Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 145 FARNUM STREET 4/30/2018
Ir 145 FARNUM STREET �) 210/107.A-0047-0000.0 { f s Lot & Street � `� ` Map/Parcel l� CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# IAJ 8 Plan Approval: Date: Z103 Approved by: ,4,zt:k Designer: , � Plan Date: Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved 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: SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? YES N Type of Construction: NEW REPAIR ' 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: NO DWC Permit Paid? YE l/, NO DWC Permit# �U Installer: 61�rg� Ae��.rSa� Begin Inspection: 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: Town of North Andover g �osrH Office of the Health Department Community Development and Services Division * . 27 Charles Street . 98 °a�.so►�Rh North Andover,Massachusetts 01845 4��acHuStit Sandra Starr Telephone(978)688-9540 Public Health Director Fax(9778)688-9542 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 07/15/03 This is to certify that the individual subsurface disposal system constructed 0 or repaired (X) by George Henderson at 145 Farnum Street 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. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. grianJ.<LaGrasse North Andover Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( )constructed; (/*4�repaired; by eo V�nP located at /9-5- Fl+(z ri 0 tAS I y Ivo(,TH A,&) Doi (L 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: �-x- Engineer Representative Final inspection date: Engineer Representative Installer: D 9cti Lic.#: Date: 7 v � C.TAN RD Engineer: Date: SS ON ��'G� r: L�'t D bc) C-J r� V-e r-/1-5� 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 Applicant: ;/z5/1 Name of Designer:,/V�5-.6� 6 Plan Date: d � Revision-Date: Date of Review: Property Address: f�� ��.C��u/�'j J/ ► Map: Lot: "7 BOH Reviewer:_ Type.of Plan:(new-of upgrade). Number of Bedrooms,in Assessor's Records: gpd)Garbage Disposal Allowed: General Information: N.A.=North Andover Septic Regulations Other numbers refer to Title 5 OK Problem N/A Street number and map/Iot-220(4)(u) 7 j 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:serve&-220(44)(a) Names of abutters from recent tax map- NA 8.02j Number of bedrooms,design.ealcs.,=NA&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' _,Z 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(4xi) Date(s) g- Off) () Dat s of soil testing 220 4 & i L Existing grade elevation of each deep hole-220(4)(h) Elevation of percolation tests L"'1`'.A.8.02'. . Name of approving authorityrepresentative-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) L/ Local upgrade approval request form submitted-403(1) 1" 7 2 /1 i� Original R.S./P.E. stamp,signature&date-220(1)&(2) P.E.,discipline specified within stamp. MGL C. 112 s. 81M sfc. supplies(w/in 400'),pub.wells(w/in 250'),pvt. wells(w/in 150')-220(4)( Location of watercourses,wetlands,wells,etc.w/in 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 UA system-DEP docs., i//Perc rate>30 MPI-not allowed for new,LUA for upgrade-245(1)&('3) ✓ Perc rate> 60 MPI-must use modified tight tank or UA technology-245(4) Proposed system qualifies as "shared"system-002(definitions) Flow is over 2,000 gpd-No KS. 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 1' above Base Flood elevation—NA 9.05 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) t/ All deep holes and peres shown,.including aborted tests—NA 8.02n 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: ground elevation el. acceptable soil el. .3Y ?—Z 7 Leach facility invert el. 6- ground water el. refusal e1. ��, a bottom of leach facility el. 16Z 0,0 - thickness of acceptable soil 73 before&after soil R&R separation to groundwater 4:/, 17 separation to refusal f 7 Z, soil class 2 r 3 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 -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 Property line 10 10 Cellar.wall 10 20 Inground pool 10 20 ✓ Slab foundation 10 10 Deck,on footings,etc. 5 10 l�V . v Waterline 10• 10 ✓ Private drinking well 75 100 �✓ Irrigation well 75 100 Wetlands 75 100 ✓ Public well 400 400 !/ Wetlands bordering surface 150 150 water Supply or trib. / (in Watershed) Trib. To Surface Water supply 325 325 Reservoirs 400 400 Tributaries to reservoirs 200 200 V/ Drains(wat. supply/,trib.) 50 100 1/ Drains(intercept g.w.) 25 50 ✓ Foundation drains 10 20 Drains(Other) 5 10 Drywells 20 25 i Downhill slope 15'to 3:1 slope 3 1 J 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) Cleanout provided every 100 feet-222(8) Manhole at any 90 degree alignment change-222(8) Invert elevation at building: 7 6 Invert elevation at septic tank: 76 Length of run: /,-57- Slope: 0, Q v (minimum of 0.01 -0.02 desired)-222(6) 10'offset to private well or suction line-222(2) Septic Tank OK/ Problem N/A iTank 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) 2-3"drop from inlet to outlet-227(5) Minimum of 4'liquid depth-223(2) 3"air space above teestbaflles(minimum)-227(4) 9"air space above flow line(minimum)-227(4) Tees are not to be replaced by bales-227(1) 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 bale installed on outlet-227(4) Access manhole cover above center of tank&each tee(except 2 compart) 22$(2) - 3-20"manholes-228(2) 1 childproof,24 riser/manhole Win 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) 7 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) Tank is watertight-221 (1) 9"of cover over tank(minimum)-228(1) H- 1 0 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 ,f t Leach lines capped, vented,or connected together-251(9) Pressure dosing guidance followed if pressure distribution-254(2)(c), Pressure dosing required over 2,000 gpd or with I/A remedial use-231(1) Leaching Trenches(Check here if not present: ) /�a i OK Problem. N/A n 4; o f-� O h n dt c a"a ✓ Number of trenches:_ , Minimum of 2 trenches-NA 9.01(2) ,� Depth of trenches(max eff.2'): gyp,5 -247(l) 17- Width of trenches(2'min.,4'max.): " _-251 (1)(b) Length of trenches(100'max.): (a ' , -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 iveii�Mm. 500 s.f)-NA 9.01(2) Z3f. Bottom=L c� x W � # = -3-o s. Sidewall=L to Z 3x D .�" x#x 2= 1 �5 s. f. Effective leach area given 77 Loading factor: 1 C3 Effective area=total area s.f.x LTAR = g/day L 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: t� ) OK Problem N/A #ofpits/pit 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 j s.f.x LIAR = g/day Effective area is>=design flow of facility being served Minimum of 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(l)(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.247.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)) :( y 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)(t) Year round access for pumping—228(2)(g) Distribution Bog(Check here if not present: ) OK Problem N/A Inlet elevation: 40 Z- 71 Outlet elevation: 16 Z. 0.17'drop from inlet to outlet(minimum)-232(3)(b) ,i 6"sump(minimum)-232(3xe) All outlets at same elevation-232(3)(b) Outlet pipes laid level for first 2 ft. -232(3)(c) Pipe Sch 40-NA 10.01. ✓ Number of outlets: l Number of laterals: Size of outlets: 1, 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. f 220(4)(r) Pump on elevation- Cf 3i. ;21 220(4)(r)' Pump=off elevation: , q6 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) Pressure dosed l.£ if flow>=2,000 gpd-254(1)(a)&254(2)(a) 71 Cycles per day is consistent with chamber volume-23 1 Volume calculations include flowback volume-2') 1(2) 5 J Length(100'max.): -252(2)(b) Width: Total area:L x W = s. f. Minimum 900 square feet-NA 9.01(1) Distribution lines connected with solid pipe—NA 15.01 Effective leach area given Loading factor: Effective area=total area s.fx LTAR = 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) 4'maximum separation from edge of field to line-252(2)(e) 10'minimum separation between adjacent leach fields 252(2)(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(11) Grading slopes away from dwelling 5/24/01 N&M Job number 1770/ TOWN OF NORTH ANDOVER INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Site: /�"� �I f-40 �� Final Date: Installer: Oe-�e © . grr) Apfsor� Tel: /Date Yes No Initials A. Bottom of Bed 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizons' 3. Edge of excavation specified distance from foundation,etc. L� Comments: (Use back of sheet for diagrams.) B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer I. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Inlet to tank cemented 4. Slope minimum 0.01 or 1/8"per foot minimum 5. Pipe properly set on compact firm base 6. Pipe laid on continuous grade in straight line 7. Cleanouts precede all change in alignment and grade 8. Manholes at any 90°change 9. 10' minimum offset to water line Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum t/ 3. Gas baffle present on outlet 4. Manhole to w/in 6"of grade 5. Manholes over center and each tee 6. 3-20"manholes 7. Outlet line cementedy 8. 2"—3"drop from inlet to outlet 9. Pipe set 10. Compact base with 6"of 3/a"crushed stone under tank 11. Tank is watertight 12. Tees 12"off side of tank r N&M Job number 1770/ Date Yes No Initials Comments: E. Pump Chamber 1. If separate from tank,compact base with 6"of 3/a"stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole t� 4. Tank level 5. Watertight 6. Tank size agrees with plan specification ✓ 7. Manhole to grade ✓ 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 1/ 10. Alarm functions L/ 1.1. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box 7/U I. D-box level l� 2. Minimum 0.17"(2")drop from inlet to outlet 1/ 3. Minimum 6"sump 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe 9. First 2' from box laid level Comments: G. Soil Absorption system 1. All stone double-washed—3/a"— 1 1/2" v -pea stone Bucket test done? 2. Minimum 2"of pea stone above distribution lines 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together t/ 5. Toe of slope stops minimum 5' from edge of property; 5a. if not,then swale. Comments: N &M Job number 1770/ Date Yes No Initials H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agrees with plan. (Max. length 100') , 3. Width of trenches agrees with plan-Minimum 2';maximum-4'. 4., Vent present if>50 feet or specified 5. Minimum distance between trenches 10' 6. Pipe slope minimum 0.005 or 6"per 100' 7. Depth of trenches below outlet invert minimum of 6". 8. Pipes set on stable base. Comments: 1. Leach Field 1. Maximum.length of field 100' 2. Pipe slope r unimum 0.005 or 6"per 100' 3. Separation bet ew en pipes 6' maximum 4. Pipes connected at en vent end raised 5. Separation between adjaceen f ds 10' minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines Comments: J. Leachi Pits 1. Minimimum inlet.pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"'wide_ 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement . 6. Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered b at least 9"soil Y P Y 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond 6. Grading meets 3:1 slope 7. Minimum of 9"of fill graded over system Z NEW ENGLAND ENGINEERING SERVICES INC June 14, 2003 Sandra Starr,Administrator North Andover Board of Health 27 Charles Street North Andover,MA 01845 Re: 145 Farnum Street, Septic system design Dear Sandra: Enclosed are three copies of the as built plan and certification for the above referenced property. The certification still needs to be signed by the installer. If you have any questions please do not hesitate to contact this office. Sincerely, C-9- c-- Benjamin C. Osgo r.,EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 i i AS-BUILT CBECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS �P. FROM SEPTIC TANK . FROM LEACH AREA LOCATIONS OF DEEP HOLES &PERE TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION pv LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES CABLE V DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX ORIGINAL STAMP & SIGNATURE _ IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW `�' LOCATION&ELEVATIONS OF BENCHMARK USED A APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: L —tL -b 3 CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALLER: SIGNATURE:-'&A Q. , ll� TELEPHONE# CHECK ONE: REPAIR: I-- NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $175.00 Fee Attached? Yes No Foundation As-built? Yes . No Floor plans on file? Yes No Approval c Date: Co 4 JUN ! 2 2003 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at �l S' /Ea.iv vv,u-A-,., s Z relative to the application of� 42 dated `4 for plans by VLF, C' -S and dated with revisions dated 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: L J'2. - b Disposal Works Construction Permit# 1OWN OF NORT F JUN 1 2 2003 i TOWN OF NORTH ANDOVER BOARD OF HEALTH Location �f� '� PermitCD CD # � , os CD y o Food Service $ CD tn ;o a 2°' ?' °= Retail Food $ p ;*x ti��o° Limited Retail $ o �' Seasonal $ CD a CD z < D y 6 m Disposal Works InstallersCD $ �» � \ 3 \ Disposal Works Construction N o O p Soil Testing $ 3 p 1 r o Design Approval Permit $ 0 co z Dumpster Permit $ s � D o 70 =r Burial Permit $ D n D O O O QSwimming Pool Permit $ D o mCD Animal Permit $ O m D ` ov Recreational Camp Permit $ Dp' a• O = Well Construction Permit $ A v� Funeral Directors Permit $ z m o 70 N Massage Establishment License $ D p° D 3 O � _ z a Massage Practice License $ o � z 0 Suntanning Establishment $ n — R' cn K Offal/Trash Hauler $ D rO - D (t Other $ 6 m 0 0 �\ O M3 p z�d ? 6951 M V w Health Agent vi; V - Traasurer 0 Wal C9111L SYSTEMS I N C Environmental Onsite Wastewater Solutions- This is to certify that , �,,_ -���,�, has satisfactorily completedZhe required training program for the installation of the INFILTRATOR® leaching chamber system for on-site wastewater disposal applications. This person is certified to install,t`he INFILTRATOR®chamber system as set forth by the rules of theme VSVVOf Department of Health. STATE This certification expires on Installer "ignature nfiltrator R sentative Signature Corporate Office P.O. Box 768 6 Business Park Road Old Saybrook,CT 06475 • (860)577-7000 Fax(860)577-7001 www.infiltratorsystems.com i 145 FARNUM STREET JS-2003-0700 r Proiect Detail Report Printed On:Wed Jul 02,2003 GIS# 7356 P'ro'ect No '. R 7S 2003 0704 = Owner of RecordREICHARDTHOMAS H8i' J 3 Mapf 1(17 -at Submitted " ` Apr 24 2003" � I4`SFARNUlVl'STREET z Block, OQ47 Status � O , � r ` ,' ., .1VORTTANDOVER 1VI penA 41$45 Lot Work Cate o .v Work Y ocat>on 145FARNUNI'STREET '. s g r3 Zoning:,. P opposed Use 3 District _ .. R land Use 101 Pro osed Use Details Subd;`iri Description Septic Design Itg E of'W' k . Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2003-0034 7/2/03-Wed.-Call from George Henderson,contractor asking also for a final inspection. Call: 978-807-6079.--p.d. 7/1/03-Tues-As Built done,ready for final inspection: Please call Ben Osgood at C:508-328- 4633. -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-Sandy faxed signed permit to Ben Osgood. DWC application given to Sandy ai she signed off. Signed permit will be left on Secretary's desk for Installer to pick up with an approved copy of plan. Tues.6/1.0/03-Ben submitted revised plans addressing two of the problem issues. Revised plan placed in Sandy's design inbox.--p.d. 6/2/03-Susan Rochwarg,real estate agent,978-475-211.1 called and left a message around 1:00 p.m.looking for status of 145 Farnum St. They are coming up on a(closing?)deadline,and neer to know. Checked Sandy's bin,and plan has not yet been reviewed. Plans were submiated on 4/24/03. Sandy is out this week. Brian advised to send septic checklist Sandy filled out to Ben. Ben received and called back. He will address the few problem areas and present back to Sandy Monday,6/9. Ben said that the property is scheduled to close on Tuesday,6/24/03.--p.d. 5/27/03-Mr.Reichard called again requesting a status of his septic plans. Please call him at 20' 795-2394(w).--p.d. 5/22/03-Mr.Reichard called and requested a status of his Design Plan submittal of April 24th. Please call him today. His number is:207-795-2394. This was previously submitted with all paperwork to the Septic Design inbox. --p.d. 1._ Permit History Type: Permit No: Issue Date Status Work Category Project No: Description of Work: GeoTMS®2003 Des Lauriers Municipal Solutions,Inc. Page 1 of 2 145 FARNUM STREET JS-2003-0700 Proiect Detail Report Printed On:Wed Jul 02,2003 Design Approval-Plans 1218 May-22-2003 OPEN JS-2003-0700 Septic Design Septic System 1302 Jun-12-2003 Open JS-2003-0700 GeoTMS®2003 Des Lauriers Municipal Solutions,Inc. Page 2 of 2 SEPTIC PLAN SUBMITTALS LOCATION: / Map & Parcel%o74 NEW PLANS: YES $225.00/Plan Check#: REVISED PLANS: YES $ 60.00/Plan Check#: SITE EVALUATION FORMS INCLUDED: NO LOCAL UPGRADE FORM INCLUDED: YES ; DATE:_ql t,4 o 3 DATE TO CONSULTANT: DESIGN ENGINEERAI E- Telephone#: 9'7 6 Cfdt 76$ When the submission is complete (including check),date stamp plans, CO -4zor,t and place in existing file with green Design Approval form. r pR242003 A Z FORM 11 SOIL EVALUATOR FORM Page I of 3 No. Date: Commonwealth Of Massachusetts Massachusetts oil 'ui ability SSMe t for n On-site Sewage Dkis poral Performed By: .... Date: ............. WitnessedBy: ..........-;7z .................................. .................................. .... ... . ......... Location Addras or 7 Owlw*§Name. Addn -4 us and Telephone 1 e Co w FCon"striuctlon El Repair M eav 9flice Review Published Soil Surve,y Available: No El Yes Year Published .............. Publication ScaleSoil Map Unit Drainage Class .............. Soil Limitations 117?) Surficial Geologic Report Available: No 91 Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) Landform Flood Insurance Rate Map: Above 500 year flood boundary No Kyes ❑ Within 500 year flood boundary No 0Yes E-1 Within 100 year flood boundary No 0Yes D Wetland Area: National Wetland Inventory Map (map unit) ........... Wetlands Conservancy Program Map (map unit) ............................... Current Water Resource Conditions (USGS): Month Range :Above Normal ONormal 4BelcwNormal ❑ Other References Reviewed: DEP APPROVED FORM 12107195 .fi FORM. 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. l)n-site Re vi:v D Deep Hole Number r Date: 'OC> Time:/.. Weather- Location (identify on siteplan) Land Use Slo ope (/01 � Surface Stones Vegetation Landform . Position on landscape --:724-9t- Distances from: Open Water Body /off feet Drainage feet Possible Wet Area -PJ-4" feet Property Line . . � feat Drinking Water Well, /5 0 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) .4 Parent Material(geologic) Y ,/�� DepthtoBedrock: Death to Groundwater: Standing Water in the Hole: !� Weeping from Pit Face: Estimated Seasonal High Ground Water: �r DEP APPROVED F'ORA1• 12/07/95 } FORM Il - SOIL EVALUATOR h0101 Page 2 of 3 Location Address or Lot No. �'%t� �/�.�t/� �,%/ �/p ���®✓��' On-site Review Deep Hole Number �. Date: ���/-3 �.'�� 9/Y� Time. T Bathe Location (identify on site plan) :7"'�/a� Land Use Slope M _5 Surface Stones Vegetation At_'1kn:7'Zw_D Landform .. -�2�v,�A �?�►"",¢/,�,r�- Position on landscape Distances from: Open Water Body feet Drainage wayA`Qd�> feet Possible Wet Area �`�'© feet Property Line 3rd.. feet Drinking Water Well., /-ro feet Other DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Texture Soil Color Soil Surface (Inches) (USDA) (Munsell) Moulin Other Mottling {Structure, Stones, Boulders, Consistency, Gravel) ZZ 95C �� �. x.3011 '�4 Parent Material (geologic)_ � � � /-7-GL DepthtoBedrock: Depth to Groundwater Standing Water in the Hole: _ Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORAS- 11/07195 _» y FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. ���//� /D_ ------,� Determinatr'on for Seasonal high Water Table Method Used: ❑ Depth observed standing in observation hole................... inches Depth weeping from side o observation hole........... .. inches Depth to soil mottles ..:.:.,:.,:......:, inchesz ❑ Ground water adjustment ................... feet . Index Well Number .................: Reading Date ................... Index well level ................... Adjustment factor ................... Adjusted ground water level ............................. ........................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in areas observed throughout the area proposed for the soil absorption system? � If not, what is the depth of naturally occurring pervious material? --- Certification I certify that on / (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 390 CMR 15.0°17. Signature ate DEP APPROVED FORM-12107/95 NEW ENGLAND ENGINEERING SERVICES INC April 22; 2003 Sandra Starr,Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 145 Farnum Street,North Andover, Septic system design Dear Sandra: Enclosed are the following documents regarding the above referenced property. 1. 5 sets of design plans. 2. Draft soil evaluator sheets. 3. Fee for review y• ImFo Perz,a:a:tic VO &A/F;Ir4r►r iYSTP�! De-f 6ti. 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, Shawn B el Cc Owner 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 NEW ENGLAND ENGNIc EERING SERVICES June 10, 2003 Sandra Starr,Administrator North Andover Board of Health 29 Charles Street North Andover, MA 01845 T� JUN 10 2003 0 Re: 145 Farnum Street, Septic system design �! J Dear Sandra: Enclosed are revised septic system design plans for the above referenced property. The changes we discussed have been made as follows. 1. The force main is shown crossing the water line 18"below the water service in a sch 40 PVC sleeve.. 2. The distribution location has been moved and raised to make installation with 2' of pipe level flowing out of the box easier. If you have any questions please do not hesitate to contact this office. I assume a permit to install the system will be issued as soon as you get a chance to look at these plans. Thank you in advance for your cooperation in this matter. Sincerely, Benjamin C. Osgood &IT President i 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 J —. x ., �_.- _ Form No.2 Town of North Andover, Massachusetts f MORTN BOARD OF HEALTH • O'��.o ,o'�yG o P r' DESIGN APPROVAL FOR CHUS SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant / C=�� � �� /L'fl Test No.— / Site Location Reference Plans and Specs. 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. CHAIRMAN,BOARD OF HEALTH Feed Site System Permit No. L� •s BOARD OF HEALTH _ NORTH ANDOVER, MASS. 01845 978-688-9540 APPLICATION FOR SOIL TESTS APR 2 9 2003 DATE: MAP&PARCEL: LOCATION OF SOIL TESTS: !SIS f542riu cel s 7?e e OWNER:A c.-A AS zG J9 Tri R E►c K 4-(2-, TEL.NO.: '778' 6�;/- 3 ADDRESS: 1 ilS )0:�iy2nu,ri rye ,tlDC"y /IA-PP0V Of& ENGINEER:N►:w c ni Cry.-A Ai P ESQ C i ay r5/4ru G- TEL.NO.: 9-76' 68 6-/76 S CERTIFIED SOIL EVALUATOR: 91CHMW 6. i,4AJ 6-/9 r"O' t iy CsGvuy Uh- Intended use of land: Residential Subdivision Single Family Home 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,deed,or letter from owner permitting tests) 2. Plot plan 3. Fee of$425.00 per lot for new construct' s covers the minimum two deep holes and two percolation tests required for each disposal area. Fee 200.00 r lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2: Only Mass.Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. .4. Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing,a scaled plan(no smaller than 1"-100')shall be submitted to the Board of Health showing the location of all tests(including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write low This Line N.A.Conservation Commission Approval: n s�Cd( hd rc. andac- Date Received: Check Amount: Check Date: 3Z9 25 , OLD LOT LINE' o 577/11?0,3'05 -' `5•. a/°23`42 OL© LOT 253. 73 -,a_- c . _ Ste, N i N*Iib ,V,09 o� KAY/ti UA. 0 1 c v o Z _ R, lip 40T C N W 3 fifes/n��rrr 8 1�1 ----------- r _. C)- Q>O RD 4 IVIF i , Wgff 0 40Mj44 .4M49ses At 1 111 1111111 milli x_ 1 IIIIIn1111111111111111 . ® 1 IIIIn 111111111111111 ����� :- E 11 1 1 1 NINE 111111111111111 1 11111 Illllnll 11111 n 1111 11111111 11111 , a, 1 11 n11n111111111111111 ������ 1 1 IIIIn1111111 1111111 ��� 1 11 IlllINNInll 11111111 1 1 IIIIIIIu1EN 1111111111 1 1 11llnllnlllllllllll111 ,�;, ���� 111 IIIIIIn11111111111 1111 : ������► 111 11111 n111111111111n11 1 1 111111 ME III111111111 z IIn11111n1E III111111111 11 1 ME 1111111111111111111111 1111Z' 11111111111 111111 11 IIGI►aIn!!101 11 1 1 11111 1111111w111�h -�11��1i11A f ���% %�► IIIIII1111111111 all • �- gill 11 1116'1 �i � 11 1 ININE II11 1111111�1AFE 111 f 1111111 �I�IIIIIn1111111111111111 ��� ,= ,, • 11' �11aI'�''i'�-��71n1111111111111111 �• ��--��� 11'a�iL '1Iallnllllllllllllllll - -, � # �"�-''%'^'�`�s k_ •.°«ywt a.• w•w:�gjw +-...,.� _ 3��+�'° ��-_. v . may +sem ",w" �� - 1z ���' _' ; '��.,�,M 4,r� .s .fir. � ...�.. R""y ,N.} �. �Y r, �' - '*,�'•�'+'*�,�\1... \R 5. �Lj k � �iii � I I � �r►�s _�-C�, -,�-� ---_ E II jI/•`/ , , _. �f � 3i`, ---- 1' � _� .� U� � - -- - I - - � ��� 1. � � �j� �)•�. _,.�+ 3S _ _ ... jA � •'r ry"rh iii U r 11t ,-4 �� '� � , �'�� //..7� ''�� ��~1 - ----- 4 1 �� � l/:. _ _ I .- �' r 1 D i�J 17 71 E Ir-v 64. ,4, v _ Z �•a`,=is,''a. .;. ,.•..:: ' - a c.:.- »' :.,,ti.' - a„`4.:J`"••"' 'a,,: ., 7.:°,'x.'s,Tv.`-iy�:. ., ' i, sar +4•�u�n`I ��dww,w",;,, ^ >r�` tS,.:�^ 1 ,'"�„++*„M°.,w•" ...n, ,. ,:, ,,. :.. �.-i,.ai++ w,. n+r ,t `," + ' • r �S.«�rr'.' �'tiaL�'.rG+,;.}F�� �����:+.'�.L!tc.: ',' i+'.''�,�+�.� t�. . -.,.- rc:,. ., ,.: .... ,,. .. .:.... .. <-... s .;`M"f„ �� `R" {ti. +,:. ^.� � !rd.:`'�' "J,, ayY-"s r ,.z-lw�YSca:�c+ .�•'� :.•r <. �. .�, .:... � :.- ;,.., - .. .. .., ..... _..;�. } r� __ ., ,;, �,.�„- '4's«.#,:.,. ��K...�K"v-'a�+v66vw. .P«.+-a.'6taCr?a ,r..+"}+L Sn"S'"„ };f"x'° �• .E., n. c+c,Y ��.... r•.- .�.sti_S.�T.,«�+.:. ,? C-.c'1„ �'wx.k{qp -A r .p.+,. asn.�:. ..w,.;... ...: ,. :`_..•.• �+..^+��•�^ ,.°;5` r r.+r+ +y...4.. ,.�,. _eG�.:x.✓r, r p�. .�.rr,,���,r..�.. � n;^�4 ...,.:.. .,. ..�,:A.r,. .,wr�,•r� ,..-:.,u.,�a�.. .��,.-� n.::w "��».ww .++:w``��.ca. �s�"� _ •�s r .«ri,.�.., ,7:.�.. �;• .... -n ,^s. - �nS+....sr ... .... ,...� w.iw �s..ws Yn.. ,.w��t+w!'�..� ,� %'*{�`y�'4 '�.g1b�S',^'iY.+'.^•rwr:�7,6{r T1YfrY�'yM.��'%S P'r�,Y,;.,^ i[.,.s?J..«r...� .g .+t- �= ��+5i.�r�'+•.v.+:o..-w«ni.iwi.s�.r..a+dwr«aw4�s•,..r.+w,x;±..�=;-',y,'-F+a,.�w.n�a ;e,,.+.ox �...vs:a w,y�.i,! "".��,�.��r� '�k.'? a. �){'",.i'iR "y";'"` ,,�^:"r'•' .i`.� .c�+..:.'.` ..,.t...<.^.L�%r�5..•�..�?r.«,,. "{""�' .��,: �..,..� � �� � ...� .,. :,. ... .�... _...... -•s. .,,,. ., ,; �i�;, 'w' >',a.Jf. .::-ark+,enk°6.7M:..:r,�« ,iYts.'r�la:;_ n.�.d_..ur v.<^.�,r,'^r �'r.,.,,.�'- fr.. _... �,s •r-r�� {a.. :"�._..... ., .,. �.M..,�7s:.:•'e'..v+�+* :a�.+�k�.r. ,,�.ux..w.�,n5•±c-,�y.a�*.:�t,:'��r ps v.�..v. :w*+=.+•z�ww,��,'.,�u.r.-'r. �.�a;. _ - .✓"i„fi,r+; t•ow. _.,?w �� �x^.Y ,..•: ,;_. ,.. ,,.r.�. .,,,.Y-. ..,er.- -. � ,�• .-+� x-_ :+.'ti.� c �`.,r: :./: -:w-. �'�"�.'-"r ,..,.;... r f+.r.. .,xrc.:.. ....}.:�+..t•._ P�;,r.:;. ..• ,, .� s, :g. .. vf....... .s nom^4- ,w ' '�, �i=• - eie� �"...s_s �-,,�,�„� .rK<. ;s�- •mar. r..3,-+:,.: .'W....+a.v`'-.'rbc-.,.. �^:?,.r.%�s� •�.*�� y �rr.�.:�:.,...+x:r_ .+:s., -7477777"7777, Y,<. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH X6'94, O AT .. .w,. �> APPLICATION FOR SITE TESTING/INSPECTION SSACHUSE��� Applicant � /� � NAME ADq_, ESS TELEPHONE Site Location Engineer NAME RESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH �J Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i s M MA.R l 4 2003 °! .._, TITLE 5 INSPECTION FORM-NOT FOR VOL - SMENTS OFFICIALS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ' PART A ` CERTIFICATION Property Address: ./%�,1�112/.//y! Owner's Name: G'frai"�/ Owner's Address: �fY Date of Inspection: Name of Inspector, ( lease print)lJdh/9 t/• /Llgee� Company Name: / a Mailing Address: Telephone Number: 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 Nee/d`s Furthei Evaluation by the Local Approving Authority airs Inspector's Signature: �t�, v.--- _ Date: v/0 The system inspector shall s bmit a copy of this inspection report tL�eApproving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at.the time-of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 ti Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERT,IF�-ICATION(continued) Property Address: i, Owner: Y Date of Inspection: zwz2y Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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: 2 ` Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: s _ 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. r 3. Other: 3 " Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address•/Ie;� ///y? T Owner: Date of Inspection: i D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes o , — ackup of sewage into�facal -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 overlbaded'or clogged SAS or cesspool 111, . iquid 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 ,bf times pumped _ V f y portion of the SAS,cesspool or privy is below high ground water elevation. �y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ VlAny portion of a cesspool or privy is within a Zone 1 of a public well. ZXoXny 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 R described in 310 CM15.303,therefore the system fails. The system owner should contact the Board of yf-1 Health to determine what will be necessary to correct the failure. E. Large Systems:, 4A To be considered a lar rge.system_the systema: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: t (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone.II of a public water supply well , If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 �I ' ,p Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B f/ CHECKLIST Property Address:,/M6--1/7/-/7/-/4/ 1�7 Owner: Date of Inspection: /o?y� Check if the following have been done.You must indicate"yes"or"no"as to each of the following: YNNO 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� 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? 1/ Was the site inspected for signs of break out Were all system components,excluding the SAS, located on site? 6,1 Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? L/ — 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: ' P f Yes no Existing information.For example,a plan at the Board of Health. Ii/— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5 Page 6 of l l e • . -i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1'/9111ty Owner:/ C�Y// ` Date of Inspection: 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: Does residence have a garbage grinder(yes or no):/V© Is laundry on a separate sewage system(yes or no)- if yes separate inspection required] Laundry system inspected,(yg�s or no):_j /1 P �� J`v d i W Aj<n r Seasonal use:(yes i ` Water meter readings,ifgailable(last 2 years usage(gpd)): p f'�;j�f�j L u �LSump Pump(Yes or no): -� �C�NlvC c TLast date of occupancy: U10 1 12 64 � T � COMMERCIAL/INDUSTRIAL Type of 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 irnspection(yes or no):_ If yes,volume pumped Jallons--How was quantity pumped determined? Reason for pumping: SOP c.7— V TYPP©F SYSTEM n x _rSeptic 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 agp 9f components,date installed(if known)and source of information: Y 1!5-7 Ci( r S Were sewage odors detected when arriving at the site(yes or no):f U o 6 • Page 7 of 11 A A M OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: i�✓� Date of Inspection: BUILDING SEWER(locate on site plan) /r Depth below grader Materials of construction: ast 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: Material of construction: oncrete_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: _-5— 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 baffle: Distance from bottom of scum to bottom pi-outlet tee or baffle: How were dimensions determined: % ---f Comments(on pumping recommendations,fnlet and ou let tee or baffle condition,structural integrity,liquid levels , p as relatedte outlet invert,evidence pf 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: r Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:Ayr, Owner: Date of Inspection: TIGHT or HOLDING TANK: (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 6 Design Flow: gallon0aay >' 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: !L(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 leakag into or out of box,etc.): , each , . PI IPeS - Ul / 0 100 d -F A PSS 01JCtIN j ti IJdo ` PUMP CHAMBER: (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.): k 1 c f i i 8 4 i " Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: , /Z7 ,-y Owner: Date of Inspection: 1 � SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type i leaching pits,number: leaching chambers,number: leaching galleries,number: ching trenches,number,length: 2 /CPN leaching fields,number,dimensions: tT 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.): d N d w, N 7eloclef CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: a Depth of scum layer: ` Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): b Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition ofvegetation,etc.): i s PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: j Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 r k N _ Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: Owner• enz, Date of Inspection: � f 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 31 1 � , 10 Page l l of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner:,r4_?,o ' Date of Inspection: Ir��l/ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater C feet Please indicate(check)all methods used to determine the high'ground water elevation: f` V 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) C/ 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: / t-)-(' / rttiCS / �l�X / �106A-e /iU Cf C C�r l C( b n t /5o / Ito/-,k'1 �)-f- C_'� MA r �Urr l , f - - h 11 / Roger Pelletier 115 Farnham Street APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, KSS. p s I hereby make application for a permit for a sewage disposal installation at 145 Farnham Street 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 1000ag 1• 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 _2_ lineal (qUNfflV) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia. ) and the pipes will be surrounded by similar �- material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia. ) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DA TE (e / ignature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DA TE Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE --,/ W_ Signature o pecting Officer Percolation Tes t 6 mih* Soil:Sandy-clay Garbage Grinder A(f BOARD OF HEATH �r ��/� TOWN OF NOk`� NJ;'J I AI'at, MASS. Z 0 L 1 LEDGE —ay- '. o ZZ i t 'DOSP. � O 1. NAME . �oC- . PEL6E-;TIF- ,;. . DATE ivlflY .I.� (o �. 145 Fra-NUK s1`. 2 v ADDRESS l° . �; V .�0 �� ���}D��V�Uc�' T NO,No,AND0rEi� . TEL K�N.€.4F P NO. OF BEDROODIS :�. . DEN YES N0. �P6 /Y/i , c�fJd' GARBAGE GRINDER . NO. . . . . . 3 - ly_ SHOW DIP0\3SIONS OF HOUSE b. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DI1 ,NSIOIdS OF LOT' g. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTA110E OF WELL FROM SEWERAGE SYSTEM C�0 W C Ls L.) ' y 10.' SHaV LOCATION OF BROOKS, STR,EANS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULAT IOI\ILS SHOULD BE READ CAREFULLY.