HomeMy WebLinkAboutMiscellaneous - 1782 SALEM STREET 4/30/2018 (2)0
Date
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ........... ......................................
....... .. . .... ....................
has permission to perform
.........................
wiring in the building of . .
......................................................................
...................... . North Andover, Mass.
FeeN6'?).0 . . .... Lic. No,�f-'/.......
ELECTRICAL INSPECTOR/
*Check # 7-611
Commonwealth of Massachusetts Official Use Only
(74
Permit No. G C P
Department of Fire Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] Leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:
City or Town of:d p t A- To the Inspector- of Wires:
By this application the undersigned gives notice o his or her intention to perform the electrical work described below.
Location (Street & Number) [ 1 U, ILM {j' � 4 4 ,)
Owner or Tenant S t Telephone No.
Owner's Address
Is this permit in conjunction wi h a)building permit? Yes E] No (Check Appropriate Box)
Purpose of Building Re - 111 f)..A I Utility Authorization No.
Existing Service Amps -3 / Volts Overhead ❑ Undgrd ❑ No. of Dieters
New Service d Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: / e 1C. PU le Alj
olid aofj�zj RAN
Cornoletion of tire 1ollowine table may be rtaived by the Inspector of lVires.
No. of Recessed Fixtures
No. of Ceil: Susp- (Paddle)
of
TransFans Total
Trsformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA
No. of Lighting Fixtures
g g
Swimming Pool Above ❑ In- ❑
g rnd. rnd.
o. o Emergency ig ing
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection and
No. of Switches
No. of Gas Burners
Initiating Devices
No. of Ranges
No. of Air Cond. Total
TonsNo.
No. of Alerting Devices
Heat Pump
Number
Tons
KW
No. of Self -Contained
of Waste Disposers
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ElCo n nnectionolo El Other
Con
No. of Dryers
rat
Heating Appliances RW
Security Systems:
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Baliasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail ifdesired. or as required by the Inspector of wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
`
CHECK ONE: INSURANCE V BOND ElOTHER El(Specify:)
(Expiration Date)
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 0& Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I certify, under the pacts acrd penalties of perjury, that the information on this application: is true and complete. *`g
FIRM NAME: ESP (.d ✓i LIC. NO.: 6 10( � �t
Licensee: �QMIe Signatur t,ary LIC. NO.:
(lfapplicable, enter"ar n pt'" itt t/re license nuntber itre.) j Bus. Tel. No. -9- - d
Address: 4 p tall Dc jee De i e e 80d � 3 d 0 Alt. Tel. No.:
ONVNER'S INSURANCE N RIVER: I am aware that W Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent"
Owner/Agent
Signature Telephone No. PERMIT FEE: S" ZD
North Andover Board of Assessors Public Access Page 1 of 1
Parcel ID: 210/106.11-0148-0000.0 Community: North Andover
SKETCH
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PHOTO
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Location: 1782 SALEM STREET
Owner Name: SMART, PAUL R
DIANE F SMART
Owner Address: 1782 SALEM STREET
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 6 - 6 Land Area: 1 acres
Use Code: 101- SNGL-FAM-RES Total Finished Area: 2738 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 538,900 503,200
Building Value: 328,900 308,900
Land Value: 210,000 194,300
Market Land Value: 210,000
Chapter Land Value:
LATEST SALE
Sale Price: 155,000 Sale Date: 10/03/1983
Arms Length Sale Code: Y -YES -VALID Grantor: MRSTIK RONALD P
Cert Doc: Book: 1730 Page: 199
http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3 &Linkld=808946 6/6/2006
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DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Wednesday, June 07, 2006 2:12 PM
To: DelleChiaie, Pamela
Subject: RE: 1782 Salem Street
Please make a note for the file that an inspection was set for Today, but was postponed by the Health Dir. due to rain
conditions. The rain started overnight Tuesday evening and has not let up yet, at 2:00 PM. It will be rescheduled after the
rain is over and the bottom of the be can be scarified and a proper bottom of bed can be set to receive the new septic
system.
-----Original Message -----
From: DelleChiaie, Pamela
Sent: Tuesday, June 06, 2006 2:27 PM
To: Sawyer, Susan
Subject: 1782 Salem Street
Susan,
Michele took a call from Jim Kellet late this a.m. asking for a Bottom of Bed for above for tomorrow. Michele said that
you are helping out with these, so I was wondering what time would be good for you to do it. Please let me know, and
will call Jim asap. Thanks.
$¢gt Ragwzds,
P4iwe04 D04.00 lflwi¢
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 01845
978.688.9540 - Phone
978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
PUBLIC HEALTH DEPARTMENT
Community Development Division
C�12TI�FIC.A7E o�F Co�t�LIANCE
As of:
June 28, 2006
This is to cert that
the individua[su6surface disposal system was
(Fully Repaired
by
James XeClett
At:
1782 Salem Street
North Andover, W,4 01845
The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
,4an 'Y.' Sawyer
(Pu61ic Ifealth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
0
A
PUBLIC HEALTH DEPARTMENT
Community Development Division
C�12TI�FIC.A7E o�F Co�t�LIANCE
As of:
June 28, 2006
This is to cert that
the individua[su6surface disposal system was
(Fully Repaired
by
James XeClett
At:
1782 Salem Street
North Andover, W,4 01845
The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
,4an 'Y.' Sawyer
(Pu61ic Ifealth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
FINAL GRADE INSPECT N
Dater
Address:
UAOAMED?
p EEDED?
e,XeOVER PER PLAN?
Other:
TOWN OF NORTH ANDOVER,ORTM 1 1 5
Office of COMMUNITY DEVELOPMENT AND SERVICES
to
Vol
p HEALTH DEPARTMENT t R- 0
15 400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845
978.688.9540 — Phone
Susan Y. Sawyer, REHS/RS 978.688.8476 — FAX
Public Health Director E-MAIL: healthdept(abtownofnorthandover.com
WEBSITE: hn://www.townofnorthandover.com
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System () constructed; ()c) repaired;
by K E LL6iT- E9 614 V, Tn A6
(Print Name)
located at l 7 S X SA LE,v7 -S 7—
(Installation
(Installation Address)
was installed in conformance with the North Andover Board of Health approved plan, originally
dated Z — (3 - O G and last Revised on
with a design flow of
q q Cgallons 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: �v - o, -or,
Final inspection date: (o L q0 to
Installer:
And - mt N
Engineer: ,
And - Print
ctaae�'v 0_4d,JO
O
�FG/S7ER%
Engineer Re entative (Signature)
SWAw.tJ Srf?,cL.
And - Print Name
__ i?2�= CO2
Engineer Represen ive (Signature)
klC J (/Z J9 e,
And - Print Name
11
(Signature) Date:
(Sirtttm ECEI L6 a
JUN 2 6 2006
TOHALTH DEPAR ME 'Tr_.R
Page 1 of 1
DelleChiaie, Pamela
From: Dan Ottenheimer [info@millriverconsulting.com]
Sent: Tuesday, June 27, 2006 3:06 PM
To: Grant, Michele; Lisa Kozel LeVasseur; Marianne Peters; DelleChiaie, Pamela; Sawyer, Susan
Subject: 1782 Inspection - Final
Attached is the inspection for 1782 Salem Street.
Daniel Ottenheimer, President
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.millriverconsult�.com
dano v,millriverconsulting.com
6/28/2006
o��O
.i'? 1'tt: I
10-
�E, -�
LAK
PUBLIC HEALTH DEPARTMENT
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 1782 Salem St MAP: 106b LOT: 148
INSTALLER: Kellett Excavating
DESIGNER: New England Engineering Services
PLAN DATE: 2/16/06
BOH APPROVAL DATE ON PLAN: 3/27/06
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: 6/15/06
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
® Existing septic tank properly abandoned
® Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
® 1500 gallon tank has been installed
H-10 loading Monolithic construction
® 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 or effluent filter) installed,
centered under access port
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Comments:
PUMP CHAMBER
Comments:
DISTRIBUTION -BOX
Comments:
NORTH
O�tt�ee �6q�0
O t�
PUBLIC HEALTH DEPARTMENT
Community Development Division
® 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
® Hydraulic cement around inlet & outlet
® Bottom of tank hole has 6" stone base
® Weep hole plugged
® 1000 gallon Pump Chamber installed
H-10 loading Monolithic construction)
® Inlet tee installed, centered under access port
® Pump(s) installed on stable base
® Alarm float working
® Pump On/Off floats working
® Separate on/off floats
® Drain hole in pressure line
® 24" inch cover to within 6" of final grade installed over
pump access port
® Water tightness of tank has been achieved
Visual testing
® Hydraulic cement around inlet & outlet
® 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)
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
y tt%.a- 16 -'Y
o 41A
41
PUBLIC HEALTH DEPARTMENT
Community Development Division
SOIL ABSORPTION SYSTEM (General)
❑
Bottom of SAS excavated down to 6 in into C soil
Alarm & Pump are on separate circuits
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
❑
Retaining wall (boulder / concrete / timber/ block)
❑
Final cover as per plan
Comments:
SOIL ABSORPTION SYSTEM (Gravel -less Chambers)
® Brand and Model of Chamber Infiltrator Quick4_
® Number of chambers per row 7_
® Number of rows (trenches) 5_
® Laterals installed and ends connected to header (and
vented if impervious material above)
® Elevations of laterals and chambers installed as on
approved plan
Comments:
CONTROL PANEL
®
Alarm & Pump are on separate circuits
®
Alarm sounds when float is tripped
®
Location of control panel: Garage wall
❑
Rated for exterior if placed outside
®
Alarm signal located inside
Comments:
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
SYSTEM ELEVATIONS
ED
O
* n K* ee
cxwi[u�iwrtw _ 1•
PUBLIC HEALTH DEPARTMENT
Community Development Division
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Building Sewer OUT 95.10
Septic Tank IN 94.90
95.25
Septic Tank OUT 94.65
95.02
Pump Chamber IN 94.60
95.00
Pump Chamber OUT 94.35
94.75
Distribution Box IN 97.77
97.81
Distribution Box OUT 97.60
97.68
Lateral 1 HIGH 97.50
97.55
Lateral 1 LOW 97.50
97.53
Lateral 2 HIGH 97.50
97.50
Lateral 2 LOW 97.50
97.52
Lateral 3 HIGH 97.50
97.52
Lateral 3 LOW 97.50
97.51
Lateral 4 HIGH 97.50
97.51
Lateral 4 LOW 97.50
97.51
Lateral 5 HIGH 97.50
97.52
Lateral 5 LOW 97.50
97.48
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
NORTh dd
G�4tL20 ,6,,
O
� A
`T �'9 COC ICM KM 7' T/
A�wrao /�1�
PUBLIC HEALTH DEPARTMENT
Community Development Division
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
s 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
Tank
SAS Sewer
®
Property line
10
10 --
®
Cellar wall
10
20 --
❑
Inground pool
10
20 --
❑
Slab foundation
10
10 --
❑
Deck, on footings, etc
5
10 --
®
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).
s 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
VkORTy q
O ttuto 16' tiO
l'? 9t - ., 6 OL
O to
CO[MiCIN
PUBLIC HEALTH DEPARTMENT
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 1782 Salem St MAP: 106b LOT: 148
INSTALLER: Kellett Excavating
DESIGNER: New England Engineering Services
PLAN DATE: 2/16/06
BOH APPROVAL DATE ON PLAN: 3/27/06
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: 6/15/06
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
® Existing septic tank properly abandoned
® Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
® 1500 gallon tank has been installed
H-10 loading Monolithic construction
® 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 or effluent filter) installed,
centered under access port
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Comments:
PUMP CHAMBER
Comments:
DISTRIBUTION -BOX
Comments:
jtORTFt
%i
y � e" y�
T O LAK■ T
�_ (O(MI(M WK• _ 1'
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
® 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
® Hydraulic cement around inlet & outlet
® Bottom of tank hole has 6" stone base
® Weep hole plugged
® 1000 gallon Pump Chamber installed
H-10 loading Monolithic construction)
® Inlet tee installed, centered under access port
® Pump(s) installed on stable base
® Alarm float working
® Pump On/Off floats working
® Separate on/off floats
® Drain hole in pressure line
® 24" inch cover to within 6" of final grade installed over
pump access port
® Water tightness of tank has been achieved
Visual testing
® Hydraulic cement around inlet & outlet
® 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)
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com
14ORTH
O
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
SOIL ABSORPTION SYSTEM (General)
❑
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
❑
Retaining wall (boulder / concrete / timber/ block)
❑
Final cover as per plan
Comments:
SOIL ABSORPTION SYSTEM (Gravel -less Chambers)
® Brand and Model of Chamber Infiltrator Quick4_
® Number of chambers per row 7_
® Number of rows (trenches) 5_
® Laterals installed and ends connected to header (and
vented if impervious material above)
® Elevations of laterals and chambers installed as on
approved plan
Comments:
CONTROL PANEL
Comments:
® Alarm & Pump are on separate circuits
® Alarm sounds when float is tripped
® Location of control panel: Garage wall
❑ Rated for exterior if placed outside
® Alarm signal located inside
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com
SYSTEM ELEVATIONS
o',�t�e° ,6�•ND
O � �it
PUBLIC HEALTH DEPARTMENT
Community Development Division
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Building Sewer OUT 95.10
Septic Tank IN 94.90
95.25
Septic Tank OUT 94.65
95.02
Pump Chamber IN 94.60
95.00
Pump Chamber OUT 94.35
94.75
Distribution Box IN 97.77
97.81
Distribution Box OUT 97.60
97.68
Lateral 1 HIGH 97.50
97.55
Lateral 1 LOW 97.50
97.53
Lateral 2 HIGH 97.50
97.50
Lateral 2 LOW 97.50
97.52
Lateral 3 HIGH 97.50
97.52
Lateral 3 LOW 97.50
97.51
Lateral 4 HIGH 97.50
97.51
Lateral 4 LOW 97.50
97.51
Lateral 5 HIGH 97.50
97.52
Lateral 5 LOW 97.50
97.48
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com
Y
O I6�6N00
,r bt d a,
1- _ ~ . A
PUBLIC HEALTH DEPARTMENT
Community Development Division
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
s 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
Tank
SAS Sewer
®
Property line
10
10 --
®
Cellar wall
10
20 --
❑
Inground pool
10
20 --
❑
Slab foundation
10
10 --
❑
Deck, on footings, etc
5
10 --
®
Waterline
10
10 10'
❑
Private drinking well
75
1042 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
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
s 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
v
fit/
�a5k�
J'�
l-7 PZ �1
AS -BUILT CHECKLIST
✓ LOT NUMBER, STREET NAME
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.
i NORTH ARROW
LOCATION & ELEVATIONS OF BENCHMARK USED
11
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOS_&-DM_NSIONS OF SYSTEM,
INCLUDING RESERVE
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
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.
i NORTH ARROW
LOCATION & ELEVATIONS OF BENCHMARK USED
11
Ile '
r
Town of North Andover
HealthDepa/iittment Date:
Location: �/ ��/�� ✓l /
(Indicate Address, if Residential, or Name of Business)
Check #:
Tvve of Permit or License: (Circle)
` ➢
Animal
$
➢
Dumpster
$
➢
Food Service - Type:
$
➢
Funeral Directors
$
➢
Massage Establishment
$
➢
Massage Practice
$
➢
Offal (Septic) Hauler
$
➢
Recreational Camp
$
➢ SEPTIC PERMITS:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval $
�ic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
➢
Sun tanning
$
➢
Swimming Pool
$
- ➢
Tobacco
$
➢
TrashlSolid Waste Hauler
$
➢
Well Construction
$
➢ OTHER: (Indicate)
Health Agent Initials
1561
White - Applicant Yellow - Health Pink - Treasurer
'' ,
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
IV ,.6
ie2im
D
Application is hereby made for a permit to:
❑Ronstruct a new on-site sewage disposal system*
epair or replace an existing on-site sewage disposal system*
❑ Repair or replace an existing system component
A. Facility Information
Address or Lot #
--
City/Town
2�TYPE OF SEPTIC SYSTEM*:
Pump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
TODAY'S DATE
250.00 — II Repair
$125.00 - Component
Vnventional System (pipe and stone system)
iltrator 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
Pow ftlai2T
Name
Address (if different from above)
City/Town
State
Zip Code
Telephone Number
3. Installer Information
mssyew
Name Name of Company
Address K[A AAA
City/T wn Stater — Zip Code — ----- - —
Telephone Number (Cell Phone # if possible please)
a. Desianer Information
Application for Disposal System Construction Permit - Page 1 of 2
Name
Name of Company
Address
City/Town
State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
µ°k. I Application for Septic Disposal System
°', 7ti
9Construction Permit - TOWN OF
`Y Y;: NORTH ANDOVER, MA 01845
e ,.
PAGE 2OF2
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
A. Facility Information continued....
5. Type of Building: residential Dwelling or ❑Commercial
B. Agreement
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 isAed by this Board pf Health.
Name
�2,
Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attacbed?
2. Project Manager Obligation Form Attacbed?
3. Pump S. sy tem? If so, Attacb copyo of Electrical Permit
4. Foundation As -Built? (new construction ronly):
(Same scale as approved plan)
5. Floor Plans? (new construction only):
Yes No
Yes2 No
dj�
Yes, V110 No
Yes_ No
Yes_ No
Application for Disposal System Construction Permit a Page 2 of 2
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at
V? %'L Saler~ sA
of J 1 VY\ 1611P � dated
datedFe_� �� , with revisions dated
relative to the application
for plans by N j E L and
I understand the following obligations for management of this project:
I . 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 approved 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
manger, 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 Tile 5 and the Board of Health Regulations may
result in a $50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be
on site.
4. As the installer I understand that only I may perform the work (other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work by others unlicensed to install septic systems in
North Andover can constitute reasons for denial of the system, and/or revocation or
suspension of my license 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 eptic Installer
Date: av
4 u
Date ...�Z.:. �1�......
+ • HORTIy
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
Thiscertifies that a�..........................................:.........................................
has permission to perform( .... ................. ......... .G%�.....
wiring in the buildin of .....:.:...................................................................
at .. Z2LP............................:-��..................... , North Andover, Mass.
Fee..................... Lic. No. ....................... ..................
ELECTRICAL INSP R
Check # .��!l
6689
1782 Salem Street - Final Construction Request Page 1 of 1
DelleChiaie, Pamela
From: Marianne Peters[mpeters@millriverconsulting.com]
Sent: Wednesday, June 14, 2006 3:53 PM
To: DelleChiaie, Pamela; 'Daniel Ottenheimer (E-mail)'; 'Lisa LeVasseur (E-mail)'; 'McBrearty Andrew
(E-mail)'
Subject: RE: 1782 Salem Street - Final Construction Request
WE CAN DO THIS TOMORROW (THURSDAY/JUNE 15 TH) AT 9:00; I'VE PLACED A CALL TO JIM KELLE I I AND
AM AWAITING HIS CONFIRMATION. WILL LET YOU KNOW IF IT DOESN'T HAPPEN.
From: DelleChiaie, Pamela[mai Ito: pdel lechia ie@townofnortha ndover.com]
Sent: Wednesday, June 14, 2006 10:02 AM
To: Daniel Ottenheimer (E-mail); Lisa LeVasseur (E-mail); Marianne Peters (E-mail); McBrearty Andrew (E-mail)
Subject: 1782 Salem Street - Final Construction Request
Importance: High
Hello,
Per Ben Osgood of NEES, the above is all set for a Final. Please call Jim Kellett at: 781.953.7146 to arrange.
Thank you.
AOS. R¢gwads,
P4iw100a D10"100 0M.010
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 01845
978.688.9540 - Phone
978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
6/19/2006
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Monday, June 19, 2006 9:56 AM
To: Grant, Michele
Subject: 1782 Salem Street - Final Grade
Hi Michele,
Please schedule a Final Grade for above when you have a chance. Jim Kellett did the work on this one. Thanks.
Bas! R¢gwads,
Pa#waBw AW004 1410io
Health Department Assistant
Town of North Andover
160o Osgood Street
Building 20, Suite 2-36
North Andover, MA o1845
978.688.9540 - Phone
978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
A
LETTER OF TRANSMITTAL
North Andover Health Department
400 Osgood Street
North Andover, MA 01845
978.688.9540 - Phone
978.688.8476 - Fax
healthdei)t(�ctownofnorthandover.com - E-mail
www.townofnorthandover.com - Website
NORTH
O�t6 q%
�- -A
O cOtMICWwKw 1-
�4SSgcHus
Page / of
TO:
DATE:
Benjamin C. Osgood, Jr., P.E.
(2 14
COMPANY:
FROM: Pamela DelleChiaie, Health Dept. Assistant
New England Engineering Services, Inc.
Mailed
RE:
Phone: 978.686.1768
Fax #
Fax: 978.685.1099
We are sending you: OPlan Review LetterPROVED
OSystem Construction Follow -Up
These are transmitted as checked below:
17NOT APPROVED
OOther
OFor your File OAs Required OAs Requested OFor Your Use
REMARKS:
COPY TO:
Fax #
or
Mailed
COPY TO:
Fax #
or
Mailed
COPY TO:
Fax #
or
Mailed
n
A,
TOWN OF NORTH ANDOVER f NORTH 1
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845'�.
cHuget
Susan Y. Sawyer, REHS/RS
Public Health Director
March 27, 2006
Paul Smart
1782 Salem Street
North Andover, MA 01845
RE: Wastewater System Plan for 1782 Salem Street, Map 106B, Lot 148
Dear Mr. Smart,
978.688.9540 - Phone
978.688.8476 - FAX
The North Andover Board of Health has completed review of the onsite wastewater treatment
and dispersal system design plans for the above referenced property submitted on your behalf by
New England Engineering Services dated February 13, 2006 and received by this office on
February 15, 2006.
The design has been approved for use in the construction of a replacement onsite wastewater
system. This approval is valid for three years from the date of this letter and during this time a
licensed septic system installer must obtain a permit and complete this work, and a Certificate of
Compliance must be endorsed by the installer, designer and the Town of North Andover. The
time period for which this plan is valid is reduced to two years from the date of an inspection of
the current wastewater system which did not meet the acceptable criteria in the state regulations.
The time period for which this plan is valid may be reduced by the North Andover Board of
Health in the event an imminent health problem such as sewage backup into the dwelling is
occurring.
This approval is subject to the following conditions:
1. 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 (3 10 CMR 15.020(1)).
2. It is the responsibility of the applicant and/or the applicant's designer, 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 and/or imply compliance with
any of the aforementioned requirements.
3. The plan does not call for installation of a primary (septic) tank effluent filter but one is
recommended. Please be advised that only certain brands of filters are permitted for use
in Massachusetts and each is required to follow certain approval criteria. Your designer
A`
A. or installer should work with you to assure a licensed brand is selected for use, if you
choose to install one.
Your effort to provide a properly functioning onsite wastewater treatment and dispersal system
for your property is greatly appreciated. The Health Department may be reached at 978-688-
9540 with any questions you might have.
Sincerel ,
` Susan Y. Sawyer, REHS/RS
Public Health Director
encl: List of licensed installers
cc: New England Engineering Services
file
EFA
TOWN OF NORTH ANDOVERf NORTN
Office of COMMUNITY DEVELOPMENT AND SERVICES �: e'ic.so � 0
HEALTH DEPARTMENT p
400 OSGOOD STREET
NORTH ANDOVER MASSACHUSETTS 01845 �i�°''e<`�'
� s^CHUg
Susan Y. Sawyer. REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 17S Z S
INSTALLER:-- KILL -z -t -
DESIGNER: Q O -S oa�
PLAN DATE: Z ��� 4—
BOH APPROVAL D TE ON PLAN:
INSPECTIONS
MAP:/r->LG LOT: l/-1 S
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
❑Topography not appreciably altered
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ 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 or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation — Feb 2006
Page 1 of 6
TOWN OF NORTH ANDOVER f NORTH 1
Office of COMMUNITY DEVELOPMENT AND SERVICES 3: ;•t"" '` a"��
HEALTH DEPARTMENT
400 OSGOOD STREET .
NORTH ANDOVER, MASSACHUSETTS 01845 ��SS'5`�
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ Combo Tank installed. Size:
❑ 1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ 24" inch cover to within 6" of final grade installed over
pump access port
❑ Water tightness of tank has been achieved
Visual testing
❑ Hydraulic cement around inlet & outlet
Comments:
ADVANCED TREATMENT TECHNOLOGY
❑ Type of treatment device:
Comments:
❑ Installed per manufacturers requirements
❑ All components working in accordance with
manufacturer's requirements
Wastewater System Documentation — Feb 2006
Page 2 of 6
TOWN OF NORTH ANDOVER E NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT p
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 �9Ss�cHoS`�
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
� _•
❑ Installed on stable stone base
❑ Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
❑ Observed even distribution
❑ Speed levelers provided (not required)
Comments:
SOIL ABSORPTION SYSTEM � �
Bottom of SAS excavated down to(/soil layer, as
y provided on plan
,�,_N--'Sife of SAS excavated as per plan
' 7i -Title 5 sand installed, if specified on plan
3/4-1 Y2" double washed stone installed
❑ 1/8-1/2" (peastone) double washed stone installed
❑ Laterals installed and ends connected to header
❑ Laterals vented if impervious material above
❑ Orifices @ 5 & 7 o'clock positions
❑ Gravel -less disposal systems: type, number and
location as per plan
❑ Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
❑ Retaining wall (boulder / concrete / timber/ block)
❑ Final cover as per plan
Comments:
-4_414—
� W
Wastewater System Documentation — Feb 2006
Page 3 of 6
TOWN OF NORTH ANDOVER f NORTH
Office. of COMMUNITY DEVELOPMENT AND SERVICES or .o `. ..�°°�
HEALTH DEPARTMENT p
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 "'9ss�cMuse``�
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
PRESSURE DISTRIBUTION
❑ -- inch manifold
❑ laterals installed with end sweeps
size:
material:
❑ Squirt test ft in height
❑ Equal distribution to all laterals
❑ orifice size inch as per plan
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel:
❑ Rated for exterior if placed outside
Comments:
Wastewater System Documentation — Feb 2006
Page 4of6
TOWN OF NORTH ANDOVER f NOR711
Office of COMMUNITY DEVELOPMENT AND SERVICES or 6'0�..+°OR
HEALTH DEPARTMENT4L
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 3,Ss';�N�St4h
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
' Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (1VA 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
Wastewater System Documentation — Feb 2006
Page 5 of 6
Tank
SAS Sewer
❑
Property line
10
10 --
❑
Cellar wall
10
20 --
❑
Inground pool
10
20 --
❑
Slab foundation
10
10 --
❑
Deck, on footings, etc
5
10 --
❑
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 (1VA 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
Wastewater System Documentation — Feb 2006
Page 5 of 6
TOWN OF NORTH ANDOVER t NORTFF
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT p
400 OSGOOD STREET "� �, '_ ,r V
NORTH ANDOVER, ^CFIU
MASSACHUSETTS 01845 �.�5'"TO
SS
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
SYSTEM ELEVATIONS
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Wastewater System Documentation — Feb 2006
Page 6 of 6
Page 1 of 1
DelleChiaie, Pamela
From: Dan Ottenheimer [info@millriverconsulting.com]
Sent: Monday, March 27, 2006 7:00 AM
To: amcbrearty@millriverconsulting.com; Lisa Kozel LeVasseur; Marianne Peters; DelleChiaie, Pamela;
Sawyer, Susan
Subject: 1782 Salem Street
Plan approval letter attached for 1782 Salem Street
Dan
u
Daniel Ottenheimer, President
Mill River Consulting, Inc.
Septic System Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www.millriverconsulting.com
dano@millriverconsulting. com
7/2006
Town of North Andover
Health Department DeP artment Date:
�+��Location: A
(Indicate Address, if Residential, or Name of Business)
Check #:
Type of Permit or License: (Circle)
➢ Animal
$
➢ Dumpster
$
➢ Food Service - Type:
$
➢ Funeral Directors
$
➢ Massage Establishment
$
➢ Massage Practice
$
➢ Offal (Septic) Hauler
$
➢ Recreational Camp
$
➢ SEPTIC PERMITS:
❑ Septic,- Soil Testing
$
J�. eptic = Design Approval
$ �
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI)
$
➢ Sun tanning
$
➢ Swimming Pool
$
➢ Tobacco
$
➢ TrasWSolid Waste Hauler;
$
➢ Well Construction
$
➢ OTHER: (Indicate)
E4 J n Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
4
TOWN OF NORTH ANDOVER t NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
F � p
HEALTH DEPARTMENT 49
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 �'SS�CMUS
Susan Y. Sawyer, REHS/RS
Public Health Director
SEPTIC PLAN SUBMITTAL FORM
978.688.9540 — Phone
978.688.8476— FAX
E-MAIL: healthdeptt@townofnorthandover.com
WEBSITE: http://www.townofnorthandover.com
Date of Submissio :VI/y Fej D&
Site Location: 4qm1g 00-1— St No Ard0ye,r HA
Engineer: ri lam Irl 0, osgor�. e� , 'p z .
Rr--Cr-
SEB 15 2006
TOWN OF NORTtA DEPAR M O TQC
New Plans? Yes ✓ $225/Plan Check # 8'J *73 (includes Is' submission and one re-
review only)
Revised Plans? Yes $75/Plan Check #
Site Evaluation Forms Included? Yes P"' No
Local Upgrade Form Included? Yes No
Telephone #: (���� (� �(p – l'J�g Fax #: (qj9) G qS- 109?
E-mail: ne4S'P�✓lQ� Qo (.CaM
Homeowner
Name: �Giu-( S�CVt&�
OFFICE USE ONLY
When the submission is complete (including check):
➢ Date stamp plans and letter
➢ Complete and attach Receipt
➢ z" Copy File; Forward to Consultant
➢ 4,Z Enter on Log Sheet and Database
NEW ENGLAND ENGINEERING SERVICES
INC
13 February 2006
Mrs. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
Re: 1728 Salem Street, North Andover, MA
Septic System Design
Dear Mrs. Sawyer,
R!,Cr!-'L
FEB 15 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
The following plans and enclosures for the above referenced property are being submitted
for approval.
1. (3) Copies of the Septic System Design Plans
2. (1) Copy of the Form 11 Soil Evaluator Sheets
3. (1) Copy of the Form 12 - Percolation Test
4. (1) Copy of the Septic Submittal Form
5. (1) Check for $225.00 for town approval fee.
If you have any comments or questions please do not hesitate to contact this office at
(978)686-1768.
Sincerely,
Z5- ��-
Benjamin C. Osgood, Jr.,
President
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
Commonwealth of Massachusetts
City/Town of /l/o4I AnJover
Percolation Test
Form 12
41M .y`'y
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VAI
rercolatlon 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.
A. Site Information
Paul Smart
uwner Name
1782 Salem Street
Street Address or Lot #
North Andover
City/Town
Contact Person (if different from Owner)
B. Test Results
MA
State
Telephone Number
01845
Zip Code
Date Time
Test Passed: ® Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Benjamin C. Osgood, Jr.
Test Performed By:
Andrew McBrearty, Mill River Consultinq
Witnessed By:
Comments:
t5form12.doc• 06/03 Perc Test • Page 1 of 1
2/7/06 9:30
Date Time
Observation Hole #
PT1
Depth of Perc
52'715"
Start Pre -Soak
9:30
End Pre -Soak
9:45
Time at 12"
9:45
Time at 9"
9.48
Time at 6"
9:52
Time (9"-6")
4 MIN.
Rate (Min./Inch)
<2 MIN. PER INCH
01845
Zip Code
Date Time
Test Passed: ® Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Benjamin C. Osgood, Jr.
Test Performed By:
Andrew McBrearty, Mill River Consultinq
Witnessed By:
Comments:
t5form12.doc• 06/03 Perc Test • Page 1 of 1
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Page 1 of 1
DelleChiaie, Pamela
From: Lisa LeVasseur [lisal@millriverconsulting.com]
Sent: Monday, January 30, 2006 9:35 AM
To: Sawyer, Susan; amcbrearty@millriverconsulting.com; DelleChiaie, Pamela;
dano@millrive orast�+tir�g c�
Subject: Soil Ev ; 1782 Salem Street
We've scheduled a soil evaluation for:
1782 Salem Street — Tuesday, February 7th @ 8:30 a.m. with
New England Engineering
Please call if you have any questions. Thanks, Marianne
Lisa LeVasseur
Mill River Consulting
Your Complete Source for Onsite Wastewater Management
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www,millri .erconsulting.com
1/30/2006
Town of North Ando er
Health Department Date< Co
r< .
Location: 1
715W (A�,Yzl-,
(Indicate Address, if Residential, or Name of Business)
Check #: M
Type of Permit or License: (Circle)
➢
Animal
$
➢
Dumpster
$
➢
Food Service - Type:
$
➢
Funeral Directors
$
➢
Massage Establishment
$
➢
Massage Practice
$
➢
Offal (Septic) Hauler
$
➢
Recreational Camp
$
➢
SEPTIC -PERMITS:
Soil Testing
eptic -
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC) $
❑
Septic Disposal Works Installers (DWI)
$
➢
Sun tanning
$
➢
Swimming Pool
$
➢
Tobacco
$
➢
Tras4/Solid Waste Hauler
$
➢
Well Construction
$
➢ OTHER (Indicate)
1364 Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
' e •
r
LETTER OF TRANSMITTAL
North Andover Health Department
400 Osgood Street
North Andover, MA 01845
978.688.9540 - Phone
978.688.8476 - Fax
healthdent(a,townofnorthandover.com - E-mail
www.townofnorthandover.com - Website Page / of
"10RTly
OE �t%.a0 06
a OA
70
n " iIN
Coe in
TO:
Daniel Ottenheimer
DATE:
/
COMPANY:
FROM: Pamela DelleChiaie, Health Dept. Assistant
Mill River Consulting
COPY TO:
RE:
Phone: 1.800.377.3044 or 978.282.0014
COPY TO:
Fax: 978.282.0012�=
�r./L%
/ J /
We are senaingyouu: -ZJ-56111 est L/Ylans for Review LJ Other (fill in below.
These are transmitted as checked below:
CFor Review and comment OAs Requested CAs Required CFor Your Use
REMARKS:
COPY TO:
COPY TO:
SIGNED:
COPY TO:
TOWN OF NORTH ANDOVER F NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES or�`�����°
HEALTH DEPARTMENTt
^
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845
,gsACNUSE<
Susan Y. Sawyer, REHS, RS 978.688.9540 - Phone
Public Health Director 978.688.8476 - FAX
healthde t a townofnorthandover.com
www.townofilorthandover.com
APPLICATION FOR SOIL TESTS
DATE: ��aoIDCo
MAP PARCEL:
�O&
! t d -
A "WOWNER-
LOCATION OF SOIL TESTS:1
J l
Tauj �J i' a4Q 7
Contact
APPLICANT: T j774/LT"
Contact
�3 9
ADDRESS: �v d !_Oht41 t;D
�/. Al. fJ
KCX O V�°✓
ENGINEER: &mA m 1 w7
Contact #:
�% %?- 6
kip %
CERTIFIED SOIL EVALUATOR: IJFI'1►Q1B 1►7 C- crp cxj,
Intended Use of Land: Res\id/ential Subdivision Single Family Hom Commercial
Is This: Repair Testing: X Undeveloped Lot Testing: Upgrade for Addition:_
In the Lake 'Cochichewick Watershed? Yes No
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
➢ Proof of land ownership (Tax bill, or letter from owner permitting test)
➢ &5"x M"Plot plan & Location of Testin-a (please indicate test pit sues on the plan)
Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or upgrades.
GENERAL INFORMATION
➢ Only Certified Soil Evaluators may perform deep hole inspections.
➢ 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 payment will be required for all additional tests within two weeks of testing.
➢ Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health
showing the location of all tests (including aborted tests).
➢ Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval Date:
Signature of Conservation Agent.
Date back to Health Department: (stamp in):
r
Grant, Michele
J
To: ; lisal@millriverconsulting.com
Subject: 1782 Salem Street North Andover
Hi Lisa,
Pam is out today so a quick note to inform you that Ben Osgood would like to set up an appointment to Evaluate Soils at
1782 Salem Street Single Family Home.
1782 Salem Street
Lot & Parcel # 106B 148
Owner: Paul Smart
Phone #: 978-794-0394
Repair Testing
Not in the Watershed
Please call Ben Osgood at 978-686-1768
If you have any questions please call me at 978-688-9540
Many Thanks
Michele E Grant
North Andover Health Department
1
01/19/2006 11:23 9786851099
lky New England
Engineering Service, Inc.
60 Bewbwood i0rive, N% Andover, MA O1W
P6orne:97&6K1768 Fax: 97&685.1099
Date: Jam>ary 19 2006
Fax #: 978-688-9542
Please Deliver To:
Company Name
Address:
North Andover Board of Heabh
From: S w
RE. soil testing 1782 Salem street
_
NEW ENG ENG
PAGE 01
FAX TRANSMITTAL
www.newmOanden n&net
Enclosed is a sketch ofthe proposed test pit locations at the above m*mnced pmpaty.
The application for soil testing was mailed without this infooration.
If you have any questions please do not hesitate to call.
Urgent Reply Requested Reply Today
Reply at Your Own Convenience X No Reply Necessary
2 Total pages, including Cover She( (ff a U pages — ,wi received pteam rro* onrfrrm at soon as pacvihle)
Thanks,
bar
Urgent Reply Requested Reply Today
Reply at Your Own Convenience X No Reply Necessary
2 Total pages, including Cover She( (ff a U pages — ,wi received pteam rro* onrfrrm at soon as pacvihle)
01/19/2006 11:23 9786851099
f
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I
NEW ENG ENG
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PAGE 02
it
IL
577'MAIN STREET
HUDSON, MA 01749
800-499-1682
WIXDR-TVER
ENVIRONMENTAL
OCT 2 8 2005
-
hiE ,.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNER'S NAME: SMART, DIANE
PROPERTY ADDRESS: 1782 SALEM ST., NO. ANDOVER, MA 01845
ADDRESS OF OWNER: SAME
(IF DIFFERENT)
DATE OF INSPECTION: OCTOBER 12, 2005
NAME OF INSPECTOR: THOMAS CHIGAS
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner's Name: SMART, DIANE
Owner's Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Date of Inspection: OCTOBER 12, 2005
Name of Inspector: (please print) THOMAS CIHGAS
Company Name: Windriver Environmental
Mailing Address: 577 Main Street
Hudson, MA 01749
Telephone Number: 800-499-1682
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
YES Fails
Inspector's Signature: lx�a�;4�
Date: OCTOBER 12, 2005
The system inspector shall submit a copy of/isnspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12.2005
Inspection Summary: Check A, B, C,®or E / ALWAYS complete all of Section D
A. System Passes:
NO I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303
or m 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
NO One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.
The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the for the following statements. If "not determined" please
explain.
NO The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
NO 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):
NO broken pipe(s) are replaced
NO obstruction is removed
NO distribution box is leveled or replaced
ND explain:
NO 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):
NO broken pipe(s) are replaced
NO obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12, 2005
C. Further Evaluation is Required by the Board of Health:
NO 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:
N/A Cesspool or privy is within 50 feet of surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
NO 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.
NO The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
NO The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
NO The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other: N/A
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12, 2005
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
YES Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
NO Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
YES Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS
or cesspool
N/A Liquid depth in cesspool is less than 6" below invert or available volume is less than '/: day flow
NO Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
NO Any portion of the SAS, cesspool or privy is below high ground water elevation.
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
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 (Yes/No) 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.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes no
N/A the system is within 400 feet of a surface drinking water supply
N/A the system is within 200 feet of a tributary to a surface drinking water supply
N/A 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.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12, 2005
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
YES Pumping information was provided by the owner, occupant, or Board of Health
NO Were any of the system components pumped out in the previous two weeks?
YES Has the system received normal flows in the previous two-week period?
NO Have large volumes of water been introduced to the system recently or as part of this inspection?
YES Were as built plans of the system obtained and examined? (If they were not available note as N/A)
YES Was the facility or dwelling inspected for signs of sewage back up?
YES Was the site inspected for signs of break out?
YES Were all system components, excluding the SAS, located on site?
YES 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?
YES Was the facility owner (and occupants if different from owner) provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
YES Existing information. For example, a plan at the Board of Health.
N/A Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12.2005
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 3
Does residence have a garbage grinder (yes or no)? NO
Is laundry on a separate sewage system (yes or no): NO [if yes separate inspection required]
Laundry system inspected (yes or no): N/A
Seasonal use: (yes or no): NO
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): NO
Last date of occupancy: CURRENT
COMMERCIALANDUSTRIAL
ATTACHED
Type of establishment:
Design flow (based on 310 CMR 15.203): _gpd
Basis of design flow (seats/persons/sgft, etc.):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: OWNER
Was system pumped as part of the inspection (yes or no)? YES
If yes, volume pumped: 1.000gallons -- How was quantity pumped determined? VOLUME PUMPED
Reason for pumping: CHECK TANK'S INTEGRITY
TYPE OF SYSTEM
YES Septic tank, distribution box, soil absorption system
NO Single cesspool
NO Overflow cesspool
NO Privy
NO Shared system (yes or no) (if yes, attach previous inspection records, if any)
NO Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
NO Tight tank Attach a copy of the DEP approval
N/A Other (describe):
Approximate age of all components, date installed (if known) and source of information: INSTALLED 12/1979,
OWNER AND PLANS
Were sewage odors detected when arriving at the site (yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12, 2005
BUILDING SEWER (locate on site plan)
Depth below grade: 29"
Materials of construction: 4"cast iron 40 PVC other (explain):
Distance from private water supply well or suction line: N/A
Comments (on condition of joints, venting, evidence of leakage, etc.): THERE WERE NO SIGNS OF
LEAKAGE IN OR AROUND PIPE. SOILS WERE CLEAN AND DRY.
SEPTIC TANK: YES (locate on site plan)
Depth below grade: 20"
Material of construction: YESconcrete metal fiberglass _polyethylene other
(explain)
If tank is metal list age: _ is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: 8'L X 51W X 5111 OUTLET INVERT aa, qg1000als
Sludge depth: 10" 9
Distance from top of sludge to bottom of outlet tee or baffle: 22"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined? ROD AND RULER
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.): THE TANK WAS PUMPED.THE INLET AND OUTLET
BAFFLES ARE INTACT, AND THERE CEMENT CONSTRUCTION THERE IS A HIGH SCUM LEVEL
IN TANK. THERE ARE SIGNS OF OVERFLOW TO D -BOX.
GREASE TRAP: NO(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12, 2005
TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other (explain):
Dimensions:
Capacity: _gallons
Design Flow: _gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no): _
Date of last pumping:
Comments (condition _ of alarm and float switches, etc.):
DISTRIBUTION BOX: YES (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 4" DEPTH BELOW GRADE: 30"
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.): THERE IS EVIDENCE OF POOR INTEGRITY WITH CRACKES AND
WEAR. THERE IS SIGNS OF HEAVY CARRYOVER FROM TANK. THERE WERE SIGNS OF HIGH
LIQUID LEVEL IN BOX, SHOWING SIGNS OF HYDRAULIC FAILURE, THE SOILS WERE WET AND
DIRTY.
PUMP CHAMBER: NO (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12, 2005
SOIL ABSORPTION SYSTEM (SAS): YES (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:
YES Leaching fields, number, dimensions: ONE, .45'L X 201W
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.): THE LEACH LINES WERE UNDER LIQUID AT TIME OF INSPECTION INDICATING
HYDRAULIC FAILURE. THE LINES ARE SCH2O PVC CONSTRUCTION
CESSPOOLS: NO (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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: NO (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12, 2005
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.
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Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1782 SALEM STREET
NO. ANDOVER, MA 01845
Owner: SMART, DIANE
Date of Inspection: OCTOBER 12, 2005
SITE EXAM
Slope: YES
Surface water: NONE
Check cellar: YES
Shallow wells: NONE
Estimated depth to ground water 4'+(aaarox) feet
Please indicate (check) all methods used to determine the high ground water elevation:
YES Obtained from system design plans on record - If checked, date of design plan reviewed: DEC 7, 1979
YES Observed site (abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health -explain:
NO Checked with local excavators, installers- (attach documentation)
YES Accessed USGS database -explain: MAPS
You must describe how you established the high ground water elevation: THE HOME HAS 8' PRECAST
FOUNDATION WITH NO SUMP PUMP AND THE BASEMENT WAS DRY THE SYSTEM IS A RAISED
SYSTEM IN FRONT YARD AND IT'S SHOWING SIGNS OF HYDRAULIC FAILURE. THE SYSTEM
WILL BE NEEDING SOIL TESTING FOR NEW DESIGN. THERE WERE NO ABUTTING PROPERTY
WELLS OR WETLANDS WITHIN 150 FROM SYSTEM.
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9
Commonwealth of Massachusetss
: Massachusetts
System Pumnina Record
rstem Owner
System Location
7Ck
Tom' Emergency Routine
Cesspool: No Yes
Date of Pumping: I S O l
System Pumped By: Wind N~ Envi an~P,r.,/
Contents transferred to:
Contents Disposed at:
Date: is /0/—
lCondition
of System/Other Comments
Pumper signature:
,1 .I
Dnp Approved Fmm - IZ/o7/95
y ���2001
Form 4 -- System Pumping Record
Septic took: No =Yes
Quantity Pumped: f S O p Gallons
Permit #:
SOIL PROFILE & PERCOLATION TEST DATA
b
'down/City No.&Street Lot No.
Loc./Subdiv. 6Y`1an Owner - -
Investigator � '`" Observer -7
SOIL PROFILES_DATE/��i
1'
Elev._ 2' Elev.� 3' Elev.� 4 '-Elev.
0 -0
0 0
1 1 GItts 1 I I 1 1
A
F
f
2
3
4
5
6
8
9
2
3
4
0?
G
9-11?
8
9
101 10
Benchmark
Elevation
2
3
4
5
6
6
8
V]
10
Location
Datum
Percolation Tests -Date
2
3
4
5
6
7
8
9
10
Pit Number 1 2 3 4 5
Start Saturation
Soak -Mins. I5�
Start Test -Time '_-�
Drop of 3" -Time gi 1124i
Drop of 6" -Time .
Mins.1st "Dro
Mi nc _ 7nH 111nrnn I�
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
iG►
Commonwealth of Massachusetss
Massachusetts
System Pumping Record
em Owner . system Location
r r C t iLe_ i. : j H'.
Farm 4 -- System1Pum. IV
CD
NOV 16 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
•i rr tt, _7' '���`•ri 41, �1 ti9 ) ,[:. „rr°V .. � :� 11 "r 1, '.
Type: Emergency Routine
Cesspool: No Yes Septic tank: Yes
Date of Pumping: Quantity mped: do s
System Pumped By: Wind River Environmental, LLC Permit #:
Contents transferred to:
Contents Disposed at:
Date:
1D�Z�J
lCondition of System/Other Comments
Fitchburg
IN -
Waste Wai
MA.
pumper T�
Dep Approved Form - 12/07/95