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Miscellaneous - 17 LACY STREET 4/30/2018
N 2 N_ O O r CT v � o � cn b � m O� m 0 North Andover Board of Assessors Public Access Page 1 of 1 norrry 743 I! of Mcwth A 4ove'r df.,�.e iryv likP Of Asse'Stscws o w h n y t °jq& es t� Property Return to the Home page click on logo Record Card Parcel ID: 210/105.D-0115-0000.0 Community:North Andover New Search SKETCH PHOTO Click on Sketch to Enlarge Sales No p�CIS re Summary Residence Available Detached Structure Condo Commercial Comparable Sales Location: 17 LACY STREET Owner Name: RUNDLE,SCOTT E HELEN DENISE RUNDLE Owner Address: 17 LACY STREET City:NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6-6 Land Area: 1 acres Use Code: 101 -SNGL-FAM-RES Total Finished Area: 2416 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 475,800 435,400 Building Value: 244,700 225,200 Land Value: 231,100 210,200 Market Land Value:231,100 Chapter Land Value: LATEST SALE Sale Price: 259,000 Sale Date: 03/30/1994 Arms Length Sale Code: Y-YES-VALID Grantor: O'DONNELL,RICHARD Cert Doc: Book: 04015 Page: 0306 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=990690 7/11/2007 no NES, IENGLND IENGENTEEPUNG SERVICES, INC. 1600 Osgood Street Building 20 Suite 2-64 North Andover, MA 01845 Tel: (978) 686-1768 • Fax: (978) 327-6138 Benjamin C. Osgood, Jr., P.E. President INSPECTION AGREEMENT Date: July , 2007 Inspector: New England Engineering Services, Inc. 1600 Osgood Street North Andover, MA 01845 System Owner: Scott and Denise Rundle 17 Lacy Street North Andover, MA 01845 It is hereby agreed that Scott and Denise Rundle agree to pay New England Engineering Services 150.00 dollars per inspection of the Enviro Septic Wastewater Treatment System installed at 17 Lacy Street,North Andover. Inspections will be done on a once annually basis and shall be done in accordance with Presby Environmental, Inc and Department of Environmental Protection guidelines. Copies of all inspection reports and inspection checklists shall be submitted by New England Engineering Services, Inc. to the local approving authority and the Department of Environmental Protection. G � Agreed this day of July 2007. Benjamin C. Osgood, Jr., PE Scott Rundle or Denise Rundle New England Engineering Services, Inc. Bk 11088 P9 1 1 2 '5182 COVER SHEET THIS IS THE FIRST PAGE OF THIS DOCUMENT DO NOT REMO VE GRANTOR GRANTEE ADDRESS OF PROPERTY CITY/TOWN TYPE OF DOCUMENT MLC ASSIGNMENT DEED 6D TYPE MORTGAGE ,---'NOTICE TYPE DISCHARGE SUBORDINATION AFFIDAVIT CERT DEC OF HOMESTEAD UCC TYPE DEC OF TRUST TYPE OTHER DESCRIBE Essex North Registry of Deeds Robert F. Kelley, Register 354 Merrimack St. Suite 304 Lawrence, MA 01843 (978) 683-2745 www.lawrencedeeds.com NOTICE The property referred to in a deed recorded at Book 4015 Page 306, located at 17 Lacy Street,North Andover, Essex County, Massachusetts has been improved with a subsurface sewage disposal system using an alternative technology know as a Presby Enviro-Septic System. Said alternative technology is approved by the Massachusetts Department of Environmental Protection and shall be operated under the terms and conditions of said approval dated July 11, 2007 including the provision that the owner maintain an operations and maintenance contract for the system with a qualified person. This notice is being given by the property owner 4fn'�'- rl&"U- - l f I tot- Scott E. Rundle Date &,-I '� ) 1) Helen Denise Rundle Date Commonwealth of Massachusetts County of Essex On This Day of VE 6 , 2008 Before me,the undersigned Notary Public,personally appeared ZCiz T-C 1 tJ l Lk r.N�) QZ Name of Document Signers Proved to me through satisfactory evidence of identification,which was/were Description of evidence of identification To be the person whose name is signed on the proceeding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. tSignaturejofNo !Pr:Iic Printed name of Notary Public BRENDA E.JARRETT NOTARY PURi in My #9fl§* W*020Date) TOWN OF NORTH ANDOVER e NORTI{ Office of COMMUNITY DEVELOPMENT AND SERVICES or HEALTH DEPARTMENT " 400 OSGOOD STREET `°• • NORTH ANDOVER, MASSACHUSETTS 01845C MUis ,SSAt� 978.688.9540-Phone Susan Y.Sawyer,RE14SIRS 978.688.8476-FAX Public Health Director E-MAIL:healthdept a,townofnorthandover.com WEBSITE:http://www.townofnorthandover.com TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( ) constructed; (�4 repaired; by T6S�_� � }/C- i� s�� CO RECEIVED (Print Name) NOV 0 6 2007 located at �7 LfIC �"�' Installation Address rowN u VOKTH ANDOVER ( ) HEALTH DE r.4RTry ENT was installed in conformance with the North Andover Board of Health approved plan,originally dated and last Revised on '7-2.0-0 7 , with a design flow of `r d gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations,and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: 10-17-52 En/neer Representative(Signature) T6SE PN BfgSSEv� And-Print Name - } Final inspection date: 1 07 G CJ Engineer Represent ve(Signature) Lae! - c of 1 o..sLp. And-Vrint Name Installer: /if (Signature) Date: �/ -Q / And-Print Name Engineer.0., (Signature) Date: 11-6--G- ©-7 fjt.1 uh, C. as d.,.Q 0>Z And-Prin arae f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out RECEIVED forms to the comu ,use �r U only the tab key 1. Inspector: MAR 2 9 2016 lV to move your Neil J. BatesonAr.NC)RANDOVER cursor-do not Name of Inspector use the return V EALTH DEPARTMEN key. Bateson Enterprises Inc. Company Name 4:1 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978475-4786 S115 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 3/17/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 e + Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 Wins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 5 5 N Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. CityTrown 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): On well water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 ' 4 111 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `< 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2015, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °< 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 9 years old, 10/22/2007, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast iron through wall 3" PVC in house no leaks visible Septic tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® 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: 10'x 5'x 4' Sludge depth: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System f=orm-Not for Voluntary Assessments F 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level . No evidence of leakage. Evidence of carryover, pumped d-box to clean. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 17 Lacy Street Property Address Scott Rundle Owner Owners Name information is required for North Andover MA 01845 3/17/2016 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 24 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Opened up inspection port, no liquid present. 10 rows of 24' chambers 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments r( 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately We �3 pe, a 4 �o �00� 0 35 P-kj�l t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Lacy Street Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 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: 5/21/2007 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data from design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts UFtreetTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Lacy S Property Address Scott Rundle Owner Owner's Name information is required for North Andover MA 01845 3/17/2016 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 • :� Commonwealth of Massachusetts City/Town of . System Pumping.Record Form 4 DEP has provided this forni for use-by local Boards of Health. Other forms may'be used, but the information,must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/Right front of house, Left/Right rear of housqaW rlghtlgde of hour eft/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityfrown v� State Zip Code 2. System Owner. �V4 le Name' Address(if different from location) CityJTown ' Sta • tP<4C.1_7,� Ip Code s Telephone Number i .B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type•of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 3-IT0 If yes, was it cleaned? ❑ Yes ❑ No ' 5. Condition of System: Noy 6.. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Location w _ re contents-were disposed: 6._ S: Lowell Waste Water AG signliuXe 9t HauierU Date ` tftrm4.doc-06103 System Pumping Record•Page 1 of 1 APPROVAL FOR REMEDIAL USE Page 1 of 7 Sawyer, Susan From: Dan Obrzut[dobrzut@miildverconsulting.com] Sent: Monday,August 27,2007 4:00 PM To: Sawyer, Susan Subject: Presby Remedial July 2007 MODIFIED APPROVAL FOR REMEDIAL USE Pursuant to Title 5, 310 CMR 15.000 Name and Address of Applicant: Presby Environmental, Inc. 143 Airport Road Whitefield,NH 03598 Trade name of technology and model: Presby Enviro-Septic Leaching System (Hereinafter called the"System"). The"Massachusetts Enviro-Septic®Wastewater Treatment System Quick Reference Guide" including schematic drawings of typical Systems, a technology checklist, and a System Installation Form are part of this Certification. Transmittal Number: W021550 Date of Issuance: November 21,2005,Revised May 22,2006,Revised June 2,2006. Revised March 16, 2007,Modified July 11, 2007 Date of Expiration: November 21,2010 Authority for Issuance Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000,the Department of Environmental,Protection hereby issues this Approval to: Presby Environmental, Inc., 143 Airport Road,Whitefield,NH 03598(hereinafter"the Company"), approving the System described herein for Remedial Use in the Commonwealth of Massachusetts. Sale and use of the System are conditioned on compliance by the Company and the System owner with the terms and conditions set forth below. Any noncompliance with the terms or conditions of this Approval constitutes a violation of 310 CMR 15.000. July 11,2007 Glenn Haas, Acting Assistant Commissioner Date Bureau of Resource Protection Department of Environmental Protection I. Purpose 1. The purpose of this approval is to allow Remedial Use of the System in Massachusetts w the necessary permits and approvals required by 310 CMR 15.000. 8/27/2007 APPROVAL FOR REMEDIAL USE Page 2 of 7 2. With the necessary permits and approvals required by 310 CMR 15.000, this Approval fc Remedial Use authorizes the use and installation of the System in Massachusetts. 3. The System may only be installed where conditions meet the criteria of 310 CMR 15.284 (2). The System is an alternative system approved in accordance with 310 CMR 15.280 through 15.289 and is used to treat and dispose of wastewater. 4. This Approval for Remedial Use allows the use of the System where the local approving authority finds that the System is for upgrade of a failed, failing or nonconforming system The Title 5 design flow for the facility must be less than 10,000 gallons per day. H. Design and Construction Standards 1. The System is a subsurface unit that replaces a soil absorption system(SAS)designed in accordance with 310 CMR 15.000. The System consists of an 11 5/8-inch diameter corrugated, high-density plastic pipe with a 9.5-inch interior diameter and a length of 10 feet. The exterior of the pipe has ridges on the peak of each corrugation. The pipe is perforated with eight holes equally distributed around its inner circumference. Each hole r a plastic skimmer extending inwards. The exterior of the pipe shall have a minimum of tw layers of material. The inner layer shall be a thick layer of coarse, randomly oriented polypropylene fibers. The outer layer shall be a non-woven geo-textile polypropylene fabs The pipe shall be installed in a concrete system sand bed and surrounded on all sides by a minimum of six inches of system sand. Depth to the high groundwater elevation shall be measured from the bottom of the system sand underlying the pipe. 2. The System sand shall meet ASTM C-33. 3. Systems shall be installed with a differential venting for aeration and inspection at end of each run of pipe, section or serial bed and whenever the System is installed under impervious surfaces.. 4. The System shall be designed and installed using distribution boxes for inspection ports. The pipe between the distribution box and the System shall be installed at a minimum slol of 0.02 feet/foot. 5. Serial distribution laterals shall be limited to no more than 500 gpd. Multi-level systems shall not be allowed. 6. The System shall be installed in a bed or field configuration,as defined in 310 CMR 15.252. The effective leaching area shall be the bottom area(length times width)of the fie or bed as presented in the Company's"Massachusetts Enviro-Septic®Wastewater Treatment System Quick Reference Guide". 7. Effluent loading rates adjusted to reduce the soil absorption system by 40 percent shall b, in accordance with 310 CMR 15.242. No System shall be installed with a leaching area of less than 400 square feet. 8. The System shall not require pressure distribution. 9. The System may be used in soils with a percolation rate of up to 90 minutes per inch (MPI). For soils with a percolation rate of 60 to 90 MPI,the effluent loading rate shall be 8/27/2007 APPROVAL FOR REMEDIAL USE Page 3 of 7 0.15 GPD/SF III. Allowable Soil Absorption System Design 1. Reduction of the Required Separation Distance to High Groundwater Elevation - An Applicant is eligible for a reduction in separation (four feet in soils with a recorded percolation rate of more than two minutes per inch or five feet in soils with a recorded percolation rate of two minutes or less per inch) between the bottom of the SAS and the high groundwater elevation, where all of the following conditions are met. A. A minimum two foot separation (in soils with a recorded percolation rate of more than two minutes per inch) or a minimum three foot separation (in soils with a recorded percolation rate of two minutes or less per inch) between the bottom of the sand underlying the SAS and the high groundwater elevation is maintained. Any such reduction must first be approved by the local approving authority and then approved by the Department pursuant to 310 CMR 15.284. B. No further reduction, than specified in Section II (7), in the required SAS size is allowed. C. No reduction in the required four feet of naturally occurring pervious material is allowed unless the Applicant has demonstrated that the four foot requirement cannot be met anywhere on the site. Any such reduction must first be approved by the local approving authority and then approved by the Department pursuant to 310 CMR 15.284. D. Where full compliance with all of the minimum set back distances in 310 CMR 15.211 is not feasible, the local approving authority may allow a reduction under a local upgrade approval in accordance with 310 CMR 15.405 (1) (a), (b), (f), (g), and (h). E. Where full compliance with all of the minimum set back distances in 310 CMR 15.211 is not feasible, even taking into account provisions for local upgrade approval as described above, then pursuant to 310 CMR 15.410, the applicant first must obtain variance(s)from the local approving authority and then approval of the Department. 2. Reduction of the Requirement for Four Feet of Naturally Occurring Pervious Material — An Applicant is eligible for a reduction in the required four feet of naturally occurring pervious material in an area of no less than two feet of naturally occurring pervious material, where all of the following conditions are met. A. The Applicant has demonstrated that the four foot requirement cannot be met anywhere on the site. Any such reduction must first be approved by the local approving authority and then approved by the Department pursuant to 310 CMR 15.284. B. No further reduction, than specified in Section II (7), in the required SAS size is allowed. C. No reduction in the required separation(four feet in soils with a recorded percolation 8/27/2007 APPROVAL FOR REMEDIAL USE Page 4 of 7 rate of more than two minutes per inch or five feet in soils with a recorded percolation rate of two minutes or less per inch) between the bottom of SAS and the high groundwater elevation is allowed unless such a reduction is first approved by the local approving authority and then approved by the Department pursuant to 310 CMR 15.284. D. Where full compliance with all of the minimum set back distances in 310 CMR 15.211 is not feasible, the local approving authority may allow a reduction under a local upgrade approval in accordance with 310 CMR 15.405 (1) (a), (b), (f), (g), and (h)• E. Where full compliance with all of the minimum set back distances in 310 CMR 15.211 is not feasible, even taking into account provisions for local upgrade approval as described above, then pursuant to 310 CMR 15.410, the applicant first must obtain variance(s)from the local approving authority and then approval of the Department. IV. General Conditions 1. All provisions of 310 CMR 15.000 are applicable to the use of this System,the System owner and the Company, except those that are varied by the terms of this Approval. 2. All sample analysis must be conducted by an independent U.S.EPA or DEP approved testing laboratory, or a DEP approved independent university laboratory. It is a violation this Approval to falsify any data collected to omit any required data or to fail to submit ar report required by such plan. 3. The facility served by the System and the System itself shall be open to inspection and sampling by the Department and the local approving authority at all reasonable times. 4. In accordance with applicable law,the Department and the to PP p cal approving authority mai require the System owner to cease operation of the system and/or to take any other action it deems necessary to protect public health, safety,welfare and the environment. 5. The Department has not determined that the performance of the System will provide a lei of protection to public health and safety and the environment that is at least equivalent to that of a sewer system. No System shall be installed,upgraded or expanded, if it is feasibl to connect the facility to a sanitary sewer, unless as allowed by 310 CMR 15.004. When sanitary sewer connection becomes feasible, the facility served by the System shall be connected to the sewer,within 60 days of such feasibility, and the System shall be abandoned in compliance with 310 CMR 15.354, unless a later time is allowed, in writing by the approving authority. 6. Design, installation and operation shall be in strict conformance with the Company's DEI approved plans and specifications, 310 CMR 15.000 and this Approval. V. Conditions Applicable to the System Owner 1. The System is approved for the treatment and disposal of sanitary sewage only. Any wase 8/27/2007 APPROVAL FOR REMEDIAL USE Page 6 of 7 procedures in paragraphs 3 above to System owners, operators, designers and installers. 5. The Company shall institute and maintain a training program in the proper design, installation and inspection techniques of its System and provide a training course at least annually for prospective designers, installers and inspectors. The Company shall certify tl installers and inspectors have completed the Company's training class, maintain a list of trained installers and inspectors, submit a copy to the Department, and update the list annually. Updated lists shall be forwarded to the Department. 6. The Company shall furnish the Department any information that the Department request: re ag rdin,g the System,within 21 days of the receipt of that request 7. The Company shall include copies of this Approval and the procedures in Section)9"3 with each System that is sold. In any contract executed by the Company for distribution o re-sale of the System,the Company shall require the distributor or re-seller to provide-ea purchaser of the System with copies of this Approval and the procedures described in Section VI(3). 4. The Company shall comply with 310 CMR 15.000 and all Department policies and guidance that apply and as they may be amended from time to time 5. If the Company wishes to continue this Approval after its expiration date,the Company shall apply for and obtain a renewal of this Approval The Company shall submit a renewi application at least 180 days before the expiration date of this Approval,unless written permission for a later date has been granted in writing by the Department This approval shall continue in force until the Department has acted on the renewal application VII. Conditions Applicable to Installers of the System 1. Each Installer shall install the System in accordance with Company training on the installation of the System and the conditions of this Certification. 2. No Installer shall install the System unless the Installer has been trained by the Company on installation of the System or the installation is overseen by a Company representative(s 3. Installers shall complete the System Installation Form and forward a copy to the Compan and the local approving authority. 4. The System installer shall provide the System owner and the local approving authority w a bill of lading certifying that the sand fill meets ASTM C-33. VIII. Reporting 1. All notices and documents required to be submitted to the Department by this Approval shall be submitted to: Director Wastewaters Management Program Department of Environmental Protection One Winter Street- 5th floor 8/27/2007 APPROVAL FOR REMEDIAL USE Page 7 of 7 Boston,Massachusetts 02108 IX. Rights of the Department 1. The Department may suspend, modify or revoke this Approval for cause, including, but not limited to, non-compliance with the terms of this Approval, non-payment of the annual compliance assurance fee, for obtaining the Approval by misrepresentation or failure to disclose fully all relevant facts or any change in or discovery of conditions that would constitute grounds for discontinuance of the Approval, or as necessary for the protection of public health, safety,welfare or the environment, and as authorized by applicable law. The Department reserves its rights to take any enforcement action authorized by law with respect to this Approval and/or the System against the owner, or operator of the System and/or the Company. X. Expiration Date 1. Notwithstanding the expiration date of this Certification, any System installed prior to the expiration date of this Certification, and approved, installed and maintained in compliance with this Certification(as it may be modified)and 310 CMR 15.000, may remain in use unless the Department,the local approving authority, or a court requires the System to be modified or removed, or requires discharges to the System to cease. No virus found in this outgoing message. Checked by AVG Free Edition. Version:7.5.484/Virus Database:269.12.2/967-Release Date:8/22/2007 6:51 PM 8/27/2007 a F N0RT1y q E - Q`1t�lO 16+ tiO 0 09A tocwit w�wrtw yl. T ��SSACHUS��y PUBLIC HEALTH DEPARTMENT Community Development Division CEXTI(FICA�I'J O F CO�VI<1'�IA�CE As of: .March S, 2008 This is to cert that the ind vidual su6surface disposal system received a S3VS1FAC70RT1XSIPECZ70Yof the: Complete Septic System Repair/Replacement By: Joseph Flak At: 17.Lacy ,Street Map 105. 1 ; Parcef11S North Andover, 5VA 01845 rihe issuance of this certiftate shall not 6e construed as a guarantee that the system will function satisfactorily. ,f � n ,�'fSus 2'. Sawyer Public Ifealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES 3r HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.8476 . FAX Public Health Director E-MAIL:healthdeptAtownofnorthandover.com WEBSITE:hgp://www.townofnorthandover.com TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( ) constructed; (t4 repaired; (Print Name) :Or 0 6 2007 located at t 7 LAC 7 S-r (Installation Address) TOWN ORTH AP�f37vER NEAL f Fi fjEf= ?i iv.ENT was installed in conformance with the North Andover Board of Health approved plan, originally dated 6-5-07 and last Revised on ?—ZO �o'7 , with a design flow of `+l a gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations,and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: EnAlneer Representative(Signature) a-6SE PN &-gsSF(_'qz' And-Print Name T Final inspection date: //11/07 C� Engineer Represen ve(Signature) z3t-► C of And-Print Name Installer: (2 !11 (Signature) Date: 0 :3ZLePA M And-Print Name oEngineer. (Signature) Date: I �' �� �Cr1/Gh ^ C_ DS4d ox- An -Prin ame 5� P c`. q �� r DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Friday, April 11, 2008 9:05 AM To: 'srundle@bwgroupusa.com' Subject: 17 Lacy Street Importance: High Message from Message from Message from KMBT_600 KMBT_600 KMBT_600 Hi Scott, Attached is a copy of your COC, Certification from the Engineer and Installer, As Built(2 separate attachments), and information on your system, and that it needs to be inspected annually. I would suggest that you call your engineer for names of companies which offer maintenance on your type of system- Presby Enviro- Septic System. Bost RagAods, pa�wa�a naeeae�sfA>a Health Department Assistant Town of North Andover 1600 Osgood Street Building 20,Suite 2-36 North Andover,MA 01845 9978.688.9540-Phone A 978.688.8476-Fax http://www.townofiiorthandover.com healthdept@townofnorthandover.com 1 Re: 17 Lacy Street Page 1 of 1 DelleChiaie, Pamela From: Scott Rundle [Srundle@bwgroupusa.com] Sent: Friday, April 11, 2008 9:16 AM To: DelleChiaie, Pamela Subject: Re: 17 Lacy Street Importance: High Thanks so much Pam. Sincerely, Scott Rundle On 4/11/08 9:04 AM, "DelleChiaie, Pamela" <pdellech@townofnorthandover.com> wrote: —Message from KMBT_600>> <<Message from KMBT_600» <<Message from KMBT_600>> Hi Scott, Attached is a copy of your COC,Certification from the Engineer and Installer,As Built(2 separate attachments), and information on your system,and that it needs to be inspected annually. I would suggest that you call your engineer for names of companies which offer maintenance on your type of system-Presby Enviro-Septic System. Best Regards, Pamela DelleChiaie Health Department Assistant Town of North Andover 1600 Osgood Street Building 20,Suite 2-36 North Andover,MA o1845 'N978.688.9540-Phone a 978.688.8476-Fax http-.11%%ww.to.wnofhorthandoN,er.com healthdept@townofnorthandover.com 4/11/2008 APPROVAL FOR REMEDIAL USE Page 5 of 7 that are non-sanitary sewage generated or used at the facility served by the System shall not be introduced into the System and shall be lawfully disposed. 7. The System owner shall at all times properly operate and maintain the on-site sewage —'� disposal system. The System owner shall have the System inspected annually by an operas trained by the Company and shall submit the results of that inspection, on a technology checklist, to the local approving authority. 8. The System owner shall furnish the Department any information that the Department requests regarding the operation and performance of the System,within 21 days of the dat of receipt of that request. 9._ N em ownershall authorize or allow the installation of the System o e by a person trained by the Company to install the System. 10. Prior to the issuance of a Certificate of Compliance for the System,the System owner shy record and/or register in the appropriate Registry of Deeds and/or Land Registration Offic a Notice disclosing both the existence of the altemative septic system subject to this Approval on the property and the Department's approval of the System. If the property subject to the Notice is unregistered land,the Notice shall be marginally referenced on the owner's deed to the property. Within 30 days of recording and/or registering the Notice, d System owner shall submit the following to the Department and the local approving authority: (i)a certified Registry copy of the Notice bearing the book and pagelnstrumen number and/or document number, and (ii)if the property is unregistered land, a Registry copy of the owner's deed to the property, bearing the marginal reference. V. o to the Company 1. By January 31st of each year,the Company shall submit a report to the Department, sign by a corporate officer, general partner or Company owner that contains information on the System, for the previous calendar year. The report shall state: the number of units of the System sold for use in Massachusetts including the installation date and date of start-up during the previous year,the address of each installed System,the owner's name and address,the type of use(e.g. residential, commercial, school, institutional) and the design flow; and for all Systems installed since the date of issuance of this Approval, all known failures, malfunctions, and corrective actions taken and the address of each such event. 2. The Company shall notify the Director of the Watershed Permitting Program at least 30 days in advance of the proposed transfer of ownership of the technology for which this Approval issued. Said notification shall include the name and address of the proposed nem owner and a written agreement between the existing and proposed new owner containing specific date for transfer of ownership, responsibility, coverage and liability between then: All provisions of this Approval applicable to the Company shall be applicable to successo and assigns of the Company,unless the Department determines otherwise. 3. The Company shall develop and submit to the Department an operating manual, includir information on substances that should not be discharged to the System and a recommende schedule for maintenance of the System essential to consistent successful performance of installed Systems within 60 days of the effective date of this Approval 4. The Company shall make available,in print and electronic format the referenced 8/27/2007 AS-BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER _ LOT LINES & LOCATION OF DWELLINGS ✓ LOC TiBNS-&DIMENSIONS OF SYSTEM, CLUDING RESERVE y' TI O�EOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES &PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM ✓� TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK& D-BOX ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS -DRIVEWAYS, ETC. NORTH ARROW ✓ LOCATION & ELEVATIONS OF BENCHMARK USED Page 1 of 1 s DelleChiaie, Pamela From: Randy Burley [rburley@millriverconsulting.com] Sent: Friday, October 26, 2007 11:39 AM To: Daniel Ottenheimer; dobrzut@millriverconsulting.com; Grant, Michele;(Marianne Peters; DelleChiaie, Pamela; Sawyer, Susan Subject: 17 Lacy St. Good day, Please find attached the construction inspection for 17 Lacy Street. Everything appeared to be in order. Please do not hesitate to contact me with any questions or concerns. Sincerely, Mill ive ---'consulting Randy Burley,Project Manager Mill River Consulting, Inc. On-Site Wastewater Management Services 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www.millriverconsulting.com rburley_a millriverconsulting.com 10/26/2007 VkORTli O o m T O COCMICMCWK•`1 T p0R,Areo ePa��S SSACHUS� PUBLIC HEALTH DEPARTMENT Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 17 Lacy Street MAP: 105 D LOT: 115 INSTALLER: Joeseph Flak DESIGNER: New England Engineering PLAN DATE: June 5, 2007, rev. July 20, 2007 BOH APPROVAL DATE ON PLAN: August 29, 2007 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTI N: October 17, 2007 DATE OF FINAL GRADE INSPECTION: 10(OR j6 SITE CONDITIONS ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SEPTIC TANK Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1500 gallon tank has been installed H-10 loading Monolithic construction H-30 ® Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) Inlet tee installed, centered under access port ® Outlet tee (gas baffle) installed, centered under access port 1600 Osgood Street,North Andover,Mossochusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com NORTH �6'9tiO 6 O0 4tL 41 �SSACHUS�� PUBLIC HEALTH DEPARTMENT Community Development Division ® 24" inch cover to within 6" of final grade installed over one access port ® Hydraulic cement around inlet & outlet Comments: DISTRIBUTION-BOX ® Installed on stable stone base ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: Distribution box is used as an inspection port only; it only had one outlet SOIL ABSORPTION SYSTEM (General) �I Bottom of SAS excavated down to 6 in into C soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan ® 40 Mil HDPE barrier installed Y ❑ Retaining wall (boulder/ concrete /timber/ block) �C Final cover as per plan Comments: ASTM C-33 sand (concrete sand) used for the entire system and overdig. As per approval letter, the installer was informed he was to provide the bill of lading to the property owner as proof of the sand quality. The installer agreed. 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com i tAORTF► O��t�eo 16q�0 6 OL O ~ M �y 10 eyy yy� T °q C"C CM K• 1 T X1,9 Tao SSAC HUSH PUBLIC HEALTH DEPARTMENT Community Development Division SOIL ABSORPTION SYSTEM (Enviro-Septic leaching pipes) ® Number of rows: 10 ® Length of rows : 26 feet ® Elevations of laterals and chambers installed as on approved plan Comments: The approval letter requires a "high" vent off the distribution box. The designer did not specify one on the plan and when questioned about it, he faxed me information from the Design Guide; specifically, section F "Venting Requirements" which does state no vent is required on the distribution box if the system is not pumped. SYSTEM ELEVATIONS INVERT IN FIELD PLAN INVERT ELEV. Building Sewer OUT 96.70 97.08 Septic Tank IN 96.50 96.78 Septic Tank OUT 96.25 96..41 Distribution Box IN 95.92 95.78 Distribution Box OUT 95.75 95.78 Enviro-Se tic Pipe 95.58 95.59 p Inverts 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnarthandover.com ,AORTy OL O A� !- A 41 O�N[OC..CM K.`y1' ��SSACHUS PUBLIC HEALTH DEPARTMENT Community Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ® Deck, on footings, etc 5 6 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains(Other)Foundation 10(5) 20(10) ❑ Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com Commonwealth of Massachusetts Map-Block-Lot 1,oRTH 105.D-0115- �; y c OL ----------------------- o p Board of Health Permit • BHP-2007-0275 • North Andover ----------------------- •;rR - ' P.I. FEE ��s3��Huyti� F.I. ----------$250:00-- Disposal Works Construction Permit Permission is hereby granted Joseph Flak------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 17 LACY STREET LACY STREET as shown on the application for Disposal Works Construction Permit No. BHP-2007-027 sat d L October_10,2007 Issued On: Oct-10-2007 Board of Health I .o„0R71, Application foe Septic Disposal System 10 - 2- o7 3? •`:'' °c TODAY'S DATE ° : = pConstruction Permit - TOWN OF ORTH ANDOVER, MA 01845 $ 250.00— Full Repai cNusr`� ° '$125. 0- omponent Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use Vepair or replace an existing on-site sewage disposal system* only the tab key to move your ❑ Repair or replace an existing system component—What? cursor-do not use the return key. A. Facility Information /�7 LAC�j Address or Lot# 1V. ANQoV<� City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name Name of Company Address rY7raJs)�J rA4 /�1.� 0/7Y7 City/Town State Zip Code 9I128 85-a o`2vo Telephone Number(Cell Phone#if possible please) 4. Designer Information Ne4J 14__�GlArwd Name Name of Company 1600 0S60o b S�- Address City/Town State Zip Code Al, C/7 86 /7(9 Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 Of N0 ao7 e14, Application for Septic Disposal System 10, - 7- 0 7 , Xonstruction Permit - TOWN OF TODAY'S DATE ORTH ANDOVER, MA01845 �,S•,..a �<y $250.00—Full Repair s�cHUse $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: 9 esidential Dwelling or❑Commercial B. Agreement I The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Name Date i A(�e Approved : (Board of Health Representative) ` l N Date Disapproved for the following reasons: For Office Use Only: Z Fee Attached.? Yes No 2. Project Manager Obligation Form Attached. Yes '� No 3. Pump System? If so,Attach copy of Electrical Permit Yes_/l�/ No 4. Foundation As-Built?(new construction ronly): Yes�/� No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 R a SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: /7 LACE 5�7 (Address of septic system) For plans by �Ew EN'jJAi u ee ri, (Engineer) O Relative to the application of3oSyQI., to P1AK (Ins aller's name) And dated N` �� '7 ngina ate Dated /0 - 9-07oay,s ciate With revisions dated (bast revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain,all permits and Board of Health approved plans prior to performing any work on a site. I must have the a1212roved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. 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 me and/or my company a. Bottom of Bed—Generally,this is the first (VS inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdel2t@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a 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. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute e reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover. significant fines to all persons involved are also possible. 5. 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 or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: A)-1-07 (Today's Date) (Name—Print) m —Signed) PE PRESBY ENVIRONMENTAL,INC. i Protecting You and the Environment r Tel: 1-800473-5298 www.presbyenvironmental.com This certifies that Joseph Flak Has completed the Presby Environmental,Inc, Enviro-Septic®Certification Class Location:Atkinson,NH Date: March 20,2007 Certificate No.: 4825MAES Other state or municipal licenses may be required. IAORTH q O �t�eo �6• X00 3� a ?, en � 09 cx.iu.~x:ncr 1 ��SSACHUS PUBLIC HEALTH DEPARTMENT Community Development Division August 29, 2007 Scott Rundle 17 Lacy Street North Andover, MA 01845 RE: Septic System Design; 17 Lacy Street, North Andover, Map 105D,Lot 115 Dear Mr. Rundle, The North Andover Board of Health has completed the review of the septic system design plans, for the above referenced property, submitted on your behalf by New England Engineering Services, dated June 5, 2007, last revised July 20, 2007. This plan has been approved. The approval includes two variances approved at a regularly scheduled Board of Health meeting held on August 23, 2007: 1) A reduction in offset distance between the deck and the leach bed from 10 feet to 6 feet 2) A reduction in offset distance between the above ground pool and the leach bed from 10 to 6 feet. This plan is valid for two years from the date of this approval. The design has been approved for use in the construction of an onsite septic system for a 4-bedroom house(maximum 9-room). During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. In the event an imminent health problem such as sewage backup into the dwelling is occurring, the North Andover Board of Health may reduce the time period for which this plan is valid. ,00d?i� ' lip This approval is subject to the following conditions: l4� z s a 1. Prior to the issuance of a Certificate of Compliance for the System, the system owner s all record in the Registry of Deeds a Notice disclosing both the existence of the alternative septic system subject to this approval on the property. A certified copy of the Notice bearing the book and page/number must be submitted as proof of this recording. 2. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit. 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com RE: Septic System Design; 17 Lacy Street,North Andover,Map 105D,Lot 115 8/29/2007 Page 2 of 3. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission,Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe or imply compliance with any of the aforementioned requirement. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you may have. IS,iincerelSawyer, HS/RS Public Health Director Encl: list of licensed septic system installers Cc: New England Engineering Services 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com NEw IENGLAND IENGINE]EM(G SERVICES, INC. 1600 Osgood Street Building 20 Suite 2-64 North Andover, MA 01845 TO: (978) 686-1768 • Fax: (978) 327-6138 Benjamin C. Osgood, Jr., P.E. President August 29, 2007 Susan Sawyer North Andover Board of Health 1600 Osgood Street North Andover, MA 01845 Re: 17 Lacey Street,North Andover Dear Susan: This letter is being written to offer some background information regarding our decision to design the septic system at the above referenced property with a 1 foot offset reduction between the bottom of the leach area and the estimated seasonal high ground water. When looking at the property and the available area to design a new system we were very limited due to the fact that there is an existing drinking water well which renders 80 percent of the property unusable for a subsurface sewage disposal system. The balance of the property is surrounded by steep slopes and some areas are covered with an above ground pool and a large deck system. While inspecting the property at the time of soil testing the most appropriate area was identified and tested. The resulting test identified a ground water which would necessitate a mounded system. A mounded system would be difficult in this area due to the steep slope at the rear of the lot and the fact that constructing a mound would necessitate building a wall along the line of the deck or filling under the deck by hand to gain the required slope offsets. If walls were to be constructed at the rear of the lot and along the deck line the owner would be forced to spend an additional 2500 to 3000 dollars plus an additional 1000 dollars for additional sand and fill. In choosing a system to design we chose the Presby system because it is allowed a 2 foot offset to ground water in some instances due to the high level of treatment it provides. By asking for a local upgrade offset of three feet I am confident that the system will offer the same equivalent environmental protection as a conventional system. If you have any questions,or need additional information,please do not hesitate to contact this office. Sincerely, g? C o Benjamin C. Osgood,Jr.,P.E. President NEw IENGLAND IENGINEERMG SERVICES, INC. 00 Osgood Street V6in—cuilding 20 Suite 2-64 North Andover, MA 01845 Tel: (978) 686-1768 • Fax: (978) 327-6138 Benjamin C. Osgood, Jr., P.E. July 23, 2007 President Susan Sawyer North Andover Board of Health 1600 Osgood Street North Andover, MA 01845 RECEIVED Re: 17 Lacy Street,North Andover JUL 2 4 2007 Septic system design TOhi� NORTH ANDOVER HEALTH DEPARTMENT Dear Susan: Enclosed are 5 copies of revised plans for the above referenced septic system design. Changes have been made to address comments in your letter dated July 7, 2007. The changes are as follows: 1. If the system is pushed back to meet the required 10 foot offset to the deck the 94 contour elevation at the rear of the property would have to be pushed back on the neighbors property. 2. A revised form 9-A is enclosed. 3. An inspection port has been added to the plans. 4. The venting is as required. The approval for remedial use of the Enviro Septic System does require venting of the system. Page 33 of the Enviro-Septic Wastewater Treatment System Massachusetts design manual states that"the roof vent will function as the high vent if there are no pumps,restrictions, or other vents between the low vent and the roof vent"This is the case at 17 Lacy Street. 5. A draft maintenance agreement is enclosed with this letter. 6. A draft deed restriction is enclosed with this letter. 7. The impervious barrier bottom elevation has been revised. If you have any questions, or need additional information,please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr.,P.E. President NEw ENGLANDENGINEERING SERVICES, INC. 1600 Osgood Street Building 20 Suite 2-64 North Andover, MA 01845 -rel: (978) 686-1768 • Fax: (978) 327-6138 June 7,2007 Project# 1379 Ms. Susan Sawyer North Andover Board of Health 1600 Osgood Street No. Andover,MA 01845 Re: 17 Lacy Street,No.Andover Local Upgrade Approval Request Dear Ms. Sawyer, The purpose of this letter is to request that the above referenced property be included in the upcoming Board of Health meeting agenda to discuss the following Local upgrade approval request: Local Upgrade Approvals Required: 1. Reduction in separation distance between the deck and the leach bed from 10 feet to 6 feet. If you have any comments or questions please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr. P.E. President 14ORTH O •o ,,•1~O F n p i► moo'• .. `yr CMU+�t� Health Department July 7, 2007 Benjamin Osgood, P.E. New England Engineering Services, Inc. 1600 Osgood Street- Building 20, Suite 2-64 North Andover, MA 01845 Re: Wastewater Treatment and Dispersal System Plan for 17 Lacy Street, Map 105D, Lot 115 Dear Mr. Osgood: The proposed wastewater system design plans for the above site dated June 5, 2007 and received on June 11, 2007 has been reviewed. Unfortunately,they cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000,the Enviro-Septic Leaching System Remedial Use Approval Letter dated March 2007, or North Andover regulation that is not met by this design follows each item. 1. While the variance requested from the North Andover Board of Health Regulation is relatively minor, it is not apparent from the design plan that full compliance with the 10' setback standard from the deck to the soil absorption system cannot be easily met. Please provide additional information to indicate why this standard cannot be achieved 2. The Application for Local Upgrade Approval section C, 2 incorrectly indicates that an alternative system is not being proposed for this site. The Enviro-Septic Leaching System has been indicated on the design plan 3. Please provide for a design of a soil absorption system that has an inspection port provided—310 CMR 15.240 4. Please provide for a design of the Enviro-Septic Leaching System which has the required differential venting system as indicated in the MassDEP Approval Letter section lI, 3 5. Please provide a draft maintenance agreement for the required annual maintenance indicated in the MassDEP Approval Letter section IV, 2 6. Please provide a draft notice to be recorded on the deed of the parcel as indicated in the MassDEP Approval Letter section IV, 5 7. You may wish to consider revising the impervious barrier bottom elevation so as to prevent the entrapment of the ground water table 1600 Osgood Street HEALTH DEPARTMENT Page 1 of 1 Building 20;Suite 2-36 E-Mail: healthdept@townofnorthandover.com North Andover,MA 01845 Phone:978.688.9540 Fax:978.688.8476 Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincerely Susan Y. Sawyer, REHS S Public Health Director cc: Owner File o = L:\ Commonwealth of Massachusetts - City/Town of ,vc RTW A t bov£R -= Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal DEP has provided this form for use by on-site professionals and local Boards of Health. Other forms may be used, but the information must be substantially the same as provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information 1. Facility Information Co Tr Di, Owner Name Map/Lot 17 QALY STREET _ Street Address M� Cil 811.5 /VO RTH State Zip Code City/Town B. Site Information 1. (Check one) New Construction ❑ Upgrade ❑ Repair 1:6 ?. Published Soil Survey available? Yes M No ❑ If yes: t 9rs-/ i ' t5-r&N o Cc Year Published Publication scale Soil Map Unit C Atiiro,v - E lrTKG1tti Y STOA-1 ST-'re P S&O PE.s Soil Name FfvE SANDY "AA1 Soil limitations 3. Surficial Geological Report available? Yes ❑ No ❑w} If yes. Year Published Publication Scale Map unit Geologic Material Landform 4. Flood Rate Insurance Map: i Within the 100 year flood boundary? Yes ❑ No Above the 500 year flood boundary? Yes �] No ❑ Y Within the 500 year flood boundary? Yes ❑ No ® Within a Velocity Zone? Yes ❑ No l 7. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal - Page 1 of 7 \ Commonwealth of Massachusetts =- City/Tovvn of V0RTW gwDoVER, == Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal 0o Range: Above Normal ® Normal E] Below Normal El6. Current Water Resource Conditions (USGS) MANY aZ 7 9 Month 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole Number: 'r p1 S-Z "� Sv,"Ay S S6 Date Time Weather 1. Location Ground Elevation at Surface of Hole ?6,0 0 Location (Identify on PlanYA Ccs C 11FA,119 JZ6 S I OJ41TI A U All Slope 2. Land Use: � Slope (%) (e.g.woodland, agricultural field,vacant lot,etc.) Surface Stones GF SC.0R G ,SASPosition 3A Landform on landscape(attach sheet) Vegetation p0 5-00 Possible Wet Area Shp 3. Distances from: Open Water Body S Drainage Way feet feet Property Line Z S Drinking Water Well 155 Other feet feet 4. Parent Material: Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrocl<❑ 5. Groundwater Observed: Yes ❑ No Y If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: �� %.§ ° Oy DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal - Page 2 of 7 sa, Commonwealth of Massachusetts City/Town of N o?_TH AwDovC R, Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal inches elevation Deep Observation Hole Number: T t Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Structure Soil Texture % by Volume Consistence Other Horizon/ Color-Moist (mottles) (Moist) Depth Layer (Munsell) (USDA) (I n.) Depth Color Percent Gravel Cobbles &Stones 0-60" F,LI- vAjU VARIC5 — �o_-tto s L —— — Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal - Page 3 of 7 \ Commonwealth of Massachusetts City/Town of NCS►rf � 4,povtlz L= =J Form 'I 1 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Cont.) TPZ s-z�'o7 9: 00 SL ,utiy ss� Deep Observation Hole Number: Date Time Weather 1. Location Ground Elevation at Surface of Hole q6`570 Location (Identify on Plan ) ZEAS YA 2. Land User Surface Stones Slope (%) (e.g.woodland, agricultural field,vacant lot,etc.) C f i�A s s gA Landform Position on landscape(attach sheet) Vegetation 3. Distances from: Open Water Body Soo Drainage Way 5'�O * Possible Wet Area feet feet feet Property Line 1'a. Drinking Water Well 13 0 Other feet feet 4. Parent Material: Unsuitable Materials Present: Yes ❑ No L4 If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes ❑ No ❑ If Yes: Depth Weeping from Pit / Depth Standing Water in Hole Estimated Depth to High Groundwater: 6O'��f00,Y) Rl-ro inches elevation DEP Form 11 Soil Suitability Assessment for on-Site Sewage Disposal - Page 4 of 7 \ Commonwealth of Massachusetts =- - City/Town of ,u o RTW A,vDovf X_ Fora 11 - Soil Suitability Assessment for ®n-Site Sewage Disposal Deep Observation Hole Number- Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Soil Texture % by volume Structure Consistence Other Horizon/ Color-Moist (mottles) (USDA) (Moist) Depth Layer (Munsell) (In.) Depth Color Percent Gravel Cobbles &Stones 0- 11 A ioYK 3/Z L JOYP 0.sr#NcS L ?5S G Z.Sy 5l6 60 sY Y/3 0,•�•«o.J Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal - Page 5 of 7 Commonwealth of Massachusetts -- C ity/Town of N o tZ i H AN D o v E l Form 11 - Soil Suitability Assessment for ®n-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method used: ❑ Depth observed standing water in observation hole A. inches B inches ❑ Depth weeping from side of observation hole A. B. inches inches ches 25 Depth to soil redoximorphic features (mottles) A. in60 B.;nches,6 ❑ Groundwater adjustment (USGS methodology) A.inches B inches Reading 2. Index Well Number g Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes M No ❑ a1 t t Lower boundary: b. If yes, at what depth was it observed? Upper boundary: (oo Low ncl,es inches F. Certification I certify that I have passed the soil evaluator examination" approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017 Signature of Soil Evaluator Date 86v37A,"#A/ C os6000, sr 11-11995 Typed or Printed Name of Soil Evaluator 'Date of Soil Evaluator Exam v �t)acT*1�44Jo vE r�AM LL_ R,V 2 CO3V s-c r.uc� RANDY 13 L, L 1 Board of Health Name of Board of Health Witness Note: This form must be submitted to the approving authority with Percolation Test Form 12 DEP Form 11 Soil Suitability Assessment for on-Site Sewage Disposal • Page 6 of 7 \ Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage disposal Use this sheet for field diagrams: See Pt-AN S DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal - Page 7 of 7 Commonwealth of Massachusetts City/Town of ,v o RrW AtiQo v6 r< Percolation Test Form 12 c, G'M Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. Important: illiA. Site Information When filling out forms on the computer,use Scott Rundle only the tab key Owner Name to move your 17 Lacy Street cursor-do not Street Address or Lot# use the return key. North Andover MA 01845 City/Town State Zip Code 978-357-0409 IL AV Contact Person(if different from Owner) Telephone Number B. Test Results 5-21-07 9:30 Date Time Date Time Observation Hole# PT1 Depth of Perc 24'7118" Start Pre-Soak 9.52 End Pre-Soak 10:07 Time at 12" 10:07 Time at 9" 10:45 Time at 6" 11:28 Time(9"-6") 43 Minutes Rate(Min./Inch) 15 min./inch Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ Thomas Hector Test Performed By: Randy Burley— Mill River Consulting Witnessed By: Comments: t5form12.doc•06/03 Perc Test•Page 1 of 1 TOWN OF NORTH ANDOVER TN MUNITY DEVELOPMENT AND SERVICES Office of CONI HEALTH DEPARTMENT 1600 OS(-3'0(')D STREET; BIALDING 20; SIA'FE 2-36 NORTI-i ANDOVER.,MASSACHUSETTS 01.845 978.688.9540—Plione Susan Y.Sawyer,REHS/RS 978.688.8476. FAX Public Health Director E-MAIL:licalthdei)tC(4towiiofnorthaiidover.coiii WEBSITE:litl:Li:,,,/-,,vww,townof'northaiidover.coin SEPTIC PLAN SUBMITTAL FORM VED FRECE ED Date of Submission: Site Location: 1-7 laru 9+ �0' yer JUN 1 �J007 3 ER OV TOWN U@N&TH ANDOVER He 'jH DEPARTMENT A; 0 TN HEALTH�L H DEPARTMENT MENT Engineer: New Plans? Yes L,-1'225/Plan Check# (includes 1St submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes No Telephone#: qj- �&—/-7b $ Fax#: 9 71-3,:) 7- bi 39 E-mail: bas_o4cd(D n")Ne1'jP41PC-CD1X 0 V J Homeowner Tundk Name: OFFICE USE ONLY When the subussion i i is complete (including check): ➢ q Date stamp plans and letter ➢ �Complete and attach Receipt ➢ Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database IZcvtsc9 -7/23 07 Commonwealth of Massachusetts City/Town of No. Andover ao Form 9A — Application for Local Upgrade Approval -�M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.415. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. A. Facility Information Important: When filling out 1. Facility Name and Address: forms on the computer,use Scott Rundle only the tab key Name to move your 17 Lacy Street cursor-do not use the return Street Address key. No Andover MA 01845 City/Town State Zip Code VQ 2. Owner Name and Address(if different from above): Same as Above 'hO7 Name Street Address City/Town State Zip Code Telephone Number 3. Type of Facility(check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: Single Family Dwelling 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Leach Field Form 9A Application for Local Upgrade Approval revised•rev.7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of No. Andover H Form 9A - Application for Local Upgrade Approval o ,M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: 440 gpd Design flow of proposed upgraded system 440 gpd Design flow of facility: 440gpd B. Proposed Upgrade of System 1. Proposed upgrade is (check one): ❑ Voluntary ❑ Required by order, letter, etc. (attach copy) ® Required following inspection pursuant to 310 CMR 15.301: Unknown date of inspection 2. Describe the proposed upgrade to the system: Replace leach field and system components 3. Local Upgrade Approval is requested for(check all that apply): ❑ Reduction in setback(s)—describe reductions: ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction ® Reduction in separation between the SAS and high groundwater: Separation reduction 1 ft. Percolation rate 15 min per inch min./inch Depth to groundwater 3 ft. Form 9A Application for Local Upgrade Approval revised•rev.7/06 Application for Local Upgrade Approval• Page 2 of 4 Commonwealth of Massachusetts City/Town of No. Andover a Form 9A - Application for Local Upgrade Approval 4c,M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test ❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the Code: 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 groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by: Randy Burley 5/21/07 Evaluator's Name(type or print) Signature Date of evaluation C. Explanation Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: No other location on the lot 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: The design uses an alternative system Form 9A Application for Local Upgrade Approval revised•rev.7/06 Application for Local Upgrade Approval* Page 3 of 4 Commonwealth of Massachusetts City/Town of No. Andover a Form 9A - Application for Local Upgrade Approval ;M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: No other adjacent is available 4. Connection to a public sewer is not feasible: Public sewer is not available in the area. 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ❑ Application for Disposal System Construction Permit ❑ Complete plans and specifications ❑ Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other(List): D. 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 deliberate violations." <f V -7 L 31�� Fadfity Owner's SicjKaiture e Date Benjamin C. Osgood Jr. P.E. (Agent for Owner) Print Name New England Engineering Services, Inc. Date 1600 Osgood Streeet No.Andover, MA Preparer's address City/Town 01845 (978)686-1768 State/ZIP Code Telephone Form 9A Application for Local Upgrade Approval revised•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4 J + TOWN OF NORTH ANDOVER o�s...o,•'gyp Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 16000SGOOD STREET; BUILDING 20; SUITE 2-36 s'• `•` NORTH USE TS 01845 �'s J 5� Susan Y. Sawyer, REHS, RS e%64 / .688.9540 _Phone Public Health Director MAY 1 0 2007 9 8.688.8476 _.FAX 9:44P h Ithde t .ownofnorthandover.com townof nortnorthandover.com TOHEAL7D�ARTM�TE- APPL I CAT IO N FOR SOI L �ST7 DATE: lS o g MAP& PARCEL: D� pavual r' LOCATION OF SOIL TESTS. P t jycr OWNER: �Cofl "RI)Y I r- Contact#. APPLICANT: Cx` Contact#. ADDRESS. ENGINEER: .() J► , Contact#. ItkCERTIFIED SOIL EVALUATOR: pV/0 OS ! - Intended Use of Land: Residential Subdivision SingleFamiIy Hom Commercial IsThis: Repair Testing: V Undeveloped Lot Testing: Upgradefor Addition: In the Lake Cochichewick Watershed? Yes No_� THE FOLLOWING MUST BE INCLUDED WITH THISFORM ➢ Proof of land awnership(Tax bill,or letter from owner permitting test) ➢ 8.5_x 11_Plot plan& Location of Testing(please indicate test pit sites on the plan) ➢ Feeof$425.00perlotfornewconstruction. This ooversthe minimum two deep holes and two percolation tests required for each disposal area Feeof$360.00 per lot for repairs or upgrades. GENERAL INFORMATION ➢ Only Certified Soil Evaluatorsmayperform deep hole inspection& ➢ Only Mass.Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area ➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. ➢ Full paymentwill be required for all additional tests within two weeks of testing. ➢ Within45daysoftesting, ascaledplan(nosmallerthan1-100)shallbesubmittedtotheBoardofHealth showing the location of ai I tests(i nd udi ng aborted tests). ➢ Within 60daysof testing soil evaluation forms shall besubmitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval Date. Signature of Conservation Agent: Date back to Health Department: (stamp in): Page 1 of 1 47 DelleChiaie, Pamela From: Marianne Peters[mpeters@millriverconsulting.com] Sent: Friday, May 25, 2007 1:54 PM To: Dan Ottenheimer; 'Lisa Kozel LeVasseur'; Marianne; Grant, Michele; DelleChiaie, Pamela; Sawyer, Susan Subject: Soil Results1LLacy S�trDeet- ay 21, 2007 Good afternoon, Attached are the results from the soil evaluation done on May 21St for 17 Lacy Street. Please call if you have any questions. Have a wonderful holiday weekend. Marianne Peters Mill River Consulting 2 Blackburn Center Gloucester, MA 01930 978-282-0014 ph 978-282-0012 fx www.miliriverconsulting.com 5/25/2007 f • 170 , f Cl -d1 f , 2,1 40 + i r � �✓ " 7� � + I ��b-J �Cl�i (t t -bo I�,�� ),��� � y� �a�l ��/ �l•�,�•� Hocyrl �� �•7�� J •a t , ' \ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the o clal T ftodcdlorf Forrrt dated 6116/2000.Ins on form may not be altered In anyway. A. Certification L UG - 1 2007 Importantvftnfl in OF NORTH ANDOVEIR When flUiro out 1. Property Information: forms on the /� TH DEPARTMENT computer,use only fhe tab key Property Add ss tomovedyournSCG!/ cursor- eot use the return nun Owners Name key. Owrjers Address r /TA/ 00 C/ Ah !'l$qs— City/rown State Zip Code Date of Inspection: Date 2. Inspector �j X1010ht's J�C9roj GZy� Name of inspector q rA CZc/eS .Se P�,'c- ¢ Drci i'v 7'v(— CompanyN_a� / --- 7"5 4,X" �� .yff o 3 8y8 crtyirown state Zip coda /-(003-lzy- &005— Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the Information reported below Is true,accurate and complete as of the time of the Inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved syptem Inspector pursuant to Section 15.340 of Me b(310 CMR 1&000).The system: ❑ Passes ❑ Conditionally Passes Fails ❑ N s Further Evaluation b the Local Approving Authority lnspfW&Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. *"*This report only describes condltlons 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. ft sp.doc•1112004 TWO b OfRdal Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) n �1cy Sf P Addaass Ciq/rown state Zip Code SCo-ff RVvcllt II S-2-1 07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 have not found any Information which indicates that any of the failure criteria described In-310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are Indicated below. Comments: 8) System Conditionally Passes: ❑ One or more system components as described In the"Conditional Pass'section need to be replaced or repaired, The system, upon oompietion 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 substant(aful 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: t5inap.doc•11/2004 Title 5 015dal Inspecdon Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 17 1-4 C\1 sf Property Address City/Town state Zip Code 5 6D# )Z"Vd'11 S--i3 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass Inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box Is leveled or replaced ND Explaln: ❑ 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: 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 t5insp.doc•11/2004 Trtle 5 ORldal Inspection Form:Subsurface Sewage Disposal System Page 3of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) /? Carey s�- Property Address /U':ftAr Q( /14 Cityfrown State Zip Code erc11-# RVVLJ c /1 S -23-Q-7 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fall unless the Board of Health (and Public Water Supplier, If any) determines that the system Is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply: ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS Is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water onalysis,'performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: ft".doc•11/2004 Title S Oficial InspecUon Forth:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) r'7 (-,1 c7 S f Properly Address /V-/-A)WV a s- City/Townstate Zip Code Col' A vv)c r r/ 5 ^23-07 z; c«,e Owner's Name / Date of Inspection 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 dogged SAS or cesspool ryf ❑ Static liquid level in the distribution box above outlet invert due to an overloaded W or clogged SAS or cesspool ❑ Liquid depth in cesspool Is less than 8'below invert or available volume is less than%day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds Indicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No y(j ❑ The system falls. 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. t5insp.doc•11/2004 TWO 5 0"1 Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) n 44u St Property Address City/Town State Zip Code ,S cO f� ��v�,`�� S-237 Owners Name Date of inspection 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 ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question In Section E the system is considered a significant threat, or answered"yes'In Section D above the large system has felled.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. t5insp.doc"11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist /7 Lq cy S t Property Address /U�ftfAov L[MA 01%YS CI /TStats Zip Code S Gown L\JvAcjj S'L1-(37 Hers Name Date of Inspection Check if the following have been done. You must Indicate"yes'or"no"as to each of the following: YES NO ❑ 'V, Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out In the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Ef Have large volumes of water been Introduced to the system recently or as part of this inspection? r f ❑ Were as built plans of the system obtained and examined?(If they were not y-� available note as N/A) ❑ Was the facllity 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? �l ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank .Inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants If different from owner) provided with Information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance Is unacceptable)(310 CMR 15.302(3)(b)] t5insp.doc•11/2004 Title 5 official I nipecUon Font:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information /- 14 q Sf P Address I �4NQ0vcf CRy/rown State zip Code s ccrff s_�3'o-7 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): T DESIGN flow based on 310 CMR 15.203(for example: Wgpd x#of bedrooms): 600 Number of current residents: — 1 Does residence have a garbage grinder? ❑ Yes 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 ,� No Last date of occupancy: C yr r'c a,fDate CommerclaUlndustrial 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): t5kW;.d.w•11/4004 Tft b ONldal inspection Form:Subsurfaw Sew aga Disposal Syztem Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) i n L,4cy S� Property Addoeaa- Citylrown State S caZip Code th ��N���� S-2�� Owners Name Date of Inspecuon General Information Pumping Records: Source of information: No Was system pumped as part of the inspection? Yes ❑ No If yes,volume pumped: Qalbne How was quantity pumped determined? Sc o--try t- 0 Reason for pumping: Type of System: Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ IrinCvaUve/AltemaUve technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date Installed(if known)and source of Information: Were sewage odors detected when arriving at the site? ❑ Yes §( No tsirtsp.doc•f Ir p" TNN 5 OAldal tnspedion Forth:Sustaiaos Sewage Dill system Page 0 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary.Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) n s� Pmpe y Address M-(�ti p vv re, 11,44 6/g` 5- Criylrown State Zip Code Owners Name Dat*of inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: `cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: 2D/ feet Comments(on conditionof joints,venting,evidence of leakage, etc.): 'Sai'-13 )rt /tv bad Shyv Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ancrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age cohfined by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: /©� Sludge depth: y" H Distance from top of sludge to bottom of outlet tee or baffle 35 Scum thickness Distance from top of scum to top of outlet tee or baffle 3 it Distance from bottom of scum to bottom of outlet tee or baffle 7 How were dimensions determined? e4st✓' t6lr�i AW•1.1/2W4 TO 5 Official InspecOn Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) /? �', —5f Property Address q /4 P—t Citylrown State Zip Code _Scoff l`2yytAc5--230-7 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, I�id levels related to outlet inv rt, eviden of i ge,etc.): �I.lit �r 7« � Grease Trap(locate on site plan): Depth below grade: feet —- 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): t5insp.doc•11/2004 Tlgo S Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Title 5 Official Inspection Form Not for.Voluntery Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 0 L fic7 5� Property Addoess Nvov(r ClItyRown stets 23--c� zip Code 7 Owner's Name Date of Inspection 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.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 11�--UY �� ��- u 11Vye4 CVWt ?irk Comments(note If box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of Ipakage intp or out of box,etc. : SS�vc SO T(�S_ I v lC aH°'�pi~1r �Ih'o 9 f Y roo V4 — --- Pump Chamber(locate on site plan): Pumps In working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No t5k�rp.doc•t 1/Z004 TWO d 011ldal Ingpectaon Form:&fturfpoe Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) !7 (1cl s/- � Property Bess - veff Do Cityfrown State Zip Code SC vnJc-j Owner's Name Date of Inspection Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located,explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number ❑ Innovative/altemative system Type/name of technology: -- — --- Comments(note condition of sob, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): lls�c� S p«0 l� mow ( �yo� �1 ��diol3 ,'v Pine; 4?L4 t5lnsp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary.Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) n LI Cy s�- y Address A/-,4 N pov pc- Clty/rown State Zip Code ,Scc"-#- g-2- owner's Name Date of Inspection 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.): t5insp.doc•11/2004 TWO b ofrldal Inspection Form:Subsurface Sewage Disposal System- Page 14 of 16 I etre 5 Ufiticial Inspection norm Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 17 <Y s� Property Address /�f,q p Al,. 100 7v� '� (K ----- CitylTownC � � ) State Zip Code ,5 U�(C-1/ S-- 23'07 Owners '07 owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. q I� IT tickCs S I • t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 A + • Commonwealth of Massachusetts Title 5 Official Inspection Form Notfor Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) /`? A N��tipvu� /t'lA p�$YS' C4 Tow jCk7// R t""J c, 23-07 21p Code owners Name Date of Inspedon Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: IS ( ,va (4,41A-- 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: Date 4/_0/_ $y ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe howou established the high ground water elevation: C,61 a� fi*0� 9U6- Down -C> It"a L%",dW 11/8084 T1tl9 6 OftW kwon ton Form:SuNurtow Sowagq 04 0"System Page 18 of 16 ~ v ^' lOyYN0FN0K1,MAND(�/ER (��iceo[ {�[�K8KOU@>TYDEV�L[)|1�ENlANDS'ER' CES FlEL-T� BU|LD|N(� 2TE U�. ��( 2-�5 WT 9,540 /��/�4 ![��-�|���� �[l�� �/�| ��------ � ' — - Kjn. � LOCAT I ON OF SOI LTEST S: Contact#: OWNER:. Oil und APPLICANT: Contact ENGINEER: nottlestaf) 1( Contact# CERTIFIED SOIL EVALUATOR: Intended Use of Land: Residential Subdivision SingleFarnily Hom-0-> Commercial IsThis: Repair Testing: V-Z Undeveloped Lot Testing:_ Upgrade for Addition: In the Lake Cochichewick Watershed? Yes No � Proof ofland ownership(Ta(bill,orletter from owner permitting test) � Fee N$��per lot for new construction. This ooverstnaminimum two deep holes and two percolation tests required for each disposal area. Feeny$360lWpe lot for repairs or upgrades. GENERAL INFORMATION � Only Certified Soil Evaiuxkmemayperform deep hole inepactiona � Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. � At least two deep holes and two percolation tests are required for each septic system disposal area � Repairs require atleast two deep holes and oLleast one peFouoLiontwst.a the discretion o[theB0H representative. � Full payrnentwill be required for all additional tests within two weeks of testing. � VVkhin45doymoitesting,usoaiodplan(noomal|e/dheo1 ,1OO )shall besubmitted tothe Board o[Health ehowingthe|ooationofal| tests(indmdinAaborted tests) � Wit hin00days o[test ingeoi| eva|uationfurms,u*a|| besubmitted Please DoNot Write Below ThiuLine N.A. Conservation Commission Signature mConservation Agent: Date back toHealth Department: (stompin): /Myq/ 9n � puu�S � I/erQ Approval under the Subdivision Control Low not required ��� 6uchdngn NORTH ANDOVER PLANNING BOARD 5VA,,� I.P. C.RUpf J CNs;nli94a n:rY;Htsra:5:'r 1(.ipirr L I1FF'!'uwRth'!n; i pl O 0� t+r+BT:t 1♦JG41VE7i I°i,hMNl��i Ilp(,gil � � - -- DATE 3 I . r �a � 1 I i I y g o la to I N 2 co 1.0040ac. N d '0 eft. r V i � r f F 1.004 a y 'ru n Qz Jyo�Bs 5 YOD t �!1! 1.0508.ac. -q S`..2 a TZ.oO _ ... -rc,.o8 73.'�J2 •_ R9.8o FOREST STREE' Town of .North Andover,Mass . , /Permit APPLICATION FOR WELL-& PUMP PERMIT Application is he-teby made for permit to drill a well ( ) . Application is made to install (_) a pump system-. Location: Address ' /11 � /� .S%- . ..Lot #- - - :3 - - - j Owner — —Addres. Well Contractor w ddress� � Tel . - - - - -- — Pump Contractor Address Tel : . . - - WELL CONTRACTOR (To be completed at time of pump test ) Type of Well A?— —_Well used for Diameter of Well y _ Size of Casing Depth .4&f Bed Rock Depth casing into Bed Rockg�Q Was Seal Tested? Yes (< No ( ) Date of Testing // 16 Depth of Well \3b(0 Well Fnded in What Material Depth to G?ater Delivers- Gals . Per Min. for 4 hours Drawdown � ►S'` feet after pumping - L� -hours at S -GPM Date of Completion ��yt SignatureContractor PUHIP INSTALLER- (To be filled -in before installation) Size & Name- Pump---__ P1 imp Type Used t,'ater Pump Delivers----GPM - Size of Tank Pipe Material Used in 1,1ell : -Cast Iron ( ) Galvani zed ( ) Plastic ( ) t,Iell Pit ( -) or Pitless- Adapter ( ) VJas sleeve used to protect pipe? Yes (_) NO( _) Type or Tame ,-Jell Seal Date ?;-„e- - - . .. . .... .. .. .. .. .. .. .. .. .. .. .. .. ,. ,, ,. ,. ., .pit°ri, i't: :, ;� .. .;;� Date 14ater analysis report submitted to Board of Health Date re-lease . given to owner of record & Bldg. Ti sp 6 Iic=•alth Inspector - - Pumps It p e Submersible n�,E'�Y� L & PUMP CO. " let IL 9 RT.28 WIN DHAM, N.H.03087 ° Centrifugal J' � e Cellar 11R SE�J` [603]898-4232 O[617]887-5888 " Sewage Tanks Filters e Softener O Iron B&R COM" TEL.NO. a Charcoal 477 ANDOVER ST 686-36 ; c Neutralizer NO ANDOVER MA 0184.5 O Cartridge Water Testing Pump Parts LOT NUMBER OR SAMPLE LOCATION: LOT" #3 LACEY ST" Motor Controls WATER TEST RESULTS 17 MAY 84 Water Softener Salt Resin Cleaner HARDNESS 0 (0-50 REC STANDARD) Rust & Stain Remover IRON 5. 5 (0—. 3 REC STANDARD) Potassium MANGANESESULFIDE , C) (s y—. i 5 REC STANDARD) Permanganate HYDROGEN SULF T DE 0 (0—.01. REC STANDARD) Plastic Pipe & Fittings Ph (ACIDITY) 7. 5 (6. 5--7. 5 REC STANDARD) TURBIDITY 2 (0-20 REC STANDARD) Lawn Watering CHLORIDES 10 (0-150 REC STANDARD) Systems COLIFORM BACTERIA C) (G REQUIRED STANDARD) Water Heaters # x • •• a� a� o Solar CHARGE FOR CHEMICAL & BACTERIA TEST' ** $25. 00 o Heat Pump c Electric ABOVE TESTS MEET REQUIRED STANDARDS AND BASED ON THESE, ° Energy Saving WATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMPTION. Wells TI•-IERE ARE OTHER LESS COMMON MINERALS WHICH CAN AFI`ECT e Drilled QUALITY OF:' WATER. O Driven C Dug e Gravel Chemical Feeders Tank Alarms & Controls Hoist Service Portable Pump Puller Emergency Service Goulds Aermotor Jacuzzi Red Jacket Fairbanks Morse Wayne Aquatron Well-X-Trot .y '7"r<� i i —IVyl-' -7 ?Jc 6N AS73yic7- -0uT 1-%,5"6 Lo T•'�� P TF N �- ti aT 3 U v0 / 62, Q Q' -o PVI 7k ENc HE'S , A5Rua 7- 30.00 �� ��.R�}.R.l.,•f 1 A 5 -� S8 P U J --- �Q� Sl1MU[[ G JA U 7-#A7- 7"4-rE 3LlIL.pl,.4 a ;.els t LoC'A7�� A'-'--7, PL.4 N �N�i w19tL/�8 !U/T'q Tt/E 9oPlx-/G Sff"7"� OF TGIF TOww UboeTf-/ _r aEJC7-/r7Y ^'�.�T 7+��. �E'c✓E D�c%Et:.i GEOTECHNICAL CONSULTANTS OF MASSACHUSETTS, INC. 799 Turnpike Street NORTH ANDOVER, MASSACHUSETTS 01845