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Miscellaneous - 15 LONG PASTURE ROAD 4/30/2018
'-� 15 Long Pasture Road I i r �- 'j"p J 1.f f!!'�•Vrl`I',{JI � ,'T )1�7�'�,)+t1,fl �t 4w.�,1,M't ll�l lr tl�'> t 1r '{' •-^'-•---'---._.__�_,..._..._ tlftr)�a777777777t-' { Ir r I�l„ f ��y) H�lt`thJ .t�J 1 i t U lA.I !� 1 l.rl •t! t n J, 1 I �,1f I t .. ,�'�±. `^ _,i[d'','�'' t,v+l �',}.)� /,•p,1�.,Cjk'(`a y , �,�'I, I,.,S Vr Y.. ' 1.1�.! • t'� r{v Ir Ilr}:•i t., �•. ) is ' ' � .1 � � ol w. SYSTCNMI Lp( AT►ON - ' .'�1��o�•rp . . (�z�m�lel' Icfr � u nou,'� f(Zf h . . • . • �`J;:;'�,,;,C�`�• AUC e �C@'' J r J ✓. .. .:�ia';,I•t`.�''�.'����'�"YI�'a_I,`.�1 i:1!>�t�i���•�1'ii�i:'i Y�;a; _,:i:�:�:.:.:.'..�, �ANTIT'Y P I% s4 :' p �-.. �:I:,j.,frl•j.?:•a�•i ,lt��' '';:�i1`,. ;�t't'''�i:,.�: �.y'•, � I '.N 0 SEPTIC' TANK: N O r F • r Iat ' %{ ' ' 'fib I , s. , .. :.� �TUFtt .OFSERVICE, ROUTINE,.' . EMER0ENCY TIONS, i U,CUYCiL ENS IN llt,A�p �• L E AC H FI C L CXGESSI:'Y!✓'. 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AO DTki lO 9 ` Town of North Andover ....... , � HEALTH DEPARTMENT CHECK#: 16' Wo DATE: LOCATION: 16 f UCJ yy� H/O NAME: CONTRACTOR NAME: Tyne of Permit or License:(Check box) ❑ Animal $ ' ❑ Body Art Establishment $ ❑ -Body Art Practitioner $ I ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ j ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ 1 ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ TitlepVnspector $ itle 5 Report $ ❑ Other:(Indicate) $ 2666 -� Heath Agent Initials White-Applicant Yellow-Health Pink-Treasurer A Commonwealth of Massachusetts RElV w Title 5 Official Inspection Form OCT G 312 07 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NORTH ANDOVER 15 Long Pasture Road IHEALTH DEPARTM T Property Address — Frances Crowell2° Owner Owner's Name information is No Andover MA 01845 10/31/07 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your Benjamin C. Osgood Jr. cursor-do not Name of Inspector use the return j key. New England Engineering Services Inc. Company Name tab 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 eturn City/Town State Zip Code 978-686-1768 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the,Local Approving Authority I nspectgK Signature Date I [ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D I 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. i 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 TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 I h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: i 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: ❑ 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 h i as a septic c tank and SAS and the SAS is within 50 feet of a private water ❑ Y P p t supply well. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2day flow ❑ 9" Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ED/ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ED,,,- Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts R Title 5 Official Inspection Form 51 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ 2--- Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [2'' Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ®' Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ©� The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ [9"� the system is within 400 feet of a surface drinking water supply ❑ P"'- the system is within 200 feet of a tributary to a surface drinking water supply ❑ Eq_--- 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. TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts „ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , a a 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No L ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ [g" 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? E] Were as built plans of the system obtained and examined? (If they were not available note as N/A) []� ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all ,system components, excluding the SAS located on site. Y P g LTJ ❑ Were the se tic tank manholes uncovered, opened,ened and the interior of the tank P inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑/ ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? i The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑� ❑ Existing information. For example, a plan at the Board of Health. Ei [�rDetermined in the field if an of the failure criteria related to Part C is at issue ( Y approximation of distance is unacceptable) [310 CMR 15.302(5)] TITLE 5 FORM 2007.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts �W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): b 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 �C] No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes M No Last date of occupancy: Gu rr>ew-L Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/.sq.ft., etc.): Grease trap present?. ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title'5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts c usetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont'.) General Information Pumping Records: Source of information: ®c 'H t�'EfZ few a ►2 Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 1XL Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool . ❑ Privy I ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a.copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: LCtq Were sewage odors detected when arriving at the site? ❑ Yes [9 No TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts _ w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /p 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont:) Building Sewer(locate on site plan): Depth below grade: feet 6 Material of construction: ❑ cast iron Z[40 PVC ❑ other(explain): Distance from private water supply well or suction line: Nl feet Comments (on condition of joints, venting, evidence of leakage, etc.): i Septic Tank (locate on site plan): Depth below grade: fee Material of construction: I © concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: OSS 6,4 L-L Sludge depth: L' Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 4-1 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle I H How were dimensions determined? ' GA:' OV-0 snctc, TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont:) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Ly��K tom/ lso�a C�Na.���J 2cconaeio ;Cv37'�41-c.l,.r� J-2-Q% oy-eA- L N LLQ rt}n� Ca.�Tt-G?' ZC Grease Trap(locate on site plan): Depth below grade: feet I 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert D- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): X t n.* Tt s TQtgL;-k)o v r(Q-A-t- Q -.� ;=-J.0 (,C LSF 1-E,4K^G.t; tt✓ 6)1 0 7 02, 4>LA D S GA. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts N F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .' 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: [� leaching trenches number, length: 1� L.4-/10 ( '�«e> ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative;system i Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): A zVz>966 A4 ti D e,v e.r c5 k=- F6 NDlu 4M t 4J,.1 , o 0v�JSu.d U(:Crt="74'7 �Ai TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): TITLE 5 FORM 200TDOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 ' Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 e building. uJ�sG 1 &4 R z5-1 0 I �,2t0C TITLE 5 FORM007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Long Pasture Road Property Address Frances Crowell Owner Owner's Name information is required for No Andover MA 01845 10/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 12�- 4-7 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ElChecked with local Boari d 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: TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 08/13/99 This is to certify that the individual subsurface disposal system . constructed (X) or repaired () I ; by Louis Baldoumas at Lot#7 Long Pasture has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit# 869 dated 12/05/97. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector '1 1, 4 C* V TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System(xconstructed; ( )repaired; by Ale> —S located at was installed in conformance with the:North Andover Board of Health approved plan, System Design Permit# �,dated / ;t. with an approved design flow of gallons per day. The material's 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 flij As-built which has been submitted to the Board of Health. Installer: /z;�LA / #: (� j� Date: t Design Engineer: Date: +� Q � �� � ��� o � � �� AS-BUILT CHECKLIST LOT NUMBER, STREET NAME c� ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION& D f N ENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA ti LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER; GAS, ELECTRIC LINES, CABLE �— DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK &D-BOX STAMP & SIGNATURE �— IMPERVIOUS AREAS -DRIVEWAYS, ETC. v NORTH ARROW _ FINAL CONTOURS c_— LOCATION & ELEVATION OF BENCHMARK USED LOCUSPLAN .t Town of North Andover, Massachusetts Form No.s t tORT" BOARD OF HEALTH ° 19 T DISPOSAL WORKS CONSTRUCTION PERMIT S^CLAUSE Applicantav,ti�S `ley its — J NAME ADDRESS TELEPHONE Site Location Lot 7 Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. b CHAIRMAN, BOARD OF HEALTH 75 Fee D.W.C. No. 9 � 1 i APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: t 1;��Z- O 1 CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALLER: I/EKA SIGNATURE: TELEPHONE#T30l CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. D Administrative Use Only $75.00 Fee Attached? Yes � No Foundation As-Built? Yes V No Approval =�� � Date: �� � 14ORTi4 q Q t[,_ED 16� ti0 3a a° 6 O %T CHUS PUBLIC HEALTH DEPARTMENT Community Development Division Date: October 29,2007 Address: 15 Long Pasture Road Re: Building application for sunroon Dear: Mr. Nigro, Your application for the sunroom has been reviewed by the Health Department. The application was denied on, October 29, 2007, for the following reason as shown in red: 01. Missing information 2. Passing Title 5 inspection of septic system required per local N. Andover regulations ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the problem(*: If#1 i ked, please supply: Floor plan of existing and proposed addition—all rooms b. Certified plot plan showing house,septic system and proposed project in scale(you may pick up an as-built septic plan at the Health Office) H# i ecked: Have the septic system inspected by a certified Title 5 inspector to determine / whether it is operating properly: (inspector list attached) OR b. Tie-in to municipal sewer If#3 is checked: a. Relocate the project If#4 is checked: Options 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult a professional engineer or registered sanitarian to determine the flow capacity of the septic system. b. Hire a professional engineer to design a new septic system that meets State Regulations C. Request approval of a deed restriction agreeing to always be a--bedroom home. i. Submit a request in writing to the Board of Health identifying why the need to upgrade the septic system is a severe hardship. ii. Attend a BOH meeting to address the board iii. If approved, record the deed restriction at the registry of deeds Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, I Sawyer, is ealth D' ector i Cc: Building Department File I 1 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com Town of North Andover, Massachusetts Form No.2 O� pOeTq BOARD OF HEALTH O L p DESIGN APPROVAL FOR �SSACHUSOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant �l� lll�l/� Test No. Site Location LDT -Po [LA Reference Plans and Specs- ENGINEER DESIGN DA /�� q -7 Permission is granted for an individual soil absorption sewage disposal syste tos a installed in accordance with regulations of Board of Health. ' a,pp --.j CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. a� I CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 T0: Ms . Sandra Starr Board of Healthp��R/ North Andover rr, "' r" RE: Septic System Design Plans V Date: 2 019% Attached areP lans for This design is a new submittal a revision with the following changes SEPTIC PLAN SUBMITTALS LOCATION: i NEW PLANS: YES $60.00/Plan REVISED PLANS: YES $25.00/Plan .DATE: DESIGN ENGINEER: / When the submission is all in 'place, route to the Health Secretary SEPTIC PLAN SUBMITTALS LOCATION: (-DT g ; P0,o+uAA- NEW PLANS: `YES $60.00/Plan REVISED PLAN : YE ) $25.00/Plan _,e DATE: DESIGN ENGINEER: When the submission is all in place, route to the Health Secretary t �I �J NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: PERMIT # 8689 DATE RECEIVED !/ohoA APPLICANT F157-je6- /le'• MAP PARCEL ADDRESS LOT ## /17 9 ENG. � � STREET Zl )X s " ADDRESS 406 SCJMMjM i , / PLAN DATE REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: /- 46 r` Z OCJT 6U/674) CS NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: PERMIT # DATE RECEIVED APPLICANT � MAP PARCEL ADDRESS LOT # ENG. 0 STREET 26 25/-7J, - ADDRESS 4100 PLAN DATE REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: , i i Town of North Andover AORTH OFFICE OF O tS t•_<o r e a AV�L COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 to °`c5 wn.LIAM J. SCOTT 9S1ACHu5S Director October 1 1996 Christiansen& Sergi 160 Summer Street Haverhill, MA 01830 Lots 7 & 8.Long Pasture Dear Phil: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following.reasons: 1: Lot 7 -No peres. r; 2. Lot 8 - Inadequate and out of date peres. 3 No further review. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Y Sincerely, 7 ----------1. Sandra Starr, R.S., Health Administrator BOARD OF APPEALS.688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 T0: Ms . Sandra Starr Board of Health eaO9TV4ANNDOVER� SOWN OF 'C V11V iLSH RD North Andover BOR. �-�-�"'I RE: Septic System Design Plans Date : 10 ZQ`fV" Attached are plans for 7 _This design is a new submittal a revision with the following changes CHRISTIANSEN & SERGI, INC. .PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 October 10, 1996 Ms . Sandra Starr North Andover Board of Health �NOF1409 146 Main St . �O B North Andover, MA 01845 RE: Lots 7 and 8, Long Pasture Dear Ms . Starr: Thank you for your October 1, 1996 comments regarding the septic systems designs for the above referenced lots . I have the following responses to your reasons for denial . There are two passing perc tests on Lot 7 . Perc tests 31 and 32 were performed on July 15, 1987 by Christiansen & Sergi, Inc . The tests were witnessed by Health Agent Michael Graf . The perc rates for both were recorded as less than 2 minutes per inch. Although the locations of the tests were indicated on the plans that were submitted to you, the test results were inadvertently left off . These test results have been added to the plan. When Soil Evaluator Daniel O'Connell performed the test pits on this lot on May 23, 1996,. he determined that the location of the proposed leaching facility should be located in an area on the lot closer to Forest Street from where the perc tests were performed. For this reason, the proposed leaching facility and reserve area are located from 40 to 50 feet from the locations of Perc tests 31 and 32 . The test pit results indicated that the soils in this area are consistent in that they have a very rapid permeability, and a field assumption was made by you and Daniel O' Connell that the perc rate would be less than 2 minutes per inch. It was obvious that the perc rate of the soils would not be greater than five minutes per inch, which is the fastest effluent loading design rate listed in Title 5 . Since the 2 minutes per inch rate requires a five foot vertical separation from groundwater, the use of this rate for design purposes results in additional protection of the groundwater. There are two passing perc tests located on Lot 8 . Perc test 1 and 2 were performed on June 22 , 1987 by Christiansen & Sergi, Inc . The tests were witnessed by Health Agent Michael Graf . The perc rates for both tests were recorded as 3 minutes per inch. When Soil Evaluator, Daniel O' Connell performed test pits on this lot on May 23, 1996, he determined that the location of the proposed leaching facility should be located further back onto the lot from Starr, October 10, 1996 page 2 where the perc tests were performed. The test pits were dug in locations that would minimize the amount of fill that would be required between the proposed house and the leaching facility. The configuration currently proposed would also allow for the construction of the reserve area without the necessity of a reinforced concrete retaining wall along Forest Street, which would be required if the locations of the leaching area and reserve area were shifted so that Perc test 2 would lie within the reserve area. This could save the future homeowners a substantial amount of money at a time when they will already face severe economic hardship. Perc Test 1 lies within the proposed reserve area and is approximately 30 feet from the proposed leaching field. Perc Test 2 lies approximately 40 feet from the reserve area. The test pit results indicated that the soils in this area are consistent in that they have a very rapid permeability, and a field assumption was made by you and Daniel O'Connell that the perc rate would be less than 2 minutes per inch. It was obvious that the perc rate of the soils would not be greater than five minutes per inch, which is the fastest effluent loading design rate listed in Title 5 . Since the 2 minutes per inch rate requires a five foot vertical effluent separation from the groundwater, the use of this rate for design purposes results in additional protection of the groundwater than if the previously measured rate of 3 minutes per inch was used. It should be noted that the septic system designs for these two lots were completed before the recent decision by the Board of Health to allow for a minimum design flow of 440 gallons per day for a single family home. Given that the proposed leaching fields on the two lots consist of the minimum size of 900 square feet of leaching area as required by local regulations, the sizes of the fields cannot be reduced. This being the case, the two septic systems would be adequately sized for any percolation rate up to and including 20 minutes per inch. (440 gallons per day/0 .53 gallons per day per square foot = a required leaching area of 830 square feet) . Since it is clear from the soil characteristics found in the test pits that it would not be possible to obtain a percolation rate in excess of 20 minutes per inch in a properly executed test, no further testing is warranted. The factor of safety of 10 regarding the perc rate and its effect on the size of the proposed leaching area, coupled with the five foot vertical separation to groundwater because of the 2 minutes per inch perc rate assumption, will result in the construction of leaching facilities that meet or exceed all state and local requirements . Starr, October 10, 1996 page 3 Regarding you comment that the perc tests performed on Lot 8 are "out of date" , we are unaware of any regulation that would deem the perc tests to be expired. Although the North Andover regulations state that "the Board of Health representative may require the area previously tested to be reperced if there is some question as to the results or location of previous tests" , the plans of record and soils test results that were submitted to the Town of North Andover with the Definitive Subdivision Plan and the Notice of Intent in 1987, clearly document the locations and results of the tests . In summation, performing additional perc tests on these two lots will have no effect on the designs of the septic systems, will have no additional benefits towards the protection of the public health, and would be a considerable waste of time and/or money for the Board of health, the engineer and the applicant . The owner of this property negotiated in good faith with the Town of North Andover to settle litigation. It was expected that use of old percolation tests would not be a problem. You and Daniel O'Connell also did new test pits on this property in 1996 to complement testing done in 1987 and 1991 . A final day of perc testing is scheduled for October 17, 1996 . I hope the testing can be resolved on October 17, 1996 so that the design work can proceed. Please contact me if you have questions or comments regarding this matter. Very truly yours Phi p G. Christiansen PGC;lc cc: William Scott Ralph Joyce Ren Crete / CHRISTIANSEN & SERGI INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960 TO�(N OF VO T4i F r1� November 6, 1996 BOARD O-' � Ms. Sandra Starr North Andover Board of Health 146 Main Street North Andover, MA 01845 Re: Lots 7 and 8 Long Pasture Dear Ms. Starr: Thank you for your recent comments on the septic system designs for the above referenced locations. I have the following responses to your reasons for disapproval: 1. The results and locations of the perc tests that were performed on 10/17/96 have been added to the plans. 2. 'The proposed leaching facilties have been changed from fields to trenches. Enclosed are three sets of the revised plans for your review. Please contact me if you have any questions regarding these designs. 4Ver ruly Yours G. Christiansen SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan REVISED PLAN YES- $25.00/Plan7 DATE: i 1 I1 DESIGN ENGINEER: e l �— When the submission is all in place, route to the Health Secretary SEPTIC PLAN SUBMITTALS LOCATION: LC NEW PLANS: YES $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: DESIGN ENGINEER: When the submission is all in place, route to the Health Secretary I� i PLAN REVIEW CHECKLIST ADDRESS 7 LD.V& -P1)-57U;eE ENGINEER C S GENERAL y� l� 3 COPIES / STAMP LOCUS NORTH ARROW SCALE CONTOURS L,,-/ PROFILE L--'� SECTION G,— BENCHMARK SOIL & PERCS )�%LEVATIONS WETS. DISCLAIMER `- WELLS & WETS WATERSHED?lt/,L DRIVEWAY �Elev) WATER LINES FDN DRAINZ/ SCH40 / TESTS CURRENT? SOIL EVAL � u SEPTIC TANK MIN 150OG Zl/ . 17 INVERT DROP L-"" GARB. GRINDERLI/O (2 comps +200) 10 ' TO FDN L/ MANHOLE04- ELEV --' GWL-""- ## COMPS. GB D-BOX SIZE # LINES S FIRST 2 ' LEVEL STATEMENT INLET OUTLET I�� 73 = j 7 (2" OR . 17 FT) TEE REQ D?� LEACHING / MIN 440 GPD? `' RESERVE AREA �---- 4 ' FROM PRIMARY? 11-----2o SLOPE 100 ' TO WETLANDS L----100 ' TO WELLS L--- 4 ' TO S.H.GW I,� 20 ' TO FND & INTRCPTR DRAINS e--' 400 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER :/ FILL? '� (15 ' ) BREAKOUT MET?-L/""' TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/100 ' ) '= SIDEWALL DIST. 3X EFF. W OR D (MIN 61 )-LZZ RESERVE BETWEEN TRENCHES?y IN FILL? � MUST BE 10 ' MIN.lz 4" PEA STONE? L- VENT? (>3 ' COVER; LINES >501 ) BOT 0 + SIDE 006 X LDNG ' 7�1- = TOT ,-- e (L x W x #) (DxLx2x#) (G/ft2) 60o 300 Copyright 0 1996 by S.L. Starr I PITS MIN 440 LEACHING MIN 1 (13 'x16 ' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x ##) (2x(L+W)xD x ##) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60 ' X 60 ' ) MIN 13 ' X 16 ' PIT i BOT + SIDE X LOAD = TOTAL (L x W x ##) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 440 GPD I/ 900 ft2 BED t/ GW MIN 4 ' BELOW BOTTOM OF FIELD '--� PIPE ENDS JOINED?_ 4" PEA STONE? DIST LINE SLOPE . 005? L---" >31COVER-VENT SCH 40 MIN 12" COVER RATE 3(v X Z-,5—) X 7�- = TOTAL 666- 7 G L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X PUMP CAPACITY gpm L W D Vol . DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1 ' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ENUF STORAGE? TDH WEIGHTED? Copyright © 1996 by S.L. Starr r Town of North Andover OFFICE OF 3? COMMUNITY DEVELOPMENT AND SERVICES ° 30 School Street ,0;1e,::; \ North Andover,Massachusetts 01845 WILLIAM J. SCOTT s^c"us Director May 28, 1997 Ms. Robin Barclay 425 Forest Street North Andover, MA 01845 i Dear Ms. Barclay: As an update on the status of Long Pasture Subdivision, please be advised that the following lots have approved septic plans: Lot #I A, Lot#7, and Lot #8. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S., Health Administrator SS/cjp cc: Wm. Scott, Director, P&CD Planning Board File CONCF.RV.ATTON 69R-9530 HEAT TH 698-9540 PT A.NNJNG 689-9535 i 77-77,777774T7, Town of North Andover, Massachusetts Form No. 1 NORTH q BOARD OF HEALTH nQx mN APPLICATION FOR SITE TESTING/INSPECTION 7,9 q�RATED PPR,`.�5 SSACHUS� Applicant NAME 41 ADDRESS TELEPHONE Site Location �y Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No.-7'L/- S.S. o. 'L/-S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. LAW OFFICES OF RALPH R. JOYCE RALPH R. JOYCE 95 MAIN STREET [508] 685-4555 NORTH ANDOVER, MA 01845 FAX 685-3148 April 24 , 1996 TOWN OF NORTH ANDOVER/ _ Board of Health BOARD OF HEALTH SANDRA STARR 120 Main Street North Andover , MA 0184 RE : LONG PASTURE SUBDIVISION Dear Ms . Starr Enclosed please find a check in the amount of $1 ,200 . 00 for 8 deep hole and percolation tests on the above-cited subdivision. Please contact ' my office with a date for these tests . Thank you for your attention to this matter . Very tr Iv .1 urs , ' e- Rai RRj:mj j I • FORM 11 s61L EVALUATOR FORM Page 1 of 3 Date: No. Commonwealth of Massachusetts Massachusetts 71,1111, ,, %,"- --- - t1ii Sui bilinLAAAssess��'l�ili����ill,�i�I I'll �t for. on-site Sewa e 1,119VOsal —S0--S Date: ........ ......... ................ ................. Performed By: ..... .11c .................. ......-................ Witnessed By: ..... 0*=T.S N&M' LGAJ PA STU IZE LAwsan Ad&W of LoT -7 (,O/J G P#' S–IL4t I LE Addftss,And -�43 Lot# Tr, I Telephow I cm Z'I ew construction Repair Office Review Yes Published Soil Survey Available: No Soil map Unit Publication Scale yearPublished ...... ...........................................................I......................................................... Drainage Class f-xCa^1,j,f,0eSS ....... Soil Limitations 0IV.6,1"If 0 E?" Yes surficial Geologic Rep Ort Available: N o year Published Publication Scale . ,.......... ......................................................................... ..... ..... ....................... Geologic Material( MaP Unit) ...... .............................. .. ........................................................ Landform ............o.VTLjft ........... Flood Insurance Rate Map: Above 500 year flood boundary No Dyes E��, Within 500.Year flood boundary No Dyes 1-1 Within 100 year flood boundary No ElYes. D, .......... WetlandArea: ........................................................... National Wetland Inventory Map (map unit) ........... ....... ........ ......... .... ...................... Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month ❑ Range :Above Normal []Normal E]Belc�iNormal Other References Reviewed: DEP APPROVED FORN' 12/07195 A % FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. P On-site Review � '/Q(- Time:. l: Z Weather PAM-,' t� y Deep Bole Number q6:-3 Date:..:.::.::.....:..tL. Location (identify on site pian Slope..-pe..--,.(%::- L) Surface Stones No ... ::...... . .....:.. .. .. Land Use �aoS -. ) ' 3 W . rf �N Vegetation WJHI. - P.(.,V'c.,./....... / Landform .... ........ ..::..... . Position on-landscape (sketch on the back) Distances from: feet Open Water Body feet Drainage way Possible Wet Area ./ -t-feet Property Line fest Other Drinking Water Well feet i DEEP OBSERVATION HOLE _OG' Depth from Soil Horizon 5 Texture Soil Color Soil ( Other (USDA) (Munsell) Mottling (Structure,Stones, Boulders, Consistency, Surface (Inches) ( + H p FS L lo`t�-3�Z n0fisSf+r� j AnfuZ r �rN0IbLIC '�.S'Nr sig ('0 w ns h ` 2 G I NN N4�t (v Sf4NoS GeLOLL) f c�rLRUsi.l, t u u L'00.5(Z y - I u u C Z Y LS i, 3 Neft'fc v<,., wuui16 L4 s�G H DepthtoBedrock: Parent Material (9e0togic) u qDepth to Groundwater. Standing Water in the Hole: ` Weeping from Pit Face: — I Hi Estimated Seasonal h Ground Water.9 DEP APPROVED FORM- 12107/95 i FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. LOT 7 (- 1A/� P�S'(t-tr — On-site Review / / b Time:. . Z Weather Deep Hole Number .6:"" Date:..:.SI.LI Location (idertifY on site plan) 3 Surface Stones A/0Land Use LJ.UOG'S Slope (%) C) Lr Vegetation tJKli'E PIN4.,_... Landform ... 0.4 71- Position on-landscape (sketch on the back) Distances from: feet Open Water Body feet Drainage way feet Property Line feet Possible Wet Area 6D Drinking Water Well feet Other :...:.....:. DEEP OBSERVATION HOLE _OGsoil color ' Soil Other Depth from Soil Horizon Soil Texture (Munsell) Mottling (Structure,Stones, aoulders, Consistency, % Surface(Inches) Gravel) 0-- A to IOU I3 S l�Csll� �vW11 N�5 , tau S L N G ( Lo N de C p i as n G L D S t�I (�►�cT(/l �1ff't Iry 5 "'b �ec.o1.J � rz.moi3 ,D 3E G-L S 5�f 3 �wits3 r u,�,F_"4 6 c.& y (u DepthMaedrock: c Parent Material (geologic) _,b' Lj`� Weeping from Pit Face: Depth to Groundwater: Standing Water in the Hole: Ile Estimated Seasonal High Ground Water: t` DEP APPROVED FORM- 12107195 FORM 11 - SOIL LVALUATOR FORM Page 3 of 3 t Location Address or Lot No. t Determination -for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole ............ .... inches Depth to soil mottles :;: . inches ❑ Ground water adjustment :.................. feet Index Well Number ........ Reading Date .................. Index well level .......... . Adjustment factor Adjusted ground water level ..................................... f Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? YQ If not, what is the depth of naturally occurring pervious material? Certification I certify that on io (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CM-R 15.017. /�zv (0 1i6 �o Signature Date ' DEP APPROVED FORM-12/07/95 t _ E..,`•,. �� t TO wzi No. 0 '\ doVerV., . ! .-_^�_ fi, �C/f/CHCE_t�..-..r ` over M '€- °g7'- q.,T .. ;eD ;� ass.PER , M1 BOARD of HE CERTIFIES THAT... `� THIS Food/Kitchen .:.. .. has permission to �:_.. erect...... . . ... eptic SYstem . ....:.... . .... : :- 0 6e occupied as... buildings on... provided that the BUILDING N PECTOR Person acce this off- Foundation Ping this .. . .................:...:.... and to the provisions of the Codes and 8 - .. ......... Buildings in the Town of North Ando -permit shall in eve ry respect conform to the terms of the a ..... Rough ver. Y Laws relating r VIOLATION of the Zoning9 to the Inspection pplication on file in Chimney or Buildin , Alteration and Construction of g Regulations Voids this Permit1 41 Final lyse i --T1.1 r PLLIIKBMG INSPECTOR ' IN 6 .���� .. jur(ON TinIVI rS F _ .................................................................... TRCAL ............ ................. ugh _ R - l' UILD••............... 0 CTo QTt rZI1C V B Service C 1117 l i_�(`11 recd t o BUILDING INSPECTOR --�__._ —_ )CCI t \\ No'iicuous '� 111k-11.71 inaYPlace on the /Lathin Premises DO NOt 13 G'AS INSPECTOR d and gorDry WallTo Be Don emove Rough pproved b eFinal Y the Building Inspector. FIRE DEPAR Burner —) / TMENT � 4 SK; ✓y C .:� .� k i �j�, � Aiid M4166 'Moqb� : + Nolrt A drove , Mass. t • ` ® r BOARD Q)F IT R aj Food/I`itchen -F romn ;. . .x .j' : m ` ys erx� BUILDING'INSPEC'I OR IS CERTIFIES THAT �. ! k- .,.;. ,., :���� �� :�'w� �', �:. •�` ` .� Y� � •.� '/`,.�+ �,• Foundation .. -► �s oo i,� sp �I 'io:�reGt... . ... • , ... bu'Id�nk � .....;: °' ♦ a u P' 9 .. . .ough _ ♦ ; 0104-1. f! `p Al iii', �r i .'.: '. ., fi :: tl')�1®aC4,'J�N6p �e� � �.. f..e , dr ChiTnney - P�+�p+_� - ion accepting cis ermit shall in eve ®s ect confer ao`th " Fes. �. . , P r . P m e terms of the �PPi�c�t�on,o,n f��� sn � - .:` . _ ' his Off �nd.to the;`rirovisions ur Ihoo Codes and '.'Y-Laws relating:lo the' ins ei tion, A eratlori arid;> onsfr:i ctien of �-" ;' r ®:eiidings in the Tow�n'of North AndoV®* /�"` IG BY� a _ � ♦ 111 i `VIOLATION of the Zoning or, buil ing iiegulations 1loids this:-Permd Roux► _ Final. *, _ - s ICAL�I�ISPEC'I'iR 1 i fix. '.,5-- 4 .,,,,�; ? ., �. ,M- ��, 1 >r� .2 ✓ � § —..x �,' �` f�7 - _ , n 01 'BU ti ' zi 'INSi' cTOR � , , x „ z 1X1 - ll ...>.. INSF0 t :. y-� '.y.:;�r rs..�[� ✓,ty<,•:;.. �.,-: :--�;:.� ,,.:,:�: � :o, ni � �R..r 9 - E. � ,\' 'le 5?'-� r t �...,� l". i" 5 a- .y' �:�.� :i•k.:': ' D�� 1a C�ncous F�a� . .. :... w On `� / sos_ Do Re_rno�ro- � �r�emi Y o L.athi� or D �I �To �t rY7. r FIRE'S EP�4It�;�I : hnti@ �ns�ect d:and 1pprov d _b too —1din ghs _,actor e Burner ,q' S ,C E S E F`'�gI :� _.4... .- :tea a' Wim,. cJP101CC Dei r �t t FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having have been obtained. This does not relieve. the applictland/or n landowner from compliance with any applicable local or state law, regulations or requirements. Applicant fills out this segtion***************** APPLICANT: Phone 46 LOCATION: Assessor's Map Number Parcel Subdivision � Lot(s) Street c. St. Number ************************Official Use Only************************ RECOMMEENDATIONS OF TOWN AGENTS: Conservation Administrator Date Approved Date Refected Comments Town Planner Date Approved ` Date Rejected Comments Food Inspector-Health Date Approved � Date Rejected Date A /Se c 1nspector-Health ejected Date Rejected Comments 'Public Works = sewer/water connections - ' 1'L�� 1 7 - driveway permit `Z 2 7 Fire Department 1 . Received by Building Inspector Date m.. FORM U - LOT RELEASE FORM IINc T AUC T IONS: This ferm is used to verity that all nec.:ssary apprevais/permits from. EOardS and Departments having jurisdiction have been obtained. This does not relieve the applicant andlor landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SEC TIC APPLICANT �o le� Cw,%l 1; C-x � C n 4. I v) PHCNc y63 -J035 1--� LOCATION: Assessors NIGP Numaer 15 Wnc.1 r l� _c PARC=_ SUEDIVISION Lo (1 C1 Po)�1)(t C-S�CLk3 LOT (S) STRE=T c! l,l�(_l� ST. NUMEE c _ OFFICIAL USE ONLY RECOMMENDA T1 NS OF TOWN AGENTS: IUD �Q CONSERVATION ADMINIST TOR DATE APPROVED " i DATE REJECTED CaM•PAEN,TS � �' 01 ,5 n TOWN PLANNER DATE AFPROVED DATE REJECTED COMMENTS FOOD INSPECT R-HEALTH DATE.APPROVED DATE REJECTED �S ?T1C�N ��ECTOR-HEAL - DATE APPROVED DATE REJECTED w ,COMMENTS PUELIC WORKS -SENER/WATER CONNECTIONS � vmbw DRIVE'NAY P RMIT FiR,1=,DEPARTh1EN T 4 rZiCEivcD OAT" E'( EUILDiNG INSPECTOR Revieed X19;im