type of sewage disposal system do you have? EJ cesspool C r.eptic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) foryour sewage disposal system on file with the Board of Health? ❑ yes F-1no [� do not know �6. How old is your-sewage disposal system? ❑ 0-5years ❑ 6-10years ❑ 11-20 years over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? Elyes ❑ no do not know i If ves, approximately how long ago? years. What was done? ! 8. How frequently is your sewage disposals stem pumped out? 0' annually Y P P y i ❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? yes ❑ no If yes, what problems? ❑ repeated pump-outs needed system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? wzshing machine dishwasher _(_ garbage disposal l— dehumidifier drain sump pump toilet � rotff/pavement drains '- shower/bathtub 11. P;Ease state the brand and type liquid or powder) of detergent you use for: dishwasher CA6c'tW �Po !OFe ., clotheswasher AMAY, tAuIjbP_v DFrgUiE, r (1 bak) WKK(LJQO1b) tvop-Y 5W; (jbo.Ub) 12. hoes your property have a lawn? [f yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre Eri '/a acre ❑ '/z acre ❑ 3/a acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? No. of applications per year. 0 Se;:sons) of the year 14. P;Lase state the brand and type (liquid or granular) of lawn fertilizer you use: ❑ Check here if your lawn is maintained by a professional landscape contractor. Laudani, Wm. ' /. eo 7 `� � Rt. 133 & Great Jlo - - Pond Rd. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. j � I hereby make application for a permit for a sewage disposal installation at ZT, 133 & GrUI)OPond Fid. . I will install this system in ac- cordance with all the laws 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%. I will install a con- crete septic tank of 1000 eal, in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 160 lineal 6wq%amw) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia. ) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE July 26, 196 1 () Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE July 26, 1965 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. / DATE 9, - /e) 6 S l )'ti.�0 J� Signature"fiof Inspecting Office— Percolation Test 5Soil: Sandy clay -ztti7t Garbage Grinder / BOARD OF HEALTH TOWN OF NORTH ANDOVE MASS. • �y' 1 .. Lios.s )o' FRs ,e1r1., vr:, lavoLAR6.Co�c. l,+ti,,� i • 20' FtzoM 1 IIC�! iu�5 Rs 1 R Cr ��NIC Fy L Ep L Ho 114 / x� Via« prZ CA n ltB•o L F , kL .314 SG.3 ?hod K S Sc tjo6L 1. NAME William Paul LAUDANI DATE July 16,1965 2. ADDRESS Junction Route 133 & Great Pend Rd, LOT NO. 24 TEL. 3. NO. OF BEDROOMS 2 DEN YES NO x 4. GARBAGE GRINDER YES NO x 5. SHOW DIMENSIONS OF HOUSE 26 x 34 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 30Ft, from road 60 Ft. from Rear Road 7. SHOW DIMENSIONS OF LOT 450 ft. Rte. 133 503 ft. Great Pond Road 190 ft. Across rear 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 1000 gal. g. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM City water 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. none 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE as required NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. A. E. Vallieres, 48 Oak Terrace Haverhill, Mass. 372-9505 Agent for Woodmaster homes. i 40 FRANKLIN STREET LAWRENCE, MASS. gallant 686-7931 22 HILLDALE AVENUE HAVERHILL, MASS. ASSOCIATES 373-0832 60 WASHINGTON STREET REAL ESTATE BROKERS SALEM, MASS. 745-3656 July 15, 1965 Mr, William Driscoll Great Pond Read No, Andover, Mass, Dear Sir; Enclosed is a form for a percolation test of a building lot at the Junction of Great gond Road and Route #133. If I. can be of more help to ,you in this matter please contact me at Haverhill 372-9505• I am the agent in this sale and I am anxious to be of assistance at any time convenient with you. I can be reached at the above telephone number. Thanking you for your cooperation. Sincerely yours 10 Adolphe E. Vallieres, 48 Oak Terrace Haverhill, Mass. P.S. I believe you made a similar test for us at Boston Road about a month age, near the ski hill area. BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL DATE July 17, 1965 NAME OF APPLICANT William Paul Laudani LOCATION Junction Rte 133 and Great Pond Rd. , Lot #24 Address of lot no. BUILDING: Dwelling X Other SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND high SUBSOIL: Clay GravelSand Y Clay PERCOLATION TEST 5 minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1,000 gallon capacity. LEACH FIELD 160 lineal feet of drain pipe. WilliamJ. ' scoll , Engine Board of Health SEPTIC SYSTEM INSPECTION FORM ADDRESS 3 �U� Co Pm,A DATE INSPECTED —7 - PROPERLY FtiNCTIONING? N WEATHER CONDITIONS COMMENTS : WA►'I✓R QuALITY rrES F_t, ? RESOLi'S? DYE TEST PERFORMED? Y N ` DATE? SKETCH: NEW ENGLAND ENGINEERING SERVICES INC June 11, 2003 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 1367 Great Pond Road,North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system FAILED our inspection. If there are any questions please call me at my office,686-1768. Sincerely C Q,� TOWN OF NORTH ANDUVER Benjamin C. Os Jr. BA HEALTH g � 9 ��RR IE? .i1771Y O .1 Ctp A�N J a I ¢ -_SUN 1 2 2003 .71 . . 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /367 "fiTr pv v 7 (2D A/otZR-f 4N.Pnyc%2, ey,* Owner's Name: if AIA/;L FS W 623A Owner's Address:_ 1367 6-Awl: poNp gp. fJOfZ* AA/P00Q r2 �A Date of Inspection• Name of Inspector:(please print) Benjamin C. Osgood, Jr. CompanyName:New England Engineering Services Inc. Mailing Address:60 Beechwood Drive, North Andover, MA 01845 Telephone Number: 978-686-1768 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _ I Date: '7 /6 0 2 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1-2,61 6-2E,9-T jE21v1_,1 62014D A2027lf (a-,y,?ooc:t2 zy A Owner. c;H O 2t,C5 Date of Inspection: 7�/i�AD Z- Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. .System Passes: 1 VynnI 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: 1:367 6-2E/}/— y-i,up (ZD ,tac 2flf QNpoJ�--R �� Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: A/dConditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 FORINT—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 13 & 7 C-2Eff i �a.�s7 /10,4p Owner; ILf�2 LL s vV l� Date of Inspection: - 2- D. D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for an inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool — Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow ✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of 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 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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 You must h irate either`des"or`4►0"to each of the following: (The following 'teria apply to large systems in addition to the criteria a e yes no _ _ the system is within feet of a surface dr' g water supply — _ the system is within 200 feet of a. ' utary to a surface drinking water supply — _ the system is located,,,u'�,ifnw"trogen sensitive Interim Wellhead Protection Area–IWPA)or a mapped Zone II of ay supply well `\ Ifou have an �' \� Y gered"yes"to any question in Section E the system is cons a significant threat,or answered "Yes"�-Section D above the large system has failed.The owner or operator�st=ccordance system considered a significant threat under Section E or failed under Section D shall upgrade the 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: 13(-? &2 Eh-Tr Pb my fzo mb No 2n-c A N S gc 2 .,d,k Owner: Q Rr2LLS W 0'BE> Date of Inspection:- ;Zf i&/o -z- Check Check if the-following havebeen.done.You-must indicate`des'-'-or`no"as to each-of-the following: --- - Yes No Pumping information was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection T v/Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _ V Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of thh baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? 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 _ 'Existing information.For example,a plan at the Board of Health. ,/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: j3 P"7 &ac- a Owner• Date of Inspection: 0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 3 Does residence have a garbage grinder(yes or no):Al o Is laundry on a separate sewage system(yes or no):�?[if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use:(yes or no): WO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):.,&q Last date of occupancy: COMMERCIAIAMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gnd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: ,r Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM c 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: Were sewage odors detected when arriving at the site(yes or no): S Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i ---5G-7 6-2 e 4-Z- ���,, (Z0 N O (Z� A—0 .J%(L Owner: c►�►4/L��`� w%a Date of Inspection: f[G/s2 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: 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:_(locate on site plan) Depth below grade: P-,,p no; i-o ca c-- Material of construction: 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness. Distance from top of scum to top of outlet tee or battle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:!(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass _polyethylene other (explain): __ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 131. 7 &4-c-tT AD /Ute Mil t_/L Owner.• Date of Inspection: ,o 2 TIGHT or BOLDING TANK: A)rr (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alar in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): i, A-�2 c rr PUMP CHAMBER: A*(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i 3G,7"7 &-(L 19—1 po�v;) (L j> No(tTR int+ Owner: L N►4(SLE w G 13 U Date of Inspection: Z _ SOIL ABSORPTION SYSTEM(SAS): (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: ,/leaching fields,number,dimensions: j K,G L:? s 2e vN�.•�o,, w/ overflow cesspool,number: innovativetalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): U-A-5-OR P0"J Nr CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:Q k(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 13�,7 C-�-(2,EtT-j- Po,,j 7 (I\-) iv0 2�1-{ /7\1&J P OuE 9- FF Owner: L' xi42 CS t,vL�B t� Date of Inspection: 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. �t EcV Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 13(-.7 64 is 1 -: Po_9 fLb iso(Lllf �N �e���2 Owner: GN 14a Lo S W E7,, ,2, Date of Inspection: SITE EXAM Slope- . Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: 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 most describe how you established the high ground water elevation: