HomeMy WebLinkAboutMiscellaneous - 183 VEST WAY 4/30/2018I
MAP # LOT #:26
..___ _ ._.....
PARCEL # STREET _6�';�_,�—�, �-.�.__,......_..._.._...._...
HAS PLAN REVIEW FEE BEEN PAID? YE9. NO
C�ti2ct � � Q/t
PLAN APPROVAL: DATE ARP. BY
DESIGNER:
�z� PLAN DATE;_ •�__ S
CONDITIONS 6�6CjOl,) 01 G�,, - U Oc_� r<--_
ty
WATER SUPPLY: TOWN WELL
WELL PERMIT DRILLER._..,•_.______._._._._..._.__._..___._._..._...._....... _......
._.._
' WELL TESTS: CHEMICAL DATE APPROVED.__.___.—_____.._..
BACT 'RIA �.- DAlE FIPPROVED..__.......•...._............___.....
BACTERIA I DATE APPROVED-
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSUE YES N
DATE ISSUED �/ 3� /� �/ _BY____G
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID ( ,.�� NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL zZE-7 NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
r4
FINAL BOARD OF HEALTH APPROVAL: DATE:_BY:_____.,___._._,__,__.
(E ., • N
SEPTIC S7A4.. A.
S_Y_STEML.._ L. N
k.. _ _._L...
... ..
IS THE INSTALLER LICENSED?
CiED NO
,,
1 TYPE OF CONSTRUCTION:
NLW REPAIR
s,,•. ,,..',: NEW CONSTRUCTION: CERTIFIED PLOT PLAN
REVIEW YES NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT
NO
DWC PERMIT N0.
INSTALLER:
C/
•',.., BEGIN. INSPECTION
EXCAVATIONS INSPECTION: NEEDEll:%,'�/i'�t/'
—
---------- -----
rs ,PASSED
1
_
i .1
INSPECTION NEEUEU
..-CONSTRUCTION a
,•t4 ..� ,, . ,;; - ; ,. !
..
1p
t'.
' AS BUILT PLAN SATISFACTORY:
L�'
1
APPROVAL TO BACKFILL: DATE: _
_.BY...... __._...___.._.._________
� {:'`:;•' FINAL GRADING APPROVAL: DATE
1'; 1
FINAL CONSTRUCTION APPROVAL:
DATE: --------
r0
46PIF,- -WIN-
Date ...C�...9110.6 ........
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
7
This certifies that ..... '"!......r .....................................
iI
has permission to perform ....... ........................... .
wiring in the building of .... f . .....................................
. ... W.Ad..,
at ... ......................... . North Andover,,.ass.
2�Fee ...b' ........... Lic. N
I ... P ELECTRICAL �I
Check #
6704
Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No. o 7e
- -
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 9/051 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: � I— O�p
City or Town of: Al, /_/n/ Dyg—o , To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) I Y3 Ve- ?
Owner or Tenant ��ya Cs"00v\0 Telephone No. 7 y'- 17"
Owner's Address 5.— t* 1; 8 7- d! t �
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appr priate Box)
Purpose of Building
Existing Service Amps Volts
New Service Amps / Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Utility Authorization No.- f�/i�
Overhead Ele Undgrd R No. of Meters
Overhead ❑ Undgrd ❑ No. of Meters
Coniplehon o%the following table may be waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ceff. Susp. (Paddle) Fans
o. of Tota
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ❑ - ❑
rnd. rnd.
o. o Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches
No. of Gas Burners
o. o Detection an
Initiating Devices
No. of Ranges
No. of Air Cond. Total Tons
No. of Alerting Devices
No. of Waste Disposers
HeatPump
Totals:
Number
I
Tons
1 11
KW
No. of Se-IT-Co—n-t-aln—ed
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local ❑ umcipa ElOther
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No, of Devices or Equivalent
No. of Water KW
Heaters
o. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or E uivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
a ecommunications irmg:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
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 ❑ BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties ofp rjury, that the information on this application is true and complete.
FIRM NAME: ToeS LIC. NO.:
Licensee: �rpk�� �,c�/ ��} Signature LIC. NO.:
(If applicable, entt exem t" in the lice se n�.) Bus: Tel. No.• ??f 4
Address: ''1 � ! S O ��u Alt. Tel. No.:
*Security System Contractor License required for this wo k; if applicable, enter the license number here:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
-j
N
J o w W
�a cc
O y
v� z Z
® f z �I
a Q 4
Lu
N �► �' W `�J
14
z � �
I�
aC V t- H
W z
ca
�..t L
m N rJ�
W UOW a
z w
O Co a
IL H
w C W
a Z w
U.
J N z FW -
N
Fw-
00 N V D
Q N
D N
W
V
H
H
co
_
°
N
aUl
c
G
v2C;
X
o
V�cd�
yyQ
W
�tWO.
=^
N�
LU
NZQ�
°
..
z
U.
a
4
o
„M
ii
Q.
m
;
a
CO
J00
W
4
W
�..
W
Z^
Z
o
N
N2�
p
W
co
v
-j
N
J o w W
�a cc
O y
v� z Z
® f z �I
a Q 4
Lu
N �► �' W `�J
14
z � �
I�
aC V t- H
W z
ca
�..t L
m N rJ�
W UOW a
z w
O Co a
IL H
w C W
a Z w
U.
J N z FW -
N
Fw-
00 N V D
Q N
D N
W
V
Commonwealth of Massachusetts
City/Town of NtA, , jkd04_M
System Pumping Record
Facility Information:
System Location:
3
Address
�All &(17"4 $4
City/Town State
System Owner:
pa. (-v--
Name:
Adress (if different from location of pump)
RECEIVED
JUN 2 0 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Zip Code
City/Town State Zip Code
5-2Telephone Number
Pumping Record
Date of Pumping 1 i'2, Quantity Pumped (� -S-0C:>gallons
Type of System _,>( Septic Tank Grease Trap Other (what)
System Pumped by: bay.p tvA��
Company: ROOTER -MAN 46 Portland Street Lawrence, MA Ol 843
Location where contents were disposed: (� z-
2
-
Signature of Hauler < Date
Town of North Andover
Health Department %/ Date:
Location: 15✓ vL''�
(Indicate Address, if Residential, or Namcxf usiness)
Check #: .410 ,4 �O '
Type of Permit or License: (Circle
z
➢ Animal $�/
➢ Dumpster $
➢ Food Service - Type: $
➢ Funeral Directors $
➢ Massage Establishment $
➢ Massage Practice $
➢ Offal (Septic) Hauler $
➢ Recreational Camp $
➢ SEPTIC PERMITS:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
➢ Sun tanning $
➢ Swimming Pool $
➢ Tobacco $
➢ TrasIVSolid Waste Hauler $
➢ Well Construction $
➢ OTHER: (Indicate)
zi , ✓�
Health Agent Initials
1556
White - Applicant Yellow - Health Pink - Treasurer
➢ OTHER: (Indicate)
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
c� a
r
Town of North Andover
Health Department Date:
G
/,U �/ `�
Location:
y -"
(Indicate Address, if Residential, or Nam of
usiness)
Check
#• alo
Tyne
of Permit or License: (Circle�.t .41
➢
Animal'-jj��
$
)0,
Dumpster
$
➢
Food Service - Type.
$
➢
Funeral Directors
$
➢
Massage Establishment
$
➢
Massage Practice
$
➢
Offal (Septic) Hauler
$
➢
Recreational Camp
$
➢
SEPTIC PERMTT$:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC) $
❑
Septic Disposal Works Installers (DWI)
$
➢
Sun tanning
$
➢
Swimming Pool
$
➢
Tobacco
$
➢
TrasWSolid Waste Hauler
$
➢
Well Construction
$
➢ OTHER: (Indicate)
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Commonwealth f Massachusetts
City/Town of 6d1 N�
System Pumping Record
Facility Information:
System Location:
Address
City/Town
System Owner:
PC, dL
Name:
Aaress fir clitterent from location of pump)
State
AUG 03 2015
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
M66
Zip Code
Lity/ I own State Zip Code
Telephone Number
Pumping Record
Date of Pumping Quantity Pumped c�0 gallons
Type of System_�_Septic Tank Grease Trap Other (what)
System Pumped by:
Company: ROOTER -MAN 46 Portland Street Lawrence, MA 01843
Location where contents ere d'posed:
Signature of Hauler Date /
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
r` Subsurface Sewage Disposal System Forme
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6115/2000. Inspection forms may not be altered in any way. Mr, f- ,IIT%—n
N . Timothy White
Name of Inspector
Homepro North shore
Company Name
PO BOX 101
Company Address
ROWLEY
Cityrrown
1-978-948-8428
Telephone Number
Ma.
State
4-27-06
Date
Ma
State
MAY 11 2006
OF NORTH ANDOVER
01845
Zip Code
01969.
Zip Code
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 ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspector's Signature
4-27-06
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.
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 1 of 16
A. Certification
Important:
When filling out
1. Property Information:
forms on the
computer, use
183 Vest Way N.Andover
only the tab key
Property Address
to move your
Kwang Oh
cursor - do not
use the return
Owner's Name
key.
183 Vest Way
Owner's Address
N. Andover
1Im
Cityrrown
Date of Inspection:
2. Inspector:
N . Timothy White
Name of Inspector
Homepro North shore
Company Name
PO BOX 101
Company Address
ROWLEY
Cityrrown
1-978-948-8428
Telephone Number
Ma.
State
4-27-06
Date
Ma
State
MAY 11 2006
OF NORTH ANDOVER
01845
Zip Code
01969.
Zip Code
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 ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspector's Signature
4-27-06
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.
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
low
Subsurface Sewage Disposal System Form
A. Certification (cont.)
183 Vest Way
Property Address
N. Andover
City/Town
Kwang Oh
Owner's Name
Ma
01845
State Zip Code
4-27-06
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:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 2 of 16
Commonwealth of Massachusetts
-- . Title 5 Official Inspection Form
Not for Voluntary Assessments
r` Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
183 Vest Way
Property Address
N. Andover Ma
City/Town
Kwang Oh
Owner's Name
B) System Conditionally Passes (cont.):
State
4-27-06
Date of Inspection
01845
Zip Code
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
[,L
❑ 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:
NA
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
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
° Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
183 Vest Way
Property Address
N. Andover
CitylTown
Kwang Oh
Owner's Name
Ma
State
4-27-06
Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
01845
Zip Code
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: NA
** 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:
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 4of16
Commonwealth of Massachusetts
ug
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
l
A. Certification (cont.)
183 Vest Way
Property Address
N. Andover Ma 01845
City/Town State ZipCode
Kwang Oh 4-27-06
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 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 Y2 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
❑ ®
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.
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official 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.)
183 Vest Way
Property Address
N. Andover
Cityrrown
Kwand Oh
Owner's Name
Ma.
State
4-27-06
Date of Inspection
01845
Zip Code
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.
Shortcut to TITLE V.Ink.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
183 Vest Way
Property Address
N. Andover Ma 01845
City/Town State Zip Code
Kwang Oh 4-27-06
Owner's 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
® ❑
El 0
® ❑
® ❑
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(3)(b)]
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: 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
183 Vest Way
®
Property Address
❑
N. Andover
Ma 01845
Cityrrown
State Zip Code
Kwang Oh
4-27-06
Owner's Name
Date of Inspection
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): 600gpd
Number of current residents:
3
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 ears usage
9 ( Y 9 (gpd))
04 & 05 168300
gal=230gpd
Sump pump?
❑
Yes
®
No
Last date of occupancy:
still
occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
❑
Yes
❑
No
Industrial waste holding tank present?
❑
Yes
❑
No
Non -sanitary waste discharged to the Title 5 system?
❑
Yes
❑
No
Water meter readings, if available:
Last date of occupancy/use: Date
Other (describe):
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
183 Vest Wa
Property Address
N. Andover
Ma 01845
City/Town
State Zip Code
Kwang Oh
4-27-06
Owner's Name
Date of Inspection
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
last pumped 2001 year Information from owner
gallons
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Yes ® No
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
Approximate age of all components, date installed (if known) and source of information:
13 years old information from owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
lug
Subsurface Sewage Disposal System Form
C. System Information (cont.)
183 Vest Way
Property Address
N. Andover
Ma. 01845
City/Town
State Zip Code
Kwang Oh
4-27-06
Owner's Name
Date of Inspection
Building Sewer (locate on site plan):
12in
Depth below grade:
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: 8ft from incoming water line to
outgoing sewer line
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints & venting good condition no evidence of leakage
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
4in
feet
® 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 ❑ Yes ❑ No
certificate)
Dimensions: 1Oft 6in long - 5ft deep - 5ft wide
1500gal
Sludge depth: lin
Distance from top of sludge to bottom of outlet tee or baffle 31 in
Scum thickness lin
Distance from top of scum to top of outlet tee or baffle lin
Distance from bottom of scum to bottom of outlet tee or baffle 18in
How were dimensions determined?
rulers & measuring rod
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection 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.)
183 Vest Wav
Property Address
N. Andover Ma 01845
City/Town State Zip Code
Kwang Oh 4-27-06
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tank was not pumped inlet baffle in good condition rear baffle in good condition - liquid at bottom of
outlet invert no sign of leakage in or out of tank
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
feet
❑ 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.):
NA
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Shortcut to TITLE V.Ink.doc • 11/2004
NA
❑ fiberglass ❑ polyethylene ❑ other (explain):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
° Not for Voluntary Assessments
r` Subsurface Sewage Disposal System Form
N
C. System Information (cont.)
183 Vest Way
Property Address
N. Andover
City/Town
Kwang Oh
Owner's Name
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
MA. 01845
State Zip Code
4-27-06
Date of Inspection
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date
Comments (condition of alarm and float switches, etc.):
NA
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 was level - distribution was equal - no evidence of any solids carryover - no sign of leakage in
or out of d -box - d -box was 22in below grade - size of d- box 29in x20 in - inside depth 15in
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
❑ Yes ❑ No
❑ Yes ❑ No
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface 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.)
183 Vest Way
Property Address
N. Andover
Ma
Cityrrown State Zip Code
Kwang Oh 4-27-06
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
01845
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
dry sand soil - no hydraulic failure - no ponding - system was under front lawn
Shortcut to TITLE V.Ink.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 13 of 16
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
®
leaching fields
number, dimensions: 1 field 41 ft x 28ft1148 sq ft
❑
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.):
dry sand soil - no hydraulic failure - no ponding - system was under front lawn
Shortcut to TITLE V.Ink.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
r` Subsurface Sewage Disposal System Form
C. System Information (cont.)
183 Vest Way
Property Address
N. Andover Ma 01845
City/Town
Kwang Oh
Owner's Name
State
4-27-06
Date of Inspection
Zip Code
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.):
na
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 14 of 16
ShW#t,UL w I I I LC v.mR.aoc - i uZuu4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 15 of 16
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Not for Voluntary Assessments
r` Subsurface Sewage Disposal System Form
C. System Information (cont.)
183 Vest Way
Property Address
N. Andover
Cityrrown
Kwana Oh
Owner's Name
Ma.
State
4-27-06
Date of Inspection
01845
Zip Code
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.
p
Commonwealth of Massachusetts
— . Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
1641 oswich Rd
Property Address
Boxford Ma. 09121
Cityrrown State Zip Code
Jianhong Zheng 4-15-06
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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
❑ 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 how you established the high ground water elevation:
from last title 5 report showed ground water at72in
Shortcut to TITLE V.Ink.doc -1112004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System -
Page 16 of 16
•bt1 t,w.'V^k^r; q �"`.r'` d-a'y'drei tst. ; y „it'I`.7 y,'><F r r. y Kt,µ '0�.4.•.ra w y.Y' ar'„dgr ;!a ! Milt bpi 't•h �,ay •f
�shyt: �' r5 l,. h a��:i�:�'7�-Vt _ •y `n 4�
� ��`.' 'iy�d�+"t,X�., Nt yRw�, i � d �" 1a d - t��r }SS..• c, '"';�a ��i.;. rt �.
11uS
r
jJMSAC ETTS _ _
CcObIlvIONWEALTH _
CUT'I-(` 10EZ3F:
bEPARTMENT-OF ENVIRANNYMAL PRO
pt -WINTER -STREET, 'BOSTON -MA -02-1d8 -(617) .292-5500----- --- -- - — _--- - ---
_.TRUDY-CO%E
.4K Secretary
--DAVID - B. STRUHS.
ARGEO PAUL CEIi"PocI Com unissioner.
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
..-.,
-.A...— Ak_ kilnOV IA rtlmne of OvmerfiJ (7 vqz;
Date of Inspection: � ` (-(90r
Name of Inspector: (Please Print) �l G1�►1�5 ' oor z�
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000)
Company Name: ) &rR[2tKS St -0 rC l �ctfn
Mailing Address: B 1WrKmny 4vc. 1 at"c43Nr I(
Telephone Number: (9''L '�7�L IS03
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails // q
Inspector's Signature: Lv�
( Date: b •• ! " C9 0
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
sys
revised 9/2/98 Page l of 11
hi Pnntea on Recycled Paper
c t _
j[ISPEC710N FORM _ -
---- — - A�DISROSAL S1lS - - — -
-t— -
- A Ea5E1N�
_ SURF - —
_.._ _ _-CERTIFICATION (continued)
"peirtrAddress: �3 VtgWAI
o -nes:.— r, . Ak Y*�i -- - - - — -- -- - - -
Date of inspection:
WSPECTIWsUMMARY: 6-
A. SYSTEM PASSES:
information which+ndicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
7� I have not found any
—tom' criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDMONALLY PASSES: the
One or more system components as described roved by thetBoard oional f Health, will passs.. section need to be replaced or repaired. The system, upon
completion of the replacement or repair, PP
s the owner or operator has provided the system inspector with a copy
of a Certificate of
ain w hy not.
Indicate yes, no, or not determined (Y, N. or ND). Describe basis of determination in all instances. loa"not
s t dto 'he date oflthe inspection; or
_ The septic tank is metal,
unless
Compliance (attached) indicating that the tank was installed within twenty shows
Y prior
the septic tank, whether or not metal, iss rkdstrrfcturahe lllxisting sepsound t
approved
is replaced wthra complying ls ptic tankas
failure is imminent. The system will pasinspection
approved by the Board of Health.
stem will pass inspection if (with approval of the Board of
_ Sewage backup or breakout or high statir'Ibut level
system in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven dist
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ year due to broken or obstructed pipe(s). The system will pass
The system required pumping more than four times a
inspection if (with approval of the Board of Health):
broken pipels) are replaced
obstruction is removed
Page 2 of 11
revised 9/2/98
w
T^ F4+
Sisk
1
c t _
j[ISPEC710N FORM _ -
---- — - A�DISROSAL S1lS - - — -
-t— -
- A Ea5E1N�
_ SURF - —
_.._ _ _-CERTIFICATION (continued)
"peirtrAddress: �3 VtgWAI
o -nes:.— r, . Ak Y*�i -- - - - — -- -- - - -
Date of inspection:
WSPECTIWsUMMARY: 6-
A. SYSTEM PASSES:
information which+ndicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
7� I have not found any
—tom' criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDMONALLY PASSES: the
One or more system components as described roved by thetBoard oional f Health, will passs.. section need to be replaced or repaired. The system, upon
completion of the replacement or repair, PP
s the owner or operator has provided the system inspector with a copy
of a Certificate of
ain w hy not.
Indicate yes, no, or not determined (Y, N. or ND). Describe basis of determination in all instances. loa"not
s t dto 'he date oflthe inspection; or
_ The septic tank is metal,
unless
Compliance (attached) indicating that the tank was installed within twenty shows
Y prior
the septic tank, whether or not metal, iss rkdstrrfcturahe lllxisting sepsound t
approved
is replaced wthra complying ls ptic tankas
failure is imminent. The system will pasinspection
approved by the Board of Health.
stem will pass inspection if (with approval of the Board of
_ Sewage backup or breakout or high statir'Ibut level
system in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven dist
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ year due to broken or obstructed pipe(s). The system will pass
The system required pumping more than four times a
inspection if (with approval of the Board of Health):
broken pipels) are replaced
obstruction is removed
Page 2 of 11
revised 9/2/98
yft{•�M yt„ �t �f.�R- _.. ^S'T ��at`F `��`.5�.,s�
q- 4'aw'Lc$ 'S•... `
�y
� 4`
i. , i5", "vA' rh v, ]Py uPi�'fc.. � 'F y.. } 'C H �
t
•iT ° +'V "'l,t
ii r
{. `FfT� t��S��cS
`i,
,
r
Ownrroper: �t A
owner: 21
Date oflnspeetioe -6=it.00 - - - - --- -. ..
r ER_EVALUATION_IS_REQLII IED 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 the
public health, safety and the environment. "
1) SYSTEM WILL PASS UNLESS -BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEMA
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 faet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, 1F ANY) DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 P2ge3of11
54 14F
4
0
rY3t}t1r"�"'
O
SUBSURFACE_SEY_AGEDISPOSAL-SYSTEM-INSPECTION FORM._
CERTIFICATION :(continued)
V f
y
Property Ad&eu; ---- -
Owner: cal .fJ-J�12:1
Date of Inspection: 4-Ckoo
D. SYSTEM FAILS:
You must indicate either "Yei" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as describgd in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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.
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98
Page 4 of 11
�„
7. e3
ACEs _GE_DISPOSAL SYSTEM WSPEC110N FO
— ---- -..
_ �B
_ - CHECKL{ST.- -- . ---- - -
property Address:
--
owner: rfLl-_ -- ----- _ _
Date of unpection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of ,he following:
Yes N ,
Pumping information was provided by the owner; occupant, or Board of Health.
wee ks
nd
he
ystem
as
ving
_ None of the system components
have been volumes of warter have not been at least tintrodu ed in otthessystemh recently oerc s` part of this flow
rates during that
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non -sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System; have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
_ nts, if different from owner) were provided with information on the proper maintenance of
The facility owner land occupa
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
;f v SUBSURFACESEWAGEDiSPOSAI SYSTEM INSPECTION FOR
_�_e�.�..__—. -----
_7
- -_.._ ----- -- SYSTEM=INFORMp�ION- --- -----
..
'►air -A:_ -- -__.._
Owr>er- � 1 A Z► —
Date of 4rspectIM — 9-dn
FLOW CONDMONS
Design, flow;_ I g.p.o.mearo m.
Number. of.bedrooms (design): *7 Number of bedrooms (actual):
Total DESIGN flow ('$-
Number of curren sldents: --
Garbage grinder as or*-
,LL
(separate ystem) lyes or t�o If as, separate inspection required '
Laundry system inspected a or no)
Seasonal use lyes or®:_
Water meter readings, if available (last two year's usage (gpd): A/�
Sump Pump (yes or�
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: apd ( Based on 15.2031
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of infoQrmation: 2(;tv1fi
System pumped as part of inspection: (yes or n _
If yes, volume pumped: 5'00 gallons I
Reason for pumping: �'f eac Sof,Aj
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: �tc�t�� fy 4h
Sewage odors detected when arriving at the site: (yes or(D —
revised 9/2/98 P2ge6of11
• �� Ip ti iN42 ''f�Jll 4
a � ���}s;
# 1 �ii4Ci k °
'Y.2
�,y (•�. i "�.. 4 .'
(yyt+r ,4.••`� jl� x� -
V
yh x.y aixi -�.
a n
s q��.
...` �,__. _
BUILDING SEWER:
ocate on site pian
Depth below grade:_
Material of construction: cast iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: Aoncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age — Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions: G X S% r S Is /I
'"
f
Sludge depth: /
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of 0tlet tee or baffle:
How dimensions were determined: %►K 1
•omments:
(recommendation for pumping, condition of inlet and outlet tees orb ffle �depj� of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) Alt, C K5 .'.I mv4 Sou tlZ- pyw�0 V�Fethh/
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7of11
5T5ILm lmrvnNwIawn tcanuw+wr
i --may-Address:-
own
A by
er: �<
Data of Inspection:. 6—
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments: -- .
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: `
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evi ence of solids carryover, evidence of leakage into or out of box, etc
k.440 0 P 1344 �)L10 . 00'skwq A L- tK > n_ C��r� l s in cmc, S
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 P2ge8of11
e � � Sr�� ( w {.y�x rL;flax u�3. +Y r,i r{',�.'""F'R���'$ ��, r-k� d�',M"? ?� cs; •..�5 w
a
- — CE.SEWAGE DISFA
SAL -SYSTEM INSPECTION FORM A. SUBStA-
_ .._�-'U.
-- _ —• _ _-- -
SYSTEMINFORMATIOtT
toperty Address:
Jwrner: F-40
Date of Inspection:- - . / �9- 0 0
SOIL ABSORPTION SYSTEM (SAS):_ roximated by non intrusive methods)
-- -06dh srt-"lan,-ifpossible:excavation-not-required,-Iocatio.n_m-oY__be_PFp._._.
If not located, explain:
Type.
leaching pits, number:_
leaching chambers, number:,_
leaching galleries, number:_
leaching trenches, number, length:�/
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition vege`ta�on,ec. VrOe
�tlk/ SOIL WFIS OPV `14��oi (eve i,n � M& OVIAV
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
-)epth of solids layer:
epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Dimensions:
Materials of construction:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
t w r wr�a fi l x ! U. 10 1
— - ---SUBSURFACE SEWAGE D(SPO,SAL SYSTEM ,WSPECTION FORM
SYSTEM INFORMAtf6g. (contirtued)T-
�ropertY Address: f
Owner . �cc� A�
4z;
'--------
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or -benchmarks
locate all wells within 100' (Locate where public water supply comes into, house)
TO -r
.9-- 70 D = 5_
A iv D
r'Qr
b,
i r
A
revised 9/2/98 P2ge10of11
,
:.SUBSURFACE SEWAGE DISPOSAL $YSTEM INSPECTION FORM--
- - SYSTEM INFORMATION (cGOU64 84
�operty
4WID VCIL - - — - - ---- - - "---
Date of Inspection:
-NRCS Report name---- —"----------- - - --
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater _ Feet Ro wq/e& dks-CAV'(CA
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
14, Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
R,/ I h"- P)Okn
revised 9/2/98 Page 11 of 11
°
BOARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32 or 33
October 4, 1990
Mr. Al Shaboo
Design Engineering
168 Pleasant St.
No. Andover, MA 01845
Re: 28 Vest Way
No. Andover„ MA 01845
Dear Al:
At the September 27th, 1990 meeting of the North Andover
Board of Health, the Board voted unanimously to grant a variance
to the local Board of Health Regulation 4.18 relative to the
Separation Distance from a Leaching Facility and Wetlands for Lot
28 Vest Way.
The variance was granted with the following conditions:
J1. That the active leaching facility be installed no closer
than 75 ft. to the wetlands.
2. That a fill and excavation easement be obtained on Lot
27 Vest Way to accommodate the required grading and
excavation for the construction of the system on Lot 28
Vest Way. The easement shall be recorded at the
Registry of Deeds and evidence of such submitted to the
Board prior to the issuing of the Building Permit
for Lot 28.
3. That the limits of the topsoil and subsoil excavation
occur in conjunction with the foundation hole
excavation. The bottom of excavation shall be inspec
and approved by the Board of Health and filling of
excavation with replacement material shall begin py
to the pouring of the house foundation.
4. That the proposed septic plans to be revised and
submitted to the Board of Health for constructic
approval along with -the required filing fee.
Shaboo
October 4, 1990
Page 2
Should you have any questions regarding this matter, please
do not hesitate to call.
Very truly yours, `
ohn S. Pizza D If,
Chairman
Board of Health '
1
0
310 CMR 10.99
Form 5
-- Commonwealth
of Massachusetts
-4-
Lots 28 & 29 Vest Way
1 'L, G• (/ C1"
DEP Fire No. 242-529
(to be awaM1 by DEP)
C ry,lown North Andover
Aopricarir J.R.-Realty Trust
Order of Conditions
Massachusetts Wetlands Protection Act
G.L. c. 131, §40
and under the Town of North Andover's Bylaw Chapter 3.5
From NORTH. ANDOVER CONSERVATION COPIMISSION
To J.R. Realty Trust—Ralpti Ciardiello, Lot 28 (Applicant) — Lot 29 Crestward Devel.
(Name of Applicant)
Trustee (Name of property owner)
47 Royalston Road,
Wellesley, MA 02181 Address 145 Pleasant St., North Andover, MA
Address -
This Order is issued and delivered as follows:
O by hand delivery to applicant or representative on
(date)
by certified mail, return receipt requested on July 18, 1990 _ (date)
This project is located at Lots 28 & 29 Vest W
The property is recorded at the Registry of Nnrrhnrn Essex
Lot 2$ 2142 24
Book Lot 29 2480 Page 91
Certificate (if registered)
The Notice of Intent for this project was filed on April 25 1990 (date)
The public hearing was closed on June 27, 1990
(date)
Findings
The North Andover Conservation Commission has reviewed the above-relerenced Notice of
Intent and plans and has held a public hearing on the project. Based on the rnlormatron avarlaDle Ie the
NACC at this time, the NACG has determined that
the area on which the proposed work is to be done is significant to the following interests in accoroance with
the Presumptions of Significance set forth in the regulations for each Area Subject to ProteC!ion Under fire
Act
/(check as appropriate):
L!d Pubiic water supply L✓J/ Flood control ❑ Land containing shellfish
Private water supply Storm damage prevention -Fisheries
Ground water supply Prevention of pollution Ld Protection of wildlife habitat
Total Filing Fee Submitted
City/Town Share
Total Refund Due S
$250.00 State Share $112.50
$137.50 (1/2 lee in excess of 1,25)
Cily(Town Portion S State Portion S ___
('/z total) ('i2 total)
Order of Conditions #242-529. Lots 28 & 29 Vest Way
PROJECT INFORMATION
The following plans and information were available to and
reviewed by the NACC in reaching its decision:
a. Notice of Intent submitted by J.R. Realty Trust,
dated April 25, 1990 (19 Pages);
b. Plan: "Site Development Alternatives Lots 27-29
Vest Way" dated 6/11/90 drawn by Design Engineering;
c. Plan: "Definitive On -Site Sanitary Waste Disposal
System for Lot 28 Vest Way", dated 2/15/88 drawn
by Design Engineering Inc.;
d. Plan: "Proposed Site Alterations, Lots 27-29 Vest
Way" dated March 1990 drawn by Design Engineering
Inc.;
e. May 21, 1990 letter from Essex County Greenbelt
Association to NACC (2 pages);
f. June 4, 1990 letter from Mallett Associates Inc.
to Alfred A. Shaboo (4 pages);
g. June 11, 1990 letter from Design Engineering to
Nacc (3 pages).
FINDINGS;
1. The following wetland resource areas are affected by the
proposed work: bordering vegetated wetland, and its associated
buffer zone. These resource areas are significant to the
interests of the Act and Town Bylaw as noted above. The
applicant has not attempted to overcome the significance of these
resource areas to the identified interests.
2. The NACC agree with the applicant's delineation of the
wetland resource areas at the site.
3. The NACC takes notice of the Town's Board of Health
requirement under Title 5 that septic systems be set back at
least one hundred (100) feet horizontally from the boundary of
the agreed resource area. The NACC also notes that on occasion a
variance may be granted from that requirement. 10.03 (3) of 310
CMR provides that a septic system constructed in compliance with
Board of Health requirements shall be presumed to protect the
interests identified in the Act only if none of the components is
located in a resource area. The applicant has not overcome such
presumption.
4. The applicant was denied a variance from the 100 ft.
requirement.
5. The applicant proposes filling Bordering Vegetated.Wetland in
order to fulfill the 100 foot setback requirement. However the
applicant's engineer stated that such filling would not effect
groundwater levels. Therefore the applicant has failed to
persuade the NACC that such filling would not effect pollution
Further, the applicant has not persuaded the NACC that such
filling would not have an adverse effect on the remaining
bordering vegetated wetland when in such close proximity to
steeply sloped filling. As is noted in 310 CMR 10.55, a
bordering vegetated wetland is "...most probably the
Commonwealth's most important inland habitat for wildlife."
DECISION•
For the reasons set forth above, the NACC denies this Notice of
Intent. However, the NACC has not considered and does not rule
on at this time other activities which are of a different size,
materials, location, design or type which the Applicant may
propose at a later date. The applicant can file a new Notice of
Intent proposing a smaller project, different design, or
different location.
#242— 529
Issued By N
SignatLre,(s)_
RTH tODOVGR _
10
Lots 28 & 29 Vest Way
Conservation Commission
This Order must be signed by a majority of the Conservation Commission.
On this 11 th day of July 19 90 , belore nue
personally appeared Paul L. Tariot , to me knowtu to be the
person described in and who executed the foregoing instrument and acknowledged that helshe executed
the same as his/her free act and -deed.
Public
September 9, 1994
My commission expires
The applicant, the owner, any person aggrieved by this Order, any owner of land abulting the land upon which Ure proposed work is to be
done or any ten residents of the city or town In which such land is located are hereby notified of their right 10 request Ure Ihy,arlment of
Environmental Quality Engineering to issue a Superseding Order, providing the request is made by certified mail or timid delivery to the
Department, with the appropriate filing fee and Fee Transmittal Form as provided in 310 CMR 10 03(7), within len days him the date of
Issuance of this Order. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation
Commission and the applicant.
If you wish to appeal this decision under the Town Bylaw,
a complaint must be filed in Superior Court.
North Andover Conservation Colum• rlorloconunencemenlolwork.
Detach on dolled line and submit to the —_..___.__—.__.__._.__. _.. P
...................................................................................................................................................................................................................
To Issuing Aulhonly
Please be advised that the Order of Conditions for the project at Lots --28---&-29 _28_&_29 Vest Waw___.__._______
File Number 242 —= ? % has been recorded at the Registry of Deeds and
has been noted in the chain of title of the alfecled properly In accordance will General Cut Wilton Bon___._
II recorded land, the instrument number which identifies this transacl on
It registered land, the document number which idenhlres this transachon is
Signature _.__-- Apphr.anl
BOARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32 or 33
October 4, 1990
Mr. Al Shaboo
Design Engineering
168 Pleasant St.
No. Andover, MA 01845
Re: 28 Vest Way
No. Andover, MA 01845
Dear Al:
At the September 27th, 1990 meeting of the North Andover
Board of Health, the Board voted unanimously to grant a variance
to the local Board of Health Regulation 4.18 relative to the
Separation Distance from a Leaching Facility and Wetlands for Lot
28 Vest Way.
The variance was granted with the following conditions:
11. That the active leaching facility be installed no closer
than 75 ft. to the wetlands.
2. That a fill and excavation easement be obtained on Lot
27 Vest Way to accommodate the required grading and
excavation for the construction of the system on Lot 28
Vest Way. The easement shall be recorded at the
Registry of Deeds and evidence of such submitted to the
Board prior to the issuing of the Building Permit
Jfor Lot 28.
3. That the limits of the topsoil and subsoil excavation
occur in conjunction with the foundation hole
excavation. The bottom of excavation shall be inspected
and approved by the Board of Health and filling of
excavation with replacement material shall begin prior
to the pouring of the house foundation.
4. That the proposed septic plans to be revised and re-
submitted to the Board of Health for construction
approval along with the required filing fee.
Shaboo
October 4, 1990
Page 2
Should you have any questions regarding this matter, please
do not hesitate to call.
Very truly yours,
qn S. Rizza D IS,
airman
Board of Health
D•tt ,10 .° •1,O
0 A
��SSAC HUs���y
BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
June 12, 1990
Design Engineering, Inc
P'0 Box 516
No. Andover, MA 01845
Re: Lots 27-29
Vest Way
No. Andover, MA 01845
Dear Al:
TEL: 682-6483
Ext. 32 or 33
This letter is to inform you and your client that the Hoard
of Health will allow the installation of a leaching facility as
close as 50 ft to drain lines associated with Vest Way, provided
that it is necessary to do so to maintain a 100 ft setback from
the edge of wetlands and the leaching facility. Please be
advised that the leaching facility should be placed as far from
the drain lines as possible, while still providing for the 100 ft
setback from wetlands.
Should you have any questions regarding this matter, please
do not hesitate to call.
Very truly yours,
Zchae� Rosat i
Acting Health Agent
MR/rel
GCORD of HFO,-IT,
N ol�TH iQ ) IPVEi,� , MA ,
L -OT 10 UeS- fly 6p, � .
pPLi Citi I. G1Z rwOOD 96
wATE� Sc� PF'L7 , 3-rbwnl D wEU ,�P ouCD lyOTc
ST
EAj
P,ar6' y- z, -8F APRZOvPJG Aurho,�,ry
��15APPxov� 5 D
IF 5t4 5
DgiE
FA � G&006rt 4WA`/ Fido'O
R (15oNS : i 1� �l�t't�5 5 w�MQ >
T&Zr65 Ca)( -P 3e- "5 ierpO t-vwti 11 to Fl i 50245-
D� (� ScPT•c c SYSTEM ► � STA t.�.,QTioiU
EYCAV4TcolJ 1NSf'eGTio&j 94rC
Q P45S ❑ F41t_
Fin'A� I V5P6—�-rloo PIPE F1 -20t -A NvcJ -Fo -W O r L1 Pry S5 J--7 R)L
4PPROOED U/3TC
f NSli01,1,G(i
AVDITIOMAL, I' -Ybb - fo"5 (11=- W I)
DlSAPPl?O\J D DA T-5
R�O�s NS •,
FVAL APPROVAL
D,oTc APmwVJG � � ► Ho l ry
MORTH 1
SSACNUSES
Applicant
Site Location
Town of North Andover, Massachusetts
BOARD OF HEALTH
occo�� 14 19
DISPOSAL WORKS CONSTRUCTION PERMIT
Form No. 3
Permission is hereby granted to Construct (L,),,6r Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
l CHAIRMAN, BOARD OF HEALTH
Fee vv D.W.C. No. 579(
OT -�8 h -_ST" &)1-2 K
AS -BUILT CHECK LIST
and
FINAL INSPECTION
Proposed Elevations As -Built Elevation
Trench Inverts
Line 1 tgq,s7- 14q-ao
Line 2
149, )8
Line 3
Line 4 _ 14G. 18
Bottom of Exc. /-¢7,
Stone OK? t/ D -box checked? ✓ Pipes cemented?
House
Tank IN�-
Tank OUT
q q , 94-
¢D-box
D-boxIN
144.74
144, 7
D -box OUT
/4q, -5-7
/4q, J_
Trench Inverts
Line 1 tgq,s7- 14q-ao
Line 2
149, )8
Line 3
Line 4 _ 14G. 18
Bottom of Exc. /-¢7,
Stone OK? t/ D -box checked? ✓ Pipes cemented?
I
Ll
LI sm
V V
�o
'Mz
0
z
V=4
LU
CL
rr
z
w
x., W p
CL. 96V
li \ Z •"J • H IV
m C C6.� .o W CD j— ` O
E C p' ft 0 m 3
cc U LL M LL m :A
H
H
E
L
12.
U
r
I~
r�
•
4
C
IV
�r L
� � V
E c a
w E h
C
o c
Z �
O
0
m
d
C
d
Q
�
a
e
=
6a
•O
rn �
U
r
I~
r�
•
4
C
IV
�r L
� � V
E c a
w E h
C
o c
Z �
O
0
m
BOARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH. ANDOVER, MASS. 01845 Ext. 32 or 33
June 12, 1990
Design Engineering, Inc
AO Box 516
No. Andover, MA 01845
Re: Lots 27-29
Vest Way
No. Andover, MA 01845
Dear Al:
This letter is to inform you and your client that the Board
of Health will allow the installation of a leaching facility as
close as 50.ft to drain lines associated with Vest Way, provided
that it is necessary to do so to maintain a 100 ft setback from
the edge of wetlands 'and the leaching facility. Please be
advised that the leaching facility should be placed as far from
the drain lines as possible, while still providing for the 100 ft
setback from wetlands.
Should you have any questions regarding this matter, please
do not hesitate to call.
Very truly yours,
MwChae Rosati
Acting Health Agent
MR/rel
Design Engineering
P.O. Box 516
North Andover, MA. 01845
September 10, 1990
Board of Health
Town of North Andover
120 Main Street
North Andover, MA. 01845
RE: Lot 28 Vest Way
Dear Board Members:
On behalf of my clients, J. R. Realty Trust, I hereby request a
variance from your Board's regulation that requires that the distance
from a subsurface disposal system to the wetlands can not be less than
one hundred (100) feet. I am requesting a variance of not more than
thirty-five (35) feet and in general less than twenty-five (25) feet,
but more specifically so that the system can be installed as shown on
the plans by this office dated, February 15, 1988 and revised September
10, 1990. My reasons for the request are as follows:
1. The corresponding State regulations require that a system
cannot be less than fifty (50) feet from a wetlands. Therefore, at the
varied distance, the system would remain fifteen (15) feet in excess of
those regulations.
2. Design Approval and Disposal Works permits (copies attached
herewith) were obtained in July 1988 based on plans by this office
(previously mentioned and enclosed herewith). The wetlands line
originally shown on those plans was flagged by J. Mallett, PhD, located
by S. Giles, RLS, and its relative distance to the system verified by
M. Graf and myself.
Page 2
September 10, 1990
3. In an attempt to meet your setback requirements, my clients
recently filed a Notice of Intent to fill wetlands on Lot 28 and
replicated them on and thereby sacrifice Lot 29. During these
proceedings, the wetlands line was found to have changed significantly,
to that presently show. The change in wetlands location was
determined, during the public hearings for the Notice of Intent, to be
due to the almost continuous flow through the drain located on the
property line between Lots 28 and 29. The continuous flow is due to
two subsurface drains located on lots across Vest Way. One, belonging
to Dion, and apparently unauthorized, drains the water table. The
other, installed at Mr. Graf's direction, drains surface and subsurface
water from the lot belonging to Ferraro.
4. The system on Lot 28 is located as remote from the adjacent
wetlands as possible, and, as the Notice of Intent demonstrated, the
one hundred (100) feet setback requirement would necessitate filling
and subsequently replicating over four thousand, six hundred (4,600)
square feet of wetlands each.
5. The variance, if granted, would totally eliminate the
necessity to fill wetlands. The filling on Lot 28 is not required in
satisfying disposal system slope requirements or in lot grading for the
dwelling.
6. Although the proposal under the Notice of Intent met all the
requirements of all governing regulations, the Conservation Commission,
in their resulting Order of Conditions, (copy enclosed herewith) denied
the proposal to fill wetlands to meet Town setback requirements. The
Commission's denial is based upon the Board of Health not granting a
variance; when, in fact, none was sought. Apparently the Commission
misinterpreted Mr. Rosati's letter dated June 12, 1990 (copy enclosed
herewith).
7. All other local and State Health criteria are satisfied by
this design. The design of the system remains unchanged from that
originally approved. The wetlands line has been accepted by the
Commission.
8. All slope requirements for the system can be met without
filling the wetlands and the proposed dwelling would separate the
majority of the system from the wetlands. Breakout of leachate and its
related down gradient contamination of the wetlands is highly
improbable. The variance will not jeopardize the wetlands and will
enhance its protection by eliminating its destruction through filling
and the possible damage caused by heavy equipment in replication.
Page 3
September 10, 1990
My clients have owned Lot 28 for over seven (7) years, but have
not developed it for various economic and logistical reasons. The lot
meets all governing zoning criteria and has been taxed as a buildable
lot for the entire period. When they purchased the property, the
wetlands line had been established at a distance significantly more
remote from the system than its present location (see line marked "BVW
per NERD 48012 and DEQE #242-95" on the plan). As recently as 1988,
that line remained over one hundred (100) feet from the system. To
date, Lots 28 and 29 have cost my clients over One Hundred and Fifty
Thousand Dollars ($150,000.00). Without the variance requested, my
clients will suffer a severe economic hardship that will not be
defrayed by the tax rebate should the lot be deemed unbuildable.
Please contact me should you require additional information or
assistance in rendering a favorable decision regarding this request for
a variance.
Thank you for your anticipated cooperation in this matter.
Sincerely,
Al ed A. Sh o, P.E.
Enclosures (4)
hurfit Nu. J
Town of North Andover, Massachusetts
BOARD OF HEALTH
pIs*
o�,4.._,•�tio 19
o s
M
• s ,.,T i
DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant C5� &44 D AGV I ADDRESS TELEPHONE
NAME
Site Location L6 r. Zd VES%
Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
Ido
Fee
CHAIRMAN, BOARD OVHEALTH
D.W.C. No. %
Applicant C c rwARV DQV Test No
Site Location Lor 27 VEST WA`t
Reference Plans and Specs. SMn &- 42
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CH RMAN, B D Of HEALTH
Fee gv
Site System Permit No. /
N
Town of North Andover, Massachusetts form N& 2
BOARD OF HEALTH
41
DESIGN APPROVAL FOR
'`CMU `
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant C c rwARV DQV Test No
Site Location Lor 27 VEST WA`t
Reference Plans and Specs. SMn &- 42
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CH RMAN, B D Of HEALTH
Fee gv
Site System Permit No. /
N
P
310 CMR 10.99
Form 5
w+
.__ Commonwealth
of Massachusetts
Fro
DEP Fib No. F242-529
(lo be vvoby DEP)
Ciry,Town North Andover
ADWIC-Inr J.R.-Realty Trust
Lots 28 & 29 Vest Way
Order of Conditions
Massachusetts Wetlands Protection Act
G.L. c. 131, §40
and under the Town of North Andover's Bylaw Chapter 3.5
NORTH ANDOVER CONSERVATION CORiIISSION
To J.R. Realty Trust —Ralph Ciardiello,- Lot 28 (Applicant) — Lot 29 Crestward Devel.
(Name of Applicant) Trustee (Name of property ownerl
47 Royalston Road,
Wellesley, MA 02181 Address 145 Pleasant St., North Andover, MA
Address
This Order is issued and delivered as follows:
D by hand delivery to applicant or representative on
(date)
by certified mail, return receipt requested on July 18, 1990 _ Idatej
This project is located at Lots 28 & 29 vest Wa
The property is recorded at the Registry of Northern r�snX
Lot 2$ 2142 24
Book Lot 29 2480 Page 91
Certificate (if registered
The Notice of Intent for this project was filed on April 25 1990 (dale)
The public hearing was closed on June 27, 1990
(date)
Findings
The .North Andover Conservation Commission has reviewed the above referenced Notice of
Intent and plans and has held a public hearing on the project. Based on the rnlormation avallaDle Ic the
NACC at this time, the NAS _ has determined Ihat
the area on which the proposed work is to be done is significant to the following interests in accoroance v.ilh
the Presumptions of Significance set forth in the regulations for each Area Subject to Prolecfion Under Ine
Act (check as appropriate):
Public water supply �� Flood control❑-✓ Land containing shellfish
�j. Private water supply ,�Storm damage prevention LvJ Fisheries
Ground water supply Ud Prevention of pollution l Protection of wildlife habitat
Total Filing Fee Submitted 4)zDV. vu
City/Town Share $137.50
Total Refund Due S City/Town Portion S
('/z total)
State Share $112.50
(1,12 lee in excess of S25)
State Portion S(1/2 total) total)
16
Order of Conditions #242-529 Lots 28 & 29 Vest Way
PROJECT INFORMATION
The following plans and information were available to and
reviewed by the NACC in reaching its decision:
a. Notice of Intent submitted by J.R. Realty Trust,
dated April 25, 1990 (19 Pages);
b. Plan: "Site Development Alternatives Lots 27-29
Vest Way" dated 6/11/90 drawn by Design Engineering;
c. Plan: "Definitive On -Site Sanitary Waste Disposal
System for Lot 28 Vest Way", dated 2/15/88 drawn
by Design Engineering Inc.;
d. Plan: "Proposed Site Alterations, Lots 27-29 Vest
Way" dated March 1990 drawn by Design Engineering
Inc.;
e. May 21, 1990 letter from Essex County Greenbelt
Association to NACC (2 pages);
f. June 4, 1990 letter from Mallett Associates Inc.
to Alfred A. Shaboo (4 pages);
g. June 11, 1990 letter from Design Engineering to
Nacc (3 pages).
FINDINGS;
1. The following wetland resource areas are affected by the
proposed work: bordering vegetated wetland, and its associated
buffer zone. These resource areas are significant to the
interests of the Act and Town Bylaw as noted above. The
applicant has not attempted to overcome the significance of these
resource areas to the identified interests.
2. The NACC agree with the applicant's delineation of the
wetland resource areas at the site.
3. The NACC takes notice of the Town's Board of Health
requirement under Title 5 that septic systems be set back at
least one hundred (100) feet horizontally from the boundary of
the agreed resource area. The NACC also notes that on occasion a
variance may be granted from that requirement. 10.03 (3) of 310
CMR provides that a septic system constructed in compliance with
Board of Health requirements shall be presumed to protect the
interests identified in the Act only if none of the components is
located in a resource area. The applicant has not overcome such
presumption.
4. The applicant was denied a variance from the 100 ft.
requirement.
5. The applicant proposes filling Bordering Vegetated Wetland in
order to fulfill the 100 foot setback requirement. However the
applicant's engineer stated that such filling would not effect
groundwater levels. Therefore the applicant has failed to
persuade the NACC that such filling would not effect pollution
Further, the applicant has not persuaded the NACC that such
filling would not have an adverse effect on the remaining
bordering vegetated wetland when in such close proximity to
steeply sloped filling. As is noted in 310 CMR 10.55, a
bordering vegetated wetland is "...most probably the
Commonwealth's most important inland habitat for wildlife."
DECISION•
For the reasons set forth above, the NACC denies this Notice of
Intent. However, the NACC has not considered and does not rule
on at this time other activities which are of a different size,
materials, location, design or type which the Applicant may
propose at a later date. The applicant can file a new Notice of
Intent proposing a smaller project, different design, or
different location.
Ell
D.E.P. #242— 529
19
Issued By NORTH
SignaJur.P,(s)
DOVER _
Lots 28 & 29 Vest Way
Conservation Commission
Irm,iii,c-
This Order must be signed by a majority of the Conservation Commission.
On this 11 th day of July 19 90 , before nle
personally appeared Paul L. Tariot to me known to be the
person described in and who executed the foregoing instrument arid acknowledged that he/she executed
the same as his/her free act andAeed.
Nolary Public
September 9, 1994
My commission expires
The applicant, the owner, any poison aggrieved by this Order, any owner of land abulling lire land upon which the proposed work is to be
done or any len residents of the city or town In which such land is located are hereby notified of their right to request the Dep,11unenl of
Environmental Ouality Engineering to Issue a Superseding Order, providing the request is made by cerfilied mail or hand delivery to filo
Department, with the appropriate filing lee and Fee Transmittal Form as provided in 310 CMR 10 03(7), within ten days Irunr the dato of
Issuance of this Order. A copy of the request shall at the same time be sent by certihod rnail or hand delivery to the Conservation
Commission and the applicant.
If you wish to appeal this decision under the Town Bylaw,
a complaint must be filed in Superior Court.
Detach on dolled line and submit to the North Andover Conservation Couun' prior to commencement of work.
..................................................................................................................................................................................................................
To
Issuing Aufi,Wyly
Please be advised that the Order of Conditions for the proiecl at Lots 28 _& 29 Vest
File Number 242 -57 - has been recorded at the Registry of Deeds and
has been noted in the chain of—title of the affected properly In accordance with General Condylion 8 on_____.__
If recorded land, the instrument number which identifies this Iransacl on is.__—___---.___--_- - - ---- !- -------- ---
If registered land, the document number which identifies this Iransachoy, is
Signature
_------ Applicant
BOARD OF HEALTH
120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32 or 33
June 12, 1990
Design Engineering, Inc
PO Box 516
No. Andover, MA 01845
Re: Lots 27-29
Vest Way
No. Andover, MA 01845
Dear Al:
This letter is to inform you and your client that the Hoard
of Health will allow the installation of a leaching facility as
close as 50 ft to drain lines associated with Vest Way, provided
that it is necessary to do so to maintain a 100 ft setback from
the edge of wetlands and the leaching facility. Please be
advised that the leaching facility should be placed as far from
the drain lines as possible, while still providing for the 100 ft
setback from wetlands.
Should you have any questions regarding this matter, please
do not hesitate to call.
Very truly yours, /
rfichae Rosat f
Acting Health Agent
MR/rel
John D. Shagoury
of Weston, Middlesex County, Massachusetts,
•, for the full consideration of Q,VE p 0 t- L 9,,� d C paid
grantto Ralph P. Ciardiello, Trustee of J.R. Realty Trust under
Declaration of Trust dated 2/24/86 and recorded with the North Essex
Registry of Deeds in Book 2142, at Page 19
of 47 Royalston Road, Wellesley, Massachusetts
with qut dghn ranenttntexkogl YA0b c
A tengiorary construction easement to allow filling and regrading
work as necessary over that portion -of Lot 27 abutting Lot 28 shown on a
-septic design plan for Lot 28 filed with the Board of Health for the Town
of North Andover dated /IPR►t-11 19?&M approved by said Board of Health.
Said construction easement shall be for the purpose of access and egress .
to those portions of Lot 27 and 28 necessary to regrade the land area to
ao= mrodate the designed septic system. Also, granted hereby is a
permanent easement in favor of the grantees and their successors in title
prohibiting the present and future owners the grantors and their
successors in title from excavating in the regraded area- Nothing under
this easement shall prohibit regrading of the area involved by filling and
contouring to higher elevations, but no work shall be allowed which would
reduce the contours below that approved for the septic design system for
Lot 28.
For grantors title see deed recorded in the North Essex Registry
of . Deeds in Book 306q, Page IVO,
Executed is a sealed instrument this fifth ay of October l9 90
alt Iffetumaumfg* Oi Alsom4ttturds
Essex as. October 5, 19 90
Then personally appeared the above named John D. S h a g o u r y
and acknowledged the foregoing instrument to he his free ee ,
Befw# tae,
J n J W i l i s, Jr. Notary Presto
mission expires 1116 19
P
FORM U - LOT RELEASE FOgM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: - � U't�c� T c{ -1—Phone 6 ag y
LOCATION: Assessor's Map Number 169� 1(7 Parcel 196
Subdivision Lot s)• i z9
Street 1 ��'' J-vt
�'�-' i St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
,,::Z 117i�7-4,L
Health Agent
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved cg /y`
Date Rejected
Comments A= Xc,4!,4�-i��L'
Public Worcs - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
e- <F75-- 2/46
/'a /yr
DATE:—<g.
ATE:" Jd-
R
ECEINI
SEP J � �nnj
TOWN OFt'.
HEALTH'
FIQ,-2-)
OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
ves�-
I
DATE OF PUMPING: C QUANTITY PUMPED GALLONS
CESSPOOL. N
• O YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: