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Miscellaneous - 146 OLYMPIC LANE 4/30/2018 (2)
�d r ' Lot & Street f" Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: L4 Approved by: Designer: , O ��_s L Plan Date: o� Conditions: Water Supply: Tovu Well Well Permit: Driller: Well Tests: icalDate Approved Sacten Date Approved Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U"Approval: Approval to Issue: YE NO Date Issued By: Conditions: Final Approval: All Permits Paid? NO Well Construction Approval? - ----NO— Septic, System Construction Approval? NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: z �� APPROVED BY: • J" SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? Type of Construction: NEW New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U NO Issuance of DWC permit: NO DWC Permit Paid? YES NO DWC Permit# ZZ 7/ Installer: zz Begin Inspection: YES NO Excavation Inspection: Needed: Passed: / By: v Construction Inspection: �.. - Needed: f✓l / y rlt Ilan Satisfactory: �aJ Approval of Backfill: Date: B y: _ Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: �/ Date: TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: ° 6/21/00 This is to certify that the individual subsurface disposal system constructed () or repaired (X) by John Soucy ° at 146 Olympic Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector _.r -..!. �' _ rti r`�:?`.•: +Lt.�. "�•' � :�•�_: i.'�"; ,�.r;.hti•. '�}tib�V.? •. r'�: r - '.zs`_�:=.r-S � r. -,i.4'� _ -`�<.�;-r ,,?K��' �:.ti':�';;;: - :�'•`C.�e%�.••.S:!+;:;.i- "L•.�- .r7 1----------------- TOWN OF `FORTH ANDOVER SFWAGE DISPOSAL SYSTEI j I-,STALLA•FION CERTIFICATION The unce:si�:ned here v certiN that the Sewa2c Disposal Svstem. ( ) cor:st.,_ict;n V) re^aired: y by located at 4 (o s__---�,�� f)-- was installed in conformance vith the N1o.-th 4o�•er Board of He-aith a:�proved plan- Svstern Desit7n Pe; ritJ1� dated 4 9 -� ;vitn an accroved desilan flow or ���`ailons per day The mate: ais uses were in coruormar .ce with those specined on the approved plan; the system was installed in accordar.ce v.ith the previsions of 3110 CMR- 15 000, Title 5 and local regilations, and the final Qradirg agrees substantially with the approved plan. :til work is accurateiv reoresented or the As-built :which has been submitted to the Board of Health. Bed inspection date: Engin ..r Final inspect:cn cafe Ln�i er Re .1,reseniar:1 Installer: o� .c.T: Date: LesiVTn EnCi e : Date: D� RICHARD o C. TANGARD Y AS-BUILT CHECKLIST 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 a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES &PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM n/ TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM IZ LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK& D-BOX 1/ ORIGINAL STAMP & SIGNATURE fIMPERVIOUS AREAS - DRIVEWAYS, ETC. --� NORTH ARROW . LOCATION &ELEVATIONS OF BENCHMARK USED E IJ INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO Initials-.- A. Bottom of Bed 1°' 1. Excavation to proper depth 2. With trenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. Comments- jj- y- 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 1. Pipe diameter minimum 4" 2. Schedule 40 pipe ✓ 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8"per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90°change 10. 10' minimum offset to water line Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20"manholes 7. Inlet tee minimum 12"under invert ✓ 8. Outlet tee minimum 14"under invert ✓ 9. Outlet line cemented 10. Air space 3"above tees _ 11. 2"-3"drop from inlet to outlet ✓ 12. Pipe set 13. Compact base with 6"of 1/4"crushed stone under tank 14. Tank is watertight ✓ Comments: i Yes NO E. Pump Chamber 1. If separate from tank,compact base with 6"of 1/4"stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole 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 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box 1. D-box level V 2. Minimum 0.IT'(2")drop from inlet to outlet 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 �� Comments: �I G. Soil Absorption system 1. All stone double-washed-'/4 1 '/2" -pea stone Bucket test done? 2. Minimum 27of pea stone above distribution lines v 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not,then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan-Minimum 2%maximum-4'. 4. Vent present if<50 feet or specified 5. Distance between trenches minimum 4'and maximum of 6' 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6"per 100' 8. Depth of trenches below outlet invert minimum of 6". i Yes, NO 9. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' ✓ ' 3. Separation between pipe 6'maximum 4. Pipes connected at end 5. Separation between adjacent fields 10'minimum _ Z 6. Pipes set on stable base r/ 7. Maximum 4'separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: -VI J. Leaching Pits /3 s 1. Minimum 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 Comments: ' K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond : Town of North Andover, Massachusetts Form No.3 < N°RTH BOARD OF HEALTH -y A �+ a DISPOSAL WORKS CONSTRUCTION PERMIT SSACHUSE� A p p I i c a n t NAM ADDRESS TELEPHONE Site Location ��Z6 Permission is hereby granted to Construct ( ) or Repair ( n Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Z" CHAIRMAN, BOARD OF HEALTH Fee /��/ D.W.C. No. ,/ F97 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERINIIT DATE: /00 CURRENT LNSTALLER'S LICENSES LOC.�TION: �l ti u_Ai 'g LICENSED D ST.0LLI: o Q c SIGNA'TU-RE: TEL HONET 7-7r- CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTTON, PLEASE ATTACH FOUT DATION AS-BUMT. Administrative Use Only 575.00 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval _ ��—0 Date: INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at / nJ01,,_ A)'l relative to the application of �"c S"44-.' 4s dated /004 for plans by ,,v, and dated / with revisions datedG C� I understand and ee t 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 Title 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 BOH,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. f _ 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. Undersign icensed Sept' I taller Date: v leu Town Of North Andover ?o's'�•D °~�; Community Development & Services William). Scott Director 27 Charles Street (978) 688 9531 -�-�-• '' ' North Andover Massachusetts 01845 SACHUSe Fax 978-688-9542 April 20, 2000 Board of Appeals (978) 688-9541 Mr. Ben Osgood, Jr. New England Engineering Building 60 Beechwood Drive Department North Andover, MA 01845 (978) 688-9545 Conservation Re: 146 Olympic Lane, No. Andover Department (978) 688-9530 Dear Mr. Osgood: Health Department This is to inform you that the revised septic system plan dated 4/18/00 for the site (978) 688-9540 referenced above has been approved. Public Health The Variances granted: Nurse (978) 688-9543 1. Distance from the leach area to the foundation to 11 feet. 2. Depth to groundwater from 4 feet to 3 feet. 3. Distance to wetlands to 50 feet. Planning Department (978) 688-9535 Please make sure your client understands that with variance number 2 there can be no additional rooms in the dwelling while the site is served by a septic system. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr,R.S., C.H.O. Health Director SS/smc Cc: Du" File Page 1 of 1 � I nabohmass From: nabohmass<nabohmass@email.msn.com> To: Gayton Osgood <gayton@mediaone.net> Sent: Tuesday, April 11, 2000 9:31 AM Subject: Variances for 146 Olympic Lane Hi, I have a pl4n for a septic repair that has asked for the following variances: 1. Reduction in the distance from the leach area to the foundation 2. Reduction in the separation to groundwater from 4'to 3' Z �J 3--R ch—area--- 4. Reduction in thq distance to wetlands to 50' I have no problem with number 1, but the combination of the next three make me very uncomfortable and I am not going to allow all three without some sort of alternative system. My rationale goes like this: With the reduction to the groundwater, the effluent is being treated less than it normally would. The leach area is a field and our regulations require a minimum of 900 square feet for a field. This is because every technical document I have read states that this should be the minimum size for a field, which tends to work like a bathtub. The field offers less effluent treatment than trenches. To add to these two variances only 50'feet to the wetlands is proposed which again limits the amount of treatment available for the effluent before it reaches water. I intond to f'ik-work something out with the engineer, but this may come to the Board. My recommendation if it does wiK(l oto require aome pre-treatment of the effluent. Just wanted to let you know. Don't forget the*- ng;,tomorrow at the Senior Center at 4:30 about the Comprehensive permit for the condos on Route 114. 1111 see you there. Sandy 4/12/2000 BOARD OF HEALTH MINUTES March 23, 2000 Mr. Osgood called the meeting to order at 7:00 p.m. MEMBERS PRESENT: Gayton Osgood, Chairman, Francis P. MacMillan, M.D., Member, John Rizza, D.M.D., Member, Susan Ford, Health Inspector, Debra Rillahan, Town,Nurse 770 BOXFORD STREET Peter Breen would like an extension on his soil test. Ms. Ford spoke regarding the soil tests extension, she thought the maximum extension was one year. Mr. Osgood allowed Mr. Breen to have an extension for two years if possible. On a motion by Dr. MacMillan, seconded by Mr. Osgood the Board voted to give Mr. Breen the maximum allowable extension. GREATER LAWRENCE SANITARY DISTRICT- MEMO SIGNING Representing GLSD was Mr. Hogan. The original memo of understanding to start the process was denied by the Selectmen and the Selectmen added to the agreement. The agreement is turned back over to the Board of Health for another signing. Dr. Rizza spoke regarding the previous memo signing. Dr. Rizza was upset at the fact that a new memo was given to the Board of Health that is different from the previous one. The Board discussed the previous agreement and Dr. Rizza liked the plan and signed the agreement. Dr. Rizza stated the Board of Health has total control of stopping this dead in the water if they want and Dr. Rizza doesn't care what the Board of Selectmen has to say. Mr. Osgood said there is a state law for site assignment, but the Board of Selectmen said there is not a law. Therefore the original agreement was a negotiating agreement in lieu of the Boards site assignment, being it is not a true site assignment it falls outside of state law, so the Selectman became involved. The Selectman set some limits to the new agreement. Mr. Osgood stated the Board really doesn't have the authority to set our own air quality standardsfthat is something that the state has to do. But when people from the environment come in here they are going to say we do have that right. We have to protect the citizens of the Town. Dr. Rizza would like the minutes to state, if the Selectmen present another agreements Dr. Rizza will not sign it. The Board would like to go to the Quincy shipyard facility to check that plant. NEW ENGLAND ENGINEERING SERVICES INC April 7, 2000 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 146 Olympic Lane,North Andover, Septic system design Dear Sandra: Enclosed are five copies of a revised septic system design for the above referenced property. These plans are being submitted for approval. The revisions made are as follows: 1. The grade on the system end invert has been changed from 101.92 to 100.92. 2. The soil class has been changed from class I to class II 3. The labels for test pits 3 and 4 have been corrected. 4. The leach bed end section dimension leaders have been corrected. These drafting changes correct the minor deficiencies pointed out in the letter from Port Engineering. I would appreciate you reviewing these changes as soon as possible and granting approval of this plan so the installation of the system can begin. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, Benj C. Osgood, Jr.,EIT President APR 10 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 Mar-22-00 04:35P Paul D. Turbide, PE/PLS 978-465-0313 P.02 1 March 22 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services {� 30 School St. North Andover, MA 01845 RE: Title V review for 146 Olympic Lane i Dear Sandra, I find that the design plans adequately address the regulations for an upgrade of a failed system. I do note the following minor drafting errors. ❑ In the system profile, the invert of the end of the distribution lines is given as 101.92', but should be 100.92'. ❑ In the design data in the upper left of the plan, the soil class is listed as Class I and should be Class II. ❑ _In the plan view, Test Pits#3 and #4 are labeled in reverse (i.e. Test Pit shown on the plan view as#3 should in fact be#4 and visa versa). ❑ In the Leach Bed End Section the 15' leader should extend to the ends of the leaching bed. If you have any questions or comments please feel free to contact me. Sincerely ? �' Carlton A. Brown,PE/PLS Olympic146.doc 146 Olympic Lane PORT E�Gi�E�RING Civil Engineers& Land Surveyors Ont,Harria Street Newburyport,MA 01950 (978)465-8594 NEW ENGLAND ENGINEERING SERVICES INC March 13, 2000 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 146 Olympic Lane,North Andover, septic design Dear Sandra: Please accept this letter as a request to have the following local upgrade approval requests and local variance requests considered at the next Board of Health meeting. I understand that the March 23, 2000 meeting is approaching quickly, however I would appreciate any effort made to have the plans reviewed prior to that meeting so a decision could be made. The local variances needed are as follows: 1. Reduction in the offset distance between the leach field and the wetlands from 100 feet required by the North Andover Bylaw section 5.02 to 50 feet. 2. Reduction in the minimum leach field size from 900 square feet required by the North Andover Bylaw section 9.01(1)to 840 square feet. The local upgrades needed are as follows: s. 1. Reduction in the separation distance between the bottom of the stone in the leach field and the water table from 4 feet required by Title 5 section 15.212(a)to 3 feet. 2. Reduction in the offset distance between a foundation and the leach field from 20 feet required by Title 5 section 15.211(1)to 13 feet. 3. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr.,�I President M 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 I r Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth ofMassachusetts husetts North A ndover 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•CMR 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. 'I 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: jPAvi.. 1>ug- sAX Address: / ,v C>t y.-t plc Phone#: I78 - �e2 r//11/ Address of facility: 2) if Applicant different from above P ( ) Name: SP+M E Address: Phone#: 3) Type of Facility: _AffResidential Commercial School Institutional (Specify) s/,v I L€ r_-An">j. y �v✓c Lc.� G- i Page 2 of 5 4) Type of Existing System: _privy ; cesspool(s) conventional system other(describe) Type of soil absorption system (trenches, chambers, pits, etc.)�,QNC �� 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system gpd Approved: dyes Approval date: 2 no Why: b) Design flow of proposed upgraded system IJ/4 gpd Why c) Design flow of facility yh!p 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: �psi Hl.,�. .v� �rs�«i•�6- sEw�'i2, s�i'T�c `�9.v�3 f�',vr� c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Oso-! 7-o mod voA7)J-✓ w-4Z.t- 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) Reduction of required separation between bottom of SAS & high groundwater(specify proposed reduction& perc rate) zp ,,�, ItEo(/C i�,vr rzc�.M y` To 15 r 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: -'A�4�v.�- 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 to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. II Page 4 of 5 List of affected abutters: 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: Z-704"01 A'"1-3 .i r!:� 'i�iC 4o1— ?D ry�E�T TIf� A/DlL�'7f �JAJi7 0�/�)2 Cl�.✓sL;7?soJ/} -7�j .y Zf- Grzd V'73' .s NS i G-. 1 w J-7h &-jZ4,Pr1U G-- e r 47w 7-h 5)A-i- AT 7HC- .eE7K pill-- 7Ht =. b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. l'vs i 141A#771,16- c) 41A#77U-c A shared system is not feasible. d) Connection to a sewer is not feasible. �'d s�v✓E2 �')crs i 3 �fv A2F,Q 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany I this application. Is the DSCP application attached? — /� yes no i d � 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." i Facility 0 er's SignatureDate [2�.�✓`tH xv gin/' 5-sC-O o 1 Print Name fi✓ Q5� 2 d o Name of Preparer Date 9!$- 686-!°748 6o P cKcvooa ©2rvE; /VOIZ I/ AA;DdCEW lv.4 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. FORM 11 - SOIL EVALUATOR FORM Page I of 3 No. Date:lt: -1101:57e> Commonwealth of Massachus'etts Massachusetts Sail Suitability.Assessment for-an-site Sewage Disposal ��m/mom PerformedBy: ............................................................................................................ Date: .......... Witnessed By: �,7? V. .................................................................................... L=ation Address or p/c Owner's Nam Lot I Address,and Tem 1 �ew Construction 0 Repair R 65-Ae — X409 Office Review Published Soil Survey Available: No El Yes KI Year Published ............. Publication Scale Soil Map Unit (f.6�........... Drainage Class 411254-1.. ....... Soil Limitations... ................................................. ....I... Surficial Geologic Report Available: No FK1 Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) ..........I.......................................................................................................... ....................... Landform ...................................................................................................................................................................................... ... Flood Insurance Rate Map: Above 500 year flood boundary No 0Yes Within 500 year flood boundary No []Yes Within 100 year flood boundary No []Yes El Wetland Area: National Wetland Inventory Map (map unit) ................. ...................................................................... Wetlands Conservancy Program Map(map unit) ............................................................................... ......... Current Water Resource Conditions(USGS): Month Range :Above Normal ONormal 9113ek-w Normal El Other References Reviewed: DEP"PROM FO&M-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 7e. Location Address or Lot No. On-site Review .� / � o Deep Hole Number ..: Date:... Time: '. Weathel��b .. . Location (identify on site plant / .. tiGT,.:..:.........ry.......,:.. Land Use Slope M r Surface Stones �.....k.,..:... : . Vegetation . G�� �� . ::.. .... .:. ..... . . Landform : �or�✓tiD �lmTZ,.¢,��t/.C� :.:. .. . ... Position on landscape (sketch on the back) .. .. .f ..:...:..:. . :.:::. ... .: ....... Distances from: Open Water Body feet Drainage way--r2feet Possible Wet Area .'S'� feet Property Line - . feet Drinking Water Well 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) leya '& MINIMUM OF 2 HULt:b REQUIRED AT EVERY PMMSED DISPOSAL AREA Parent Material(geologic) �G���.A� L t. DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole:_ �3 Weeping from Pit Face: ✓ Estimated Seasonal High Ground Water: COP DEP APPROVED FORM•12107/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. On-site Review Deep Hole Number Date:..- DelTime:.. ..:::�.�a WeatherC4� '���.,.� �� l Location (identify on site plan) ��t��T ........:.:.. .:. . ..:..v::.:......, ..... G Sloe (%) . . Surface Stones - Slope Use .r l �d`� P _...�w.,.... .,......... Land .,vx�.. .� . .v.ri ,.,�. ... : .. ... Vegetation .,' ......:..... �....... v.. ... .. .....:.....,.,:. ..... .r: ..v� A... :..:: .... Landform �oj' D:,,.::../?�p ,,¢is✓.. i .. : AA::.:...: ....:. :::...:..v:a.... ...... v.,. .:.:....,..., .. .... Position on landscape (sketch on the back) .:.:.: ....... :... . Distances from: Open Water Body feet Drainage war�ee' . feet Possible Wet Area .:.� feet Property Line ..:.1. ..: feet Drinking Water Well .. .... . . . feet Other ....,... .,,..:._ ..w.:.....:.�. DEEP OBSERVATION HOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(inches) (USDA) (Munsell) Mottling (Structure,Stones,Bo lledlrs,Consistency, % Gravp it 45 ? moo 011 � COf Parent Material(geologic) 721 G L pthtoBedrock: • Death to Groundwater: Standing Water in the Hole: Weeping P 9 from Pit Face: Esjimated Seasonal High Ground Water. ''-- DEP APPROVED FORM-12/07/95 )i A7;vcr, at•� FORM 11 - SOIL EVALUATOR FORM Page 2 or 3 Location Address or Lot iJo.,1 On-site Review Deep Mole Number � .. Date:..am/� Time:.. -:.:� Weather .Location (identify on site plan) :.• .:. Land Use 174W, Slope Surface Stones ., v•,.:.•...:.: Vegetation :. , .Y�"2s, ...:...,.. :.�..:.....: v.: .... ... ..........,, .._...., .........� r.........,.. ... ...« :... Landform .......:..��PCZj2,.::::.. . �l�l;?, /.+�1.� : r.:.:..... :....,v: .... :.::..:..... .:..:........,.... .... Position on landscape (sketch on the back) .:•:.: ....... ,�'�:•.'..•:�•�:.•.:-•• ��::: �• •'•�: �' Distances from: Open Water Bodye-� feet Drainage way feet Possible Wet Area .:. 6'� feet Property Line ..:.I.......... feet Drinking Water Well .,..... . . . feet Other ....,, .�.�.h..�..��...., DEEP OBSERVATION MOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency, % r Gravel) -0�4 .� Parent Material(geologic) g; g- G 7 4-�' DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Esjimated Seasonal High Ground Water: -•-- ®,c �>iT— <!P DEP APPROVED FORM•12107195 � -_ FORM 11 - SOIL EVALUATOR FORA Page 2 of 3 Location Address or Lot No. /4� On-site Review Deep Hole Number _ ....: Date:.,. . Time:.. ..;.®6 Weather� `�✓�..:. Location (identify on site plan) .:: .MM-.LAO e=7—..w.r......:..,:...._...r..:_...._:. n�.�v...... ........:.::. .... . ..::.:.......:.. ...... Land Use1. �:. .4: Slope %1 . Surface Stones Vegetation 5 _ .. ......,:.... Landform .:.:.:.:.. .::1Z�>.:,:..✓Y��TZf/1S% .. : __..::� »....,.,. ...:..�.,........ .... Position on landscape (sketch on the back) .:...: . :•_. �1. Distances from: Open Water Body Ate. feet Drainage waye�9, �. feet Possible Wet Area feet Property Line ..:� ... feet Drinking Water Well feet Other .....,.._,s,.'.............._. DEEP OBSERVATION HOLE LOGS Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, % Gravel) 7257 44— L . � ''I'O /•Y �L„ ,, 8 1-f Y40 .3L. Parent Material(geologic) 2' DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: — -•—.-- AEP APPROVED FORM•12107/95 i FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 l _ Location Address or Lot No. ��� o_AAyl e_ 4 A/0. . Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole................... inches ❑ Depth weeping from side observation hole�.........�inches ❑ Depth to soil mottles .::::..::::: inches Z-- Z ❑ Ground water adjustment.................... feet — s 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 al areas observed throughout the area proposed for the soil absorption system? _ 5 If not, what is the depth of naturally occurring-pervious material? Certification I certify that on q�date) I have passed the soil evaluator examination approved by the Del5airtment of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR Signature Date DEP APPROVED FORM-12/07/95 May-27-99 12 : 45P North Andover Com. Dev . 508 688 9542 P . 01 SEPTIC PLAN SUBMITTAL FORM LOCATION: /ly& df Yn ptC= -..4-gM ---�-- c,iz17-1 AIL)Po�-E4-- NEW PLANS: YL ' S 125.00/13lan_-�— REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE: ! 00 DESIGN ENGINEER: A+ Fv,) C4J&tix,,oD C/v6-Ia.J E,jz//L)G— DATE TO CONSLrL.TANT: *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. I �•u. 68�- G4-1 .Z_ -F °g r 91 Cl- P W ` V i SEPTIC PLAN SUBMITTAL FORM LOCATION: Y NEW PLANS: YES $125.00/Plan I el REVISED PLANS: � $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: YESO� DATE: to 0 0 DESIGN ENGINEER: DATE TO CONSULTANT: s *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port " Engineering. . When the submission is all in place, route to the Health Secretary. Town of North Andover, Massachusetts Form No.s • pORTh BOARD OF HEALTH p ' DESIGN APPROVAL FOR SSACHUSE'( SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant-PP Test No. Site Location I'z`Cv Reference Plans and Specs. NGINEER / IGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. r c AIRMAN,BOARD OF HEALTH Fee_ f Site System Permit No. 107 FOREST STREET FILE# 120199A MIDDLETON,MA 01949 (978)774-2772 SEPTIC & DRAIN SERVICE i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: DUBASKA PROPERTY ADDRESS: 146 OLYMPIC LANE,NORTH ANDOVER ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: DECEMBER 1, 1999 NAME OF INSPECTOR: THOMAS CHIGAS * THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 107 FOREST STREET FILE# 120199A MIDDLETON,MA 01949 (978)774-2772 SEPTIC&DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:146 OLYMPIC LANE NAME OF OWNER: DUBASKA NORTH ANDOVER ADDRESS OF OWNER: SAME DATE OF INSPECTION: DECEMBER 1, 1999 NAME OF INSPECTOR: (PLEASE PRINT)THOMAS CHIGAS I AM A DEP APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (3 10 CMR 15.000) COMPANY NAME: CURRIER SEPTIC & DRAIN MAILING ADDRESS: 107 FOREST STREET: MIDDLETON, MA 01949 TELEPHONE NUMBER: (978) 774-2772 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED BELOW IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. THE SYSTEM: PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY YES FAILS f INSPECTOR'S SIGNATURE: DATE: DECEMBER 1, 1999 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPECTIOREPORT TO THE APPROVING AUTHORITY(BOARD OF HEALTH OR DEP) WITHIN THIRTY(30)DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GALLON GPD OR GREATER,THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMIT THE REPORT TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION. THE ORIGINAL SHOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO THE BUYER,IF APPLICABLE,AND THE APPROVING. NOTES AND COMMENTS: N/A REVISED 9/2/98 PAGE 1 OF 11 1' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 INSPECTION SUMMARY: CHECK A, B, C, OR @ A. SYSTEM PASSES: N I HAVE NOT FOUND ANY INFORMATION,WHICH INDICATES THAT ANY OF THE FAILURE CONDITIONS DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONIDTIONALLY PASSES: NONE 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. INDICATE YES,NO,OR NOT DETERMINED(Y,N, OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL INSTANCES. IF"NOT DETERMINED",EXPLAIN WHY NOT. N THE SEPTIC TANK IS METAL,UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE SYSTEM INSPECTOR WITH A COPY OF A CERTIFICATE OF COMPLIANCE(ATTACHED)INDICATING THAT THE TANK WAS INSTALLED WITHIN TWENTY(20)YEARS PRIOR TO THE DATE OF THE INSPECTION;OR THE SEPTIC TANK,WHETHER OR NOT METAL,IS CRACKED, STRUCTURALLY UNSOUND, SHOWS SUBSTANTIAL INFILTRATION OR EXFILTRATION,OR TANK FAILURE IS IMMINENT. THE SYSTEM WILL PASS INSPECTION IF THE EXISTING SEPTIC TANK IS REPLACED WITH A COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH. N SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL OBSERVED IN THE DISTRIBUTION BOX IS DUE TO BROKEN OR OBSTRUCTED PIPE(S)OR DUE TO A BROKEN, SETTLED OR UNEVEN DISTRIBUTION BOX. THE SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF THE BOARD OF HEALTH). N BROKEN PIPE(S)ARE REPLACED N OBSTRUCTION IS REMOVED N_ DISTRIBUTION BOX IS LEVELLED OR REPLACED N THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR OBSTRUCTED PIPE(S). THE SYSTEM WILL PASS INSPECTION IF(WITH APPROVAL OF THE BOARD OF HEALTH): N BROKEN PIPE(S)ARE REPLACED N OBSDTRUCTION IS REMOVED REVISED 9/2/98 PAGE 2 OF 11 } SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) I PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRNONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A 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 AND SAFETY AND THE ENVIRONMENT: N THE SYTEM 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. N THE SYTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL, UNLESS A WELL WATER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS NDICATES 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. METHOD USED TO DETERMINED DISTANCE (APPROXIMATION NOT VALID). 3) OTHER: N/A REVISED 9/2/98 PAGE 3 OF 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSEPCTION:DECEMBER 1, 1999 D. SYSTEM FAILS: YOU MUST INDICATE EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: Y I HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS DESCRIBED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF HEALTH SHOULD BE CONTRACTED TO DERTERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. YES NO YES BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6'BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN 1/2 DAY FLOW. N REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE(S). NUMBER OF TIMES PUMPED UN ANY PORTION OF THE SOIL ABSORPTION SYSTEM,CESSPOOL OR PRIVY IS BELOW THE HIGH GROUNDWATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A PRIVATE WATER SUPPLLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. IF THE WELL HAS BEEN ANALYZED TO BE ACCEPTABLE,ATTACH COPY OF WELL WATER ANALYSIS FOR COLIFORM BACTERIA,VOLATILE ORGANIC COMPOUNDS,AMMONIA NITROGEN AND NITRATE NITROGEN. E. LARGE SYSTEM FAILS: MUST INDICATES EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: FOLLOWING CRITRTIA APPLY TO LARGE SYSTEMS IN ADDIT TO THE CRTERIA ABOVE: N THE SYST RVES A FACILITY WITH A DESIGN FLO 10,000 GPD OR GREATER(LARGE SYSTEM) AND THE SYSTEM IS A S FICANT THREAT TO PUBLIC LTH AND SAFETY AND THE ENVIRONMENT BECAUSE ONE OR MORE OF T LLOWING COND NS EXIST: YES NO THE SYSTEM IS WIT 00 FEET SURFACE DRINKING WATER SUPPLY THE SYSTEM I THIN 200 FEET OF A T TARY TO A SURFACE DRINKING WATER SUPPLY THE SYS S LOCATED IN A NITROGEN SENSI AREA(INTERIM WELLHEAD PROTECTION AREA-IWP A MAPPED ZONE II OF A PUBLIC WATER SUP WELL THE 0 OR OPERATOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTE ACCORDANCE WITH 310 CM .304(2).PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FURTHER FORMATION. REVISED 9/2/98 PAGE 4 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PART B CHECKLIST PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1. 1999 CHECK IF THE FOLLOWING HAVE BEEN DONE: YOU MUST INDICATE EITHER"YES"OR"NO"AS TO EACH OF THE FOLLOWING: YES NO Y PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF HEALTH. Y NONE ON THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE VOLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYTEM RECENTLY OR AS PART OF THIS INSPECTION. Y AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED.NOTE IF THEY ARE NOT AVAILABLE WITH N/A. Y THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. Y THE SYSTEM DOES NOT RECEIVE NON-SANITARY OR INDUSTRIAL WASTE FLOW. Y THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT, Y ALL SYSTEM COMPONENTS, EXCLUDING THE SOIL ABSORPTION SYSTEM HAVE BEEN LOCATED ON THE SITE. Y THE SEPTIC TANK MANHOLES WERE UNCOVERED, OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION, DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,DEPTH OF SCUM. THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN DETERMINED BASED ON: Y EXISTING INFORMATION. FOR EXAMPLE,PLAN AT B.O.H. Y DETERMINED IN THE FIELD (IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE,APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [15.302(3)(b)] Y THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS. REVISED 9/2/98 PAGE 5 OF 11 ti SUBURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1. 1999 FLOW CONDITIONS RESIDENTIAL: DESIGN FLOW:440G.P.D.BEDROOM. NUMBER OF BEDROOMS(DESIGN):4 NUMBER OF BEDROOMS(ACTUAL):4 TOTAL DESIGN FLOW:440 I NUMBER OF CURRENT RESIDENTS: 3 GARBAGE GRINDER(YES OR NO):YES LAUNDRY(SEPARATE SYSTEM)(YES OR NO):NO;IF YES, SEPARATE INSPECTION REQUIRED LAUNDRY SYSTEM INPECTED(YES OR NO):N/A SEASONAL USE(YES OR NO):NO WATER METER READINGS,IF AVAILABLE(LAST TWO YEAR'S USAGE(GPD): 197.000 GALS USAGE FORM LAST TWO YEARS. SUMP PUMP(YES OR NO):NO LAST DATE OF OCCUPANCY: CURRENT COMMERCIALANDUSTRIAL: PE OF ESTABLISHMENT: DES FLOW: GPD(BAESED ON 15.203) BASIS OF IGN FLOW: GREASE TRAP SENT(YES OR NO): INDUSTRAIL WAST LDING T PRESENT(YES OR NO): NON-SANITARY WASTE RGED TO THE TITLE 5 SYSTEM(YES OR NO): WATER METER REDA ,IF ILABLE: LAST DATE OF 0 ANCY: OTHE SCRIBE): DATE OF OCCUPANCY: GENERAL INFORMATION PUMPING RECORDS AND SOURCE OF INFORMATION: SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO):NO IF YES,VOLUME PUMPED:N/A GALLONS REASON FOR PUMPING: LAST PUMP WAS FALL 1998 TYPE OF SYSTEM YES SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM N SINGLE CESSPOOL N OVERFLOW CESSPOOL N PRIVY N SHARED SYSTEM(YES OR NO)(IF YES,ATTACH PREVIOUS INSPECTION RECORDS,IF ANY) N UA TECHNOLOGY ETC. ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANVE CONTRACT TIGHT TANK COPY OF DEP APPROVAL OTHER:N/A APPROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF INFORMATION: 19 YEARS OLD.OWNER. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE(YES OR NO):NO REVISED 9/2/98 PAGE 6 OF 11 SUBSURFACEEW S AGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1. 1999 BUILDING SEWER: (LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE: 21" MATERIAL OF CONSTRUCTION:YES CAST IRON 40 PVC OTHER(EXPLAIN) DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE:N/A DIAMETER: 4" COMMENTS: (CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.) THE INLET PIPE WAS IN GOOD CONDITION,NO SIGNS OF LEAKAGEI IN OR OUT SOILS ARE CLEAN AND DRY SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GARDE: 12 MATERIAL OF CONSTRUCTIOMYESCONCRETE METEL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN):NEA IF TANK IS METAL,LIST AGE NEA IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE(YES/NO) DIMENSIONS: 81 X 4'W X 5'H OUTLET INVERT @ 4'2" = 1000 GAL TANK SLUDGE DEPH: 8" DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE:NEA SCUM THICKNESS: <2" DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE:N/A DISTANCE FROM BOTTOM OF SCUM TO BOTTON OF OUTLET TEE OR BAFFLE:N/A HOW DIMENSIONS WERE DETERMINED: SLUDGE JUDGE.ROD.RULER COMMENTS: (RECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL IN REALTION TO OUTLET INVERT, STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE,ETC.)THERE'S NO OUTLET TEE BAFFLE ON OUTLET PIPE THE LIQUID LEVEL @ NORMAL HIGHT NO SIGNS OF LEAKAGE IN OR OUMSOILS WERE CLEAN AND DRY.THERE WAS NO SIGNS OF DECAY IN OR AROUND COVER AREAS GREASE TRAP: N LOCATE ON SITE PLAN) DEPT LOW GRADE: MATERIAL ONSTRUCTION: CONCRETE ML FIBERGLASS POLYETHLENE OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM T P OF OUTLET TEE OR BAFFLE: DISTANCE FROM BOTTOM 0 UM TO ON OF OUTLET TEE OR BAFFLE: DATE OF LAST PUMPIN COMMENTS: (RECO NDATION FOR PUMPING, CONDITION OF INLET A TLET TEES OR BAFFLES,DEPTH OF LIQUID L IN REALTION TO OUTLET INVERT, STRUCTURAL INTEGRIT IDENCE OF LEAKAGE,ETC.) REVISED 9/2/98 PAGE 7 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1. 1999 TIGHT OR HOLDING TANK:N(TANK MUST BE PUMPED PRIOR TO,OR TIME OF,INSPECTION) CATE ON SITE PLAN) DEPTH B W GRADE: MATERIAL OF STRUCTION: CONCRETE AL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN) DIMENSIONS: CAPACITY: GALLONS DESIGN FLOW: GALL /DAY ALARM PRESENT: ALARM LEVEL: ALARM IN WORKING ORD YES NO DATE OF PRE US PUMPING: COMME . (CO TION OF INLET TEE, CONDITION OF ALRM AND FLOAT TCHES, ETC.) DISTRIBUTION BOX: YES (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE, 22" COMMENTS: (NOTE IF LEVEL AND DISTRIBUTION IS EQUAL,EVIDENCE OF SOLIDS CARRYOVER,EVIDENCE OF LEAKAGE INTO OR OUT OF BOX,ETC.) THE D-BOX WAS IN POOR CONDITION,SHOWS SIGNS OF DECAY AND LEAKAGE THERE WAS SIGNS OF SOLID CARRYOVER.AND SIGNS OF HYDRAULIC FAILURE THERE WAS LIQUID POOLING IN THE LEACHLINES. PUMP CHAMBER:N OCATE ON SITE PLAN) PUMPS IN G ORDER(YES 0): ALARMS IN WO ORD ES OR NO): COMMENTS: (NOTE COND S OF PUMP C ER, CONDITION OF PUMPS AND APPURTENANCES,ETC.) REVISED 9/2/98 PAGE 8 OF I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 SOIL ABSORPTION SYSYEM (SAS): YES (LOCATE ON SITE PLAN,IF POSSIBLE;EXCAVATION NOT REQUIRED,LOCATION MAY BE APPROXIMATED BY NON-INTRUSIVE METHODS) IF NOT LOCATED,EXPLAIN: TYPE: LEACHING PITS,NUMBER: LEACHING CHAMBERS,NUMBER: LEACHING GALLERIES,NUMBER: LEACHING TRENCHES,NUMBER,LENGTH:FOUR SCH2O PVC 24"W X 801 TRENCHES LEACHING FIELDS,NUMBER,DIMENSIONS: OVERFLOW CESSPOOL,NUMBER: ALTERNATIVE SYSTEM: NAME OF TECHNOLOGY: COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,DAMP SOIL,CONDITION OF VEGETATION,ETC.) THE LEACH LINES ARE SHOWING SIGNS OF SOLID CARRYOVER AND SIGNS OF FAILURE HAD DUG OUT IN TRENCH AREA LOCATED STONE AND PIPEYOUND TO BE UNDER HYDRALIC FAILURE CESSPOOL:_ N ( CATE ON SITE PLAN) NUMBE ND CONFIGURATION: DEPTH-TOP LIQUID TO INLET INVERT: DEPTH OF SOIL AYER: DEPTH OF SCUM LA R: DIMENSIONS OF CESSP L: MATERIALS OF CONSTRU INDICATION OF GROUND T INFLOW(CESS OL MUST PUMPED AS PART OF INSPECTION) COMME S: (NOT ONDITION OF SOIL,SIGNS OF HYDRAULIC FAILUR EVEL OF PONDING,CONDITION OF VEGETATION,ETC.) PRIVY: _N ATE ON SITE PLAN) MATERIALS OF TRUCTION: IMENSIONS: DEPTH SOLIDS: COMMENTS: (NOTE CONDIT F SOIL,SIGNS OF HYDRA AILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.) REVISED 9/2/98 PAGE 9 OF 11 s. SUBSURFACE SENYAGE DISPOSAL SYSTEM INSPECTION FORM y PART C J • _ .. SYSTEM INFORMATION(CONTINUED) Py�pP 'Y ADDRESS: 146 OLYMPIC INN. 9WMA5K0: x ' DAT]3!OF ITISPECTION:DECEMBER 1999 ` , SKETCH OF SEWAGE DISPOSAL SYSTEM: ":INCLUDE TIES TO AT LEAST TWO'P£RM-ANENT REFERENCE LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100',(I,ACATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE) al 14: • t J , Nouse 13 ra S Jn S S�Phc, 00❑ fTrroeh uneS ef 25 12 M Ll 7 c REVLSED PAGE 10 OF 11 ti fF�,•^ - / _ .�a ..t - tit, ^+a+..J .�-_.�+—..._..-,_ - - � _ 'm,. :...v - � \ .. \ �) �� 4r'4fa_j 1 .:.� f - ''�ytt {{ y,ems• �,S•v tt J` - t _ � e:.t` }� ;.. Y y a tt�u� t�' � T.�,���� "�'>.-s`""` 4 °.-w_,^ •?'- � �`t .as. .�. - f ;t!- ,bt a 'a .��F'.;r k 4 4'ag%r,'t'�,;e+kE :.k •g 4 t :a i�.;&. _ .*ea .s. h.".::, 'ut C i � _ -..a . . ., ., ...♦.r .rg g5.,.;`n>• �"5t-.; : a- -,+'-.�S r =F"Y .r fi"r�'. .:S E. .�33�y� ,,�,'S .'� � 'fir •xz � 's c.. i+: .f.s �� ""s:. .y.�t 'la ,�` t n 'j-1'•-. .'t•.. -i. b v`ti .,sv� Y'y'. !,. 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F kk.' :a++-^,a+e -y....�: �€,� - ''+�`°_, � f rsk �rfxxt, J f. ♦ r � r . -"�` �v' C:t;' .- +•C' v •_... f n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS: 146 OLYMPIC LN,N.ANDOVER OWNER:DUBASKA DATE OF INSPECTION:DECEMBER 1, 1999 NRCS REPORT NAMEN/A SOIL TYPE N/A TYPICAL DEPTH TO GROUNDWATER N/A USGS DATE WEBSITE VISITED OBSERVATION WELLS CHECKED GROUNDWATER DEPTH: SHALLOW N/A MODERATE DEEP SITE EXAM SLOPE SURFACE WATER CHECK CELLAR SHALLOW WELLS ESTIMATED DEPTH TO GROUNDWATER 4'APPROX FEET PLEASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: Y OBTAINED FROM DESIGN PLANS ON RECORD Y OBSERVED SITE (ABUTTING PROPERTY, OBSERVATION HOLE, BASEMENT SUMP, ETC.) Y DETERMINED FROM LOCAL CONDITIONS N CHECKED WITH LOCAL BOARD OF HEALTH N CHECKED FEMA MAPS Y CHECKED PUMPING RECORDS N CHECKED LOCAL EXCAVATORS, INSTALLERS Y USED USGS DATA DESCIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION. (MUST BE COMPLETED) THE HOUSE HAS 8'FOUNDATION W/NO SUMP PUMP IN BASEMENT AND IT'S DRY THERE IS A SPOT OF WETLANDS IN BACK YARD LESS THAN 50'AWAY.THERE NO SIGNS OF ABBUTTING PROPERTY'S WELLS WITHIN 100'. REVISED 9/2/98 PAGE 11 OF 11 BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: d� c a LOCATION OF SOIL TESTS: 1 Y(o Assessor's map & parcel number: /04�g — i y OWNER: Pno L TEL. NO.: R76 - ADDRESS: r q(- D I`,��w..y,c L.,.� . N • NLw N v-e. •�v ENGINEER: �c,t•�� E2�,U� ` �� _ TEL. NO.: 178 -ice 86- 7 S CERTIFIED SOIL EVALUATOR: A.-Acno C ir�,UCrA2�,. j3�„ Dsy000 j Intended use of land: re idential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than V-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. .r i r ��► 4�' �4�,S���.�. 440353 :z 11 i3 w LOA 'eroo oop t r .100i go r i i 0 "� go i jiii �Ilf : � 1 � � �I � rII� , :a 'fit it� . � �#= ISE I� �� ii11 � � i 'ii � ���� { - tel � � � 7: i �r11 I , Feb-10-00 05: 13P Paul D. Turbide, PE PLS 978-465-0313 P_05 I AN - - - I a v, , a► - - AF c _ ID } i 4 1 ! I I t �..: a. 1 i 7� M�! . ■ r . �" Ir r • f �r