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Home My WebLink AboutMiscellaneous - 191 GRANVILLE LANE 4/30/2018 191 GRANVILLE LANE 210/106.C-0062-0000.0 y. AW , UPC 14081 Pio.t002-5A &P-slE p, . Residential Property Record Card PARCEL ID:210/106.C-0062-0000.0 MAP:106.0 BLOCK:0062 LOT:0000.0 PARCEL ADDRESSA91 GRANVILLE LANE FY:2012 PARCEL INFORMATION Use-Code: 101 Sale Price: 396,000 Book: 8577 Road Type: T Inspect Date: 04/12/2010 Tax Class: T Sale Date: 02/20/04 Page: 163 Rd Condition: P Meas Date: 04/12/2010 Owner: Tot Fin Area: 2208 Sale Type: P Cert/Doc: Traffic: M Entrance: C LYNCH, DAVID Tot Land Area: 1.05 Sale Valid: Y Water: Collect Id: RRC LYNCH, KATHLEA Address: Grantor: DAVID BERLIND Sewer: Inspect Reas: C 191 GRANVILLE LANE Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: CL Tot Rooms: 7 Main Fn Area: 1200 Attic: NBHD CODE: 6 NBHD CLASS: 6 ZONE: R2 Story Height: 2.00 Bedrooms: 4 Up Fn Area: 1008 Bsmt Area: 1200 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: L Full Baths: 1 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1.000 206,910 Ext Wall: AV Half Baths: 2 Unfin Area: Bsmt Grade: 2 R 101 A 0 0.050 380 Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2208 VALUATION INFORMATION Foundation: CN Bath Qual: T RCNLD: 211783 Current Total: 419,100 Bldg: 211,800 Land: 207,300 MktLnd: 207,300 Kitch Qua[: T Eff Yr Built: 1987 Mkt Adj: Prior Total: 419,100 Bldg: 211,800 Land: 207,300 MktLnd: 207,300 Heat Type: HW Ext Kitch: Year Built: 1981 Sound Value: Fuel Type: G Grade: AG Cost Bldg: 211,800 Fireplace: 1 Bsmt Gar Cap: Condition: A Att Str Val 1: Central AC: N Bsmt Gar SF: Pct Complete: Aft Str Val2: Att Gar SF: 576%Good P/F/E/R: //100/88 Porch Type Porch Area Porch Grade Factor W 168 SKETCH PHOTO 14t 12 w 12 .i 168 Sqft A 14 8 24 i Fu c P - 1008 SgFt 576 SgFt FM/B 24 24 *�� 28 1200 SgFt 28 al 24 1 36 M 191 GRANVILLE LANE Parcel ID:210/106.C-0062-0000.0 as of 6/19/12 Page 1 of 1 lP own of North Andover f gORTN 0 Office of the Health Department 3� •'�' �'�'k Community Development and Services Division "U 27 Charles Street '' °+ • •r • °•,h°✓'" North Andover,Massachusetts 01845 C�,us tarr 978.688.9540-Phone Public Health Director 978.688.9542-Fax %fYFR I FICA.TIF OE C0911PLIAJVCE As of: u ust 252004 This is to cert that the individual subsurface disposal system re aired X — EuffS stem p � � y by John Soucy at 191 Granville .Gane North Andover, JKA 01845 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover 0oard of Yfealth regulations. 'The Issuance of this certificate shalt not 6e construed as a guarantee that the system will function satin actoril. .� f y S an 7 Sawyer, REi[S/Rof It 6lic%ealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 RECEIVED AUG 13 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT TOWN*OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( )constructed; (X repaired; b.. C> Ho ' located at I I I Cr(Z19 AJ U t e._L r Lfl A� was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# ,plan dated �, u w cs3 , with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR.15.000,Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: -71 el 10y c 7�t�0 Engineer Representative Final inspection date: g 101 0 C o Engineer Representative Installer: �� • .t` Lic.#: Date: H Os -4c Enginee wA Date: '�91i O&&y Vl �l NO.45891 Message Page 1 of 1 6 Dellechiaie, Pam From: Andrew McBrearty [amcbrearty@millriverconsulting.com] Sent: Monday, July 19, 2004 1:33 PM To: 'Susan Sawyer'; 'Pamela Dellechiaie' Cc: info@millriverconsulting.com Subject: 191 Granville Lane Sue& Pam, Attached, you will find the final construction inspection report for 191 Granville. Inspection was 7/13, but I failed to input this and send it to you -sorry. Soucy is asking for a letter stating that this is ready to be covered. I believe I gave John a verbal OK, but they need a letter to release escrow monies. I'll call you shortly on this. thanks, -andy I it iver consulting Andrew McBrearty,, Project Manager Mill River Consulting Septic System Management Services 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 www.millrivercansulting.cam amcbrearty@millriverconsulting.com 7/19/2004 TOWN OF NORTH ANDOVER °f NORTF,1 Office of COMMUNITY DEVELOPMENT AND SERVICES o?•'z� ��`��°°� HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER,MASSACHUSETTS 01845 '3 440 Stt Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX ADDRESS: 191 Granville Rd MAP: LOT: INSTALLER: Soucy's Sewer & Septic Service DESIGNER: NEES PLAN DATE: jj,j t . 2) BOH APPROVAL DA E ON PLAN: 1218/ 00 DATE OF BED BOTTOM INSPECTION: I DATE OF FINAL CONSTRUCTION INSPECT ON: 7/13/2004 DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE Pressure Dosing COMPONENT SUMMARY FROM PLAN GALLON TANK = 1500 LOADING OF SEPTIC TANK = H-10 GALLON PUMP CHAMBER = 1000 LOADING OF PUMP CHAMBER = H-10 TYPE OF SAS = Infiltrator Trenches DIMENSIONS AND DETAILS OF SAS: 3 rows, 5 chambers each SITE CONDITIONS Date & Initials Inspections ®Existing septic tank properly abandoned Internal plumbing all to one building sewer Topography not appreciably altered Comments: Page 1 of 1 TOWN OF NORTH ANDOVER °t NOFTH . Office of COMMUNITY DEVELOPMENT AND SERVICES o y`I.o ?.�,o . O HEALTH DEPARTMENT '° 27 CHARLES STREET " NORTH ANDOVER, MASSACHUSETTS Ol 845 Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX SEPTIC TANK ® 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) ® Inlet tee installed, centered under access port ® Outlet tee gas baffle 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 Comments: PUMP CHAMBER ® Bottom of tank hole has 6" stone base ® ep hole plugged ® 100 gallon Pump Chamber installed -10 loading 2-Piece construction) ® Inlet tee installed, centered under access port ® Pump(s) installed on stable base ® Alarm float working ® Pump On/Off float working ® 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: Page 2 of 2 TOWN OF NORTH ANDOVER NORTy Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT Y A 27 CHARLES STREET .'pr R4� roo NORTH ANDOVER,MASSACHUSETTS 01845 'Ss,CN�stt Susan Y. Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX D-BOX ® Installed on stable stone base ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM Bottom of SAS excavated down to soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan ❑ 3/4-1 '/2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ® laterals installed and ends connected to header (and vented if impervious material above) ❑ Orifices @ 5 & 7 o'clock positions ® Gravelless 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: Page 3 of 3 TOWN OF NORTH ANDOVER Ot NORTH 7 Office of COMMUNITY DEVELOPMENT AND SERVICES o `i`�� O :. . O HEALTH DEPARTMENT 27 CHARLES STREET r o��,«sus• �+ NORTH ANDOVER, MASSACHUSETTS 01845 �'Ss;;CN„S t� Susan Y. Sawyer, REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX 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: SYSTEM ELEVATIONS Benchmark: 100.00 Rod at Benchmark: 4.10 Height of Instrument: 104.10 INVERT ON DESIGN PLAN INVERT ELEVATION Building Sewer OUT 97.38 97.54 Septic Tank IN 97.22 97.30 Septic Tank OUT 96.97 97.06 Pump Chamber IN 96.93 96.80 Pump Chamber OUT 0.00 96.46 Distribution Box IN 0.00 99.52 Distribution Box OUT 99.38 Manifold Lateral 1 HIGH 9924 99.30 Lateral 1 LOW 9924 99.27 Lateral 2 HIGH 99.24 99.30 Lateral 2 LOW 9924 99.28 Lateral 3 HIGH 9924 99.29 Lateral 3 LOW 99.24 99.28 Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW Page 4 of 4 r a' + -11A 04 re_ . taw :.:i �`a5,. # ;, � J ((�►(c{{,�� *'4 4 j �.;£" 5a ��g� r.;�, 3 'i ;�, ,* 'Pi� ,z's-. � u s. ��at '� +;� &s t�> r.x- .};'..pr^�..n r, �' b�.?:. •: � '"v- f�2 y` "*��k 'g ';'�`'�"w"zaa�'� �' k :fi*�,Y � XK, r.�,.. '�k 1 TOWN OF NORTH ANDOVER E µORTH Office of COMMUNITY DEVELOPMENT AND SERVICES a °°t* 6Ati°fi HEALTH DEPARTMENT p 27 CHARLES STREET > NORTH ANDOVER,MASSACHUSETTS 01845 9SSACHl1$tiS Susan Y.Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX healtbdept@townofnorthandover.com www.townofnorthandover.com APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: y LOCATION: I I2 LICENSED INSTALLER NAME: guel / PLEASE PVNT SIGNATURE:/1',ht a TELEPHONE# Ll_`!�" C �I CHECK ONE: FULL SYSTEM REPAIR: COMPONENT REPAIR (indicate what parts): * NEW CONSTRUCTION: * If NEW CONSTRUCTION,please attach the Foundation As-Built Plan. $250,00 Fee Attached? Yes No Project Manager Obligation From Attached? Yes—L.Z No Foundation As-Built? Yes No Floor Plans? Yes No Approval of Health Agent Date: Lr INSTALLER PROJECT MANAGEMENT OBLIGATIONS As-the North Andover licensed installer for the construction of the septic system for the property at �� (O .�y� relative to the application Of o /i ll dated. 41. y Z/ '?QS and dated / with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the 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. Undersi icensed Septic a er Date: -7 Date: Dispo al Works Construction Permit TOWN OF NORTH ANDOVER of NOR7N 1 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 'SS,�Hust< 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.9542—FAX Public Health Director healthdept a,townofnorthandover.com http://www.townofnorthandover.com July 19, 2004 John Soucy Fax: 603.898.1876 P.O. Box 4158 Andover, MA 01810 RE: 191 Granville Lane,North Andover, MA Dear John Per your request,this letter is to state that the above property is currently undergoing a septic installation by you. The property passed a Final Construction Inspection on July 13, 2004, and according to our consultant is ready to be covered. This letter does not guarantee approval of a Final Grade Inspection by the North Andover Public Health Director. In addition, a Certificate of Compliance from the Health Department will not be issued until we receive the following paperwork: Septic System As Built and Installation Certification forms (signed by installer and Engineer). I hope that this information is enough to release the escrow monies that you are requesting from the homeowner. Please feel free to call me if you have any questions. Sincerely, Pamela DelleChiaie Health Dept. Assistant Cc: Susan Sawyer, Health Director File e TOWN OF NORTH ANDOVER f NORTk q Office of COMMUNITY DEVELOPMENT AND SERVICES o HEALTH DEPARTMENT 27 CHARLES STREET gO'p1Tt°'fi NORTH ANDOVER, MASSACHUSETTS 01845 "sSACHUSES Heidi Griffin 978.688.9540—Phone Acting Health Director 978.688.9542 —FAX December 8, 2003 Karin Berlind 191 Granville Lane North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan for 191 Granville Lane, Map 106C, Lot 62, North Andover, Massachusetts Dear Ms. Berlind, The North Andover Board of Health has completed review of the septic system design plans for the above referenced property submitted on your behalf by New England Engineering Services dated November 14, 2003. The design has been approved for use in the construction of a replacement onsite septic 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 a septic system inspection 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 septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. 3. The impermeable barrier specified on the design plan is may cause interference with ground water during the periods of high water table. You are encouraged to discuss this with your septic system design and submit a revised plan for consideration should it be deemed desired. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincerely, Heidi Griffin, Acting Health Director encl: List of licensed septic system installers cc: file New England Engineering Services 4 3 c.nov 14 :ud ui.:uJp nuXH HNIJU VEK 1 , 9'7868HSS4Z- p. l .. Town of North Andover HEALTH DEPARTMENT 27 Charles Street North Andover,MA 01845 978.688,9540 healthde u)toivno northandover com SEPTIC PLAN SUBMITTAL FORM DATE OF SUBMISSION: i 03 SITE LOCATION:„ ENGINEER:-]\)F,..v C,vCr��Fw �N( 1 N c: /L• .+ (r NEW PLANS: YES $225.00/Plan Check#: (Includes 1�e�+8wP hand one Re Review Only) REVISED PLANS: YES $75.00(Plan Check#: SITE EVALUATION FORMS INCLUDED: YES O LOCAL UPGRADE FORM INCLUDED: YES O Telephone#: 9 78- !76`a Fax#: 13? E-mail: / !CC-CSeN HOMEOWNER NAME: V_ k-n gel) L_I N OFFICE USE ONLY When the submission is complete(including check). _ 1• `/ate stamp plans and letter 2. /y/) Complete and attach Receipt 3• Copy File; Forward to Consultant f +tiDv � Q 4 Enter on Log Sheet and Database NEW ENGLAND ENGINEERING SERVICES INC November 14, 2003 Brian LeGrasse North Andover Board of Health 27 Charles Street North Andover, MA 01845 NOV 1 4 2003 Re: 191 Granville Lane,North Andover, Septic system design Dear Brian: Enclosed are the following documents concerning the above referenced property. 1. 5 sets of septic system design plans. 2. Application for plan approval. 3. Check to cover the approval fee. This plan has been revised to address the issued raised in your letter dated October 16, 2003 except the reduction in separation distance between the bottom of the leach trenches and the groundwater. I previously submitted a letter requesting the local upgrade approval. If you have any comments or questions please do not hesitate to contact this office. Sincerely, n ,�3, C cJ.. Benjamin C. Osgo d, Jr.,EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 NEW ENGLAND ENGINEERING SERVICES INC November 13, 2003 Brian LaGrasse North Andover Board of Health 27 Charles Street North Andover, MA 01845 CMV 13 V3 Re: 191 Granville Lane, Septic system design r Dear Brian: Please accept this letter as a request to be included on the next board of Health meeting agenda. The purpose of the request is to request that the Board of Health consider the following local upgrade approval request for the septic system design at the above referenced property. 1. Allow a reduction in the offset distance between the bottom of the stone in the leach trench from 4 feet required by Title 5 section 15.212(a)to 3 feet. I will be at you meeting next Thursday to discuss this matter. A plan has been submitted previously that requires this local upgrade approval in order to be approved. If you have any questions please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr., EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 Page 1 of 1 DelleChiaie, Pamela From: Dan Ottenheimer[info@milldverconsulling.com] Sent: Thursday, October 16,2003 1:23 PM To: 'Pamela DelleChiaie' Subject: RE: 191 Granville Lane Pam, 81 Sawmill was sent yesterday. I am re-sending it in case you did not get it for some reason. We have not yet looked at 191 Granville but will do so shortly. Dan Mill RiverConsulting e Septic System Management Services 5 Blackburn Center Gloucester,MA 01930-2259 978-282-0014 or 1-800-377-3044 fax:978-282-0012 info@millriverconsulting.com -----Original Message----- From: Pamela DelleChiaie [mailto:pdellechiaie@townofnorthandover.com] Sent:Thursday,October 09, 2003 11:10 AM To: Daniel Ottenheimer(E-mail) Subject: 191 Granville Lane Hi Dan, Ben Osgood called and was happy about the 151 Abbott Street approval. He was also wondering what the status was on 191 Granville Lane. No pressure, but also,what is the status of 81 Sawmill Road? Thanks, Pam Pamela DelleChiaie, Health Dept.Assistant Town of North Andover Community Development&Services 27 Charles Street North Andover, MA 09845 pdellechiaie@townofnorthandover.com Tel 978-688-9540 Fax 978-688-9542 10/16/2003 o TOWN OF NORTH ANDOVER N09tTH 31IJ Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 27 CHARLES STREET *'q :.��411 NORTH ANDOVER N4ASSACHTJSETTS 01845 Heidi Griffin 978,688,9540—Phone Acting Health Director 978.688.9542 -FAX October 16,2003 Richard Tangard New England Engineering Services,Inc. 60 Beechwood Drive North Andover,MA 01845 Re: 191 Granville Lane,Map 106C,Lot 62 Dear Mr. Tangard: The proposed septic system design plans for the above site dated September 19,2003 have been reviewed. Unfortunately,the plans cannot be approved as submitted. The following items are in need of attention prior to approval: 1. Please provide the location and elevation of the foundation drain. If there is no drain,please make a statement to that effect on the plan. (NA 8.02y) 2. The septic tank detail does snot depict that the inlet and outlet tees are to be located underneath an access port. This is important for maintenance purposes and should be clearly shown. (3 10 CMR 15.227) 3. Please indicate that removal of soil horizons fill,A&B shall extend at least 6" into the suitable soil of the C horizon. (NA 9.02) 4. Soil evaluation reports on the design plan and on the Form 11 submitted do not coincide regarding the depth of the estimated seasonal high ground water. 5. Please list the specific section of the North Andover Board of Health Regulations for which the listed variance is being sought. 6. Setback standards from the septic tank,pump chamber and soil absorption system to the wetland resource area are not provided in compliance with the North Andover Board of Health Regulations. 7. The design includes a Local Upgrade Approval request to reduce the separation from the bottom of the soil absorption system to the estimated seasonal high ground water from the required 4' to 3'. Several sections of Title 5 do not allow this request to be granted including 310 CMR 15.401 and 404(1)which indicate that whenever feasible a design should maintain full compliance with the standards in the regulations. First, Title 5 requires an upgraded system to be utilized which is in full compliance with the code, including the possible use of an approved treatment unit allowed for remedial use situations. If specified in this instance, full compliance with the Y regulations could likely be maintained. Additionally, the Application for Local Upgrade Approval indicates the reason this is not specified is for cost purposes. However,with the savings associated with reduction in leach trench size or in the depth to ground water separation(and coupled with the existing need for utilizing a pump and pump chamber system),the cost difference is likely not significant. Second,Local Upgrade Approvals are to be implemented in a particular order of selection with criteria based upon risk to public health, safety and the environment. Using those standards,there exist other Local Upgrade Approvals which can and should be utilized prior to the one selected. (3 10 CMR 15.404 &405) While not a reason for disapproval,you may wish to consider the following items: 1. The pump specified will produce a flow of over 100 gallons per minute to the distribution box. You may be able to reduce construction and operation expenses and reduce flow volumes with a different pump. 2. The system profile indicates removal of soil and replacement with sand to what appears to be a depth greater than required. You may wish to review this and possibly amend the detail to provide greater clarity to the Disposal System Installer. 3. The soil absorption layout currently requires the removal of the walkway to the dwelling. It may be possible to reorient the leach trenches(and perhaps utilize a small retaining wall)to eliminate disturbance to the walkway. 4. Please review the bottom elevation of the impervious barrier indicated on the design plan. It appears to intercept the ground water table and may lead to entrapment of groundwater or wastewater. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a replacement septic system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Si erel 7 Brian LaGrasse Health Inspector cc: Homeowner CD&S Dir. �F`ile ' SEPTIC PLAN SUBMITTALS J LOCATION: 1°t1 6-)P-6 o i I-i-L% Map & Parcel NEW PLANS: YE $225.00/Plan Check#: 6131 REVISED PLANS: YES $ 60.00/Plan Check#: SITE EVALUATION FORMS INCLUDED: YES NO LOCAL UPGRADE FORM INCLUDED: YES NO DATE: ja`� a 3 DATE TO CONSULTANT: DESIGN ENGINEER: W,.j k v�jL sl FNS A-CJat G- Telephone#: When the submission is complete (including check),date stamp plans, COPY for Conservation, and place in existing file with green Design Appro�orm: r moo-�r •, ter t 2 8 2003 s Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL; Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non-conforming system with a design flow of<10,000 gpd,where full compliance,as defined in 310•CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non-conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404 1 is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: �4R1� S4 R►-iN Address: i 91 G-2 A Al VW.� J-is N , No" A.,J n 0 o 0 2. .h th Phone#: q7,9- &81(.- )-7Z_,; Address of facility: i q 6'P_AAJ LI LU( LA/v �„, ,�� ,�,,,��,��2 �vc►9 2) Applicant(if different from above) Name: Address: Phone#: 3) Type of Facility: 1( Residential Commercial School Institutional (Specify) S►N(rLC �/�� LH t lJ ,n } Page 2 of 5 4) Type of Existing System: _privy cesspool(s) _conventional system other(describe) Type of soil absorption system(trenches, chambers, pits,etc.) i g-gc,t-L r-1eLD 5) Design Flow Based on 310 CMR 15.203: a) Design,flow of existing system y �o gpd Approved: des Approval date: f.-70-g no Why: b) Design flow of proposed upgraded system �y�_gpd Why i2 Qj t R e p c) Design flow of facility V Yo gpd 6) Proposed upgrade of existing system is: a) Voluntary required by order, letter, etc. (attach copy) I Required following inspection required b 31 CMR 15.301 Pe �l Y (provide date inspection form was submitted to the approving authority) ,v (date) b) Describe the proposed upgrade to the system: TA,v« r PO^4 P A-,-'> c=►'ht vt IN S cl 1+.S !!NG- SYST�/Vl. c) Which of the following are applicable to the proposed upgrade? ,/Reduction of setback(s)(list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per inch(state actual perc rate) Up to 25% reduction in subsurface disposal area design requirements (state required& proposed size) Relocation of water supply well(identify well, describe relocation) /Reduction of required separation between bottom of SAS & high groundwater(specify proposed reduction& perc rate) r! Z. �N�/Yi7Jt/ w�� To �fA[H N�LCA FYtJ,v� �` 70 IS( Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405,or in full compliance with the requirements of 310 CMR 15.000 require a P �1 eq variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation,an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater 3 feet As determined by: Evaluator's name: L ec t F H i;L Am Evaluator's Signature: Date of evaluation: 9 y Z'00.3 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the department is the approving authority,then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Date notified # Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9)' Explain why full compliance,as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: �.�?T nz�E5 �voT H14�e ��l c�e,✓� ,9-�2�r� � _Arc0^4 PG/Sh( I.p �,��v1PLI, 1y i UP&)Z,40F R-Obi v 6 sYsr �m o C Ay' /�O a,)j C._ LAj DOL D e_P+-se- C— /}.y0 D't41,U 'q- MO AZ'CMS 5YS-;-FM +-s 9es;,,n�� FIto M /40,'S C (--.TH r=W/s f( Gr,q14 P #7 -SIL-4- i-cu el b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. c) A shared system is not feasible. X4654 Fw.sis /-OT d) Connection to a sewer is not feasible. 10)An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications,site evaluation forms), must accompany. this application. Is the DSCP application attached? V yes no t Page 5 of 5 11)Certification ; "I,the facility owner,certify under penalty of law that this document and all attachments, to the best of my knowledge and belief,are true,accurate,and complete. I am aware that .there may be significant consequences for submitting false information, including,but not limited to, penalties or fine and/or imprisonment for knowing violations." v } Facility Owner's Signa ate Print Name Name of Preparer Date 6 —!?6 0 l3C�Ct{wOvJ ��uC /Va�,711 f�.�,�c7 Telephone No. &Address of Preparer NOTE: Title 5,310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 No. -/ Date: o? Lo__5 Commonwealth of Massachusetts Massachusetts Soil Suitability Assessment for On-site Sewage Disposal 7��1� � C. X 1d3)Perforrned By: ............ ............... ... '/ . ......�� Date: � �� Witnessed By: ............C.- �C� ... .. l !c/............................................ ........_... ...... _ .. location Address or Lot/ ( Address,and ' Y �• �I�(�0�� Telephone/ /% / �F��/kl/�G C� �f'��S New Construction ❑ Repair [N Office Review Published Soil Survey Available: No ❑ Yes Q Year Published 9W ................... Publication Scale ✓................ . Soil Map Unit L.r�_..._. .. Drainage Class �10 !��... Soil Limitations .... Surficial Geologic Report Available: No ® Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) ........................................................................................................................___ ....... .... ... ... Landform _... . . 4 Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes Q Within 500 year flood boundary No []Yes ❑ Within 100 year flood boundary No ❑Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) .................................................................... ....... .._ . Current Water Resource Conditions (USGS): Month., Range :Above Normal Normal ❑Belcw Normal ❑ Other References Reviewed: DEP APPROVED FORM-12/07/95 FORM. 11 - SOIL F,VALUATOR FOPm Page 2of3 Location Address or Lot No. /c7/ z- e— L�k�, I.,(o • , HCl( tltZZ On-site Review /� � � Deep Hole Number Date:. . •3 Time: D. � � Weather / 0 Location (identify on site plan) m�li C Land Use 1��&77W- Slope M " Surface Stones `— Vegetation Landform Position on landscape . .. ....... ..... :. Distances from: Open Water Body feet Drainage ways feet Possible Wet Area feet Property Line ..:......a. feet Drinking Water We111715�. feet Other . ....v. ,A.......,.. DEEP O$SERVATION HOLE LOGO Depth from Soil Horizon Soil lecture Soil Color Soil Other Surface (Inches)' (USDA) (Munsell) Mottling (Structure, Stones, Boulde(s, Consistency. °ro Gravel) 9�3 7�� g . s r � � l I Parent Material(geologic) ��®5 �L DepthtoBedrock: r __ Depth tp,Groundwater: Standing Water In the Hole: Weeping from Pit Face: Estimated Seasonal High (around Water: 4& DEP APPROVED 70"1• 12107n9S FORM. 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No, On-site Review a Deep Hole Number ,. Date:— !�'�� Time: Weather PC- 7z Location Identify on site planizm^�7 Land Use Slope M Surface Stones --.: Vegetation Landform Position on landscape Distances from: Open Water Body feet Drainage way � � feet Possible Wet Area . 75. feet Property Line ... feet Drinking Water Well feet Other .. .v...........'-..:::,.......:_.::.. DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency. °a Gravel) lLG �Ql � ��- /ayr "/ h1l,r- L 5 P"r- Parent Material (geologic) �L DepthtoBedrock: Depth to Groundwater: Standing Water In the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM• 11/07/95 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole................ inches ❑ Depth weeping from side of observation hole................. inches Depth to soil mottles .........P inches `416;r y ❑ Ground water adjustment ................... feet ' °Z` -40 Index Well Number .................. Reading Date .................. Index well level ................... Adjustment factor ................... Adjusted ground water level ...................................................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in I areas observed throughout the area proposed for the soil absorption system? l If not, what is the depth of naturally occurring pervious material? Certification I certify that on �(date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. - Signature DEP APPROVED FORM•12/07/95 FORM 12 -PERCOLATION TEST Location Address or Lot No. COMMONWEALTH OF MASSACHUSETTS No(Liv AA-,o -0J fiWassachusetts Percolation Test` Date: :w�. w.:. .��r� Time:. ../�+3`� ...: M Observation Hole # [D�epthf Perc 0 11s Start Pre-soak End Pre-soak IL 14 Time at 12" Time at 9" Time at 6" Time (9"-61 Al I Al Rate Min./Inch 4 Minimum of 1 percolation test must be performed in both the primary area AND reserve area. I' Site Passed Site Failed ❑ ...................................... ............ ........_._..__,_.............. Performed By: Q Witnessed By: �. sem► kn L t�?k p C�%,vS.iL - � nn �L2, Ti9NTS Comments: :.....v..,.:::n.:.,..v...�.:::.::: .::xAw::...:.M .H�._.. :::.....:::....:....::::...::.:..:..:..Aw_.x�.w. DEP APPROVED FORM_12/07/95 191 GRANVILLE LANE JS-2004-0214 Project Detail RepoYt Printed On:Fri Aug 13,2004 ;Project Name: GIS#•• - - - - GI ,7181 Project No: JS- - - -- Owner of Record DAVID LYNCH Map: +106.0 Date Submitted: +Aug-20-2003 - 191 GRANVILLE LANE Block: 0062 Status: iOpen NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 191 GRANVILLE LANE Zoning: Proposed Use: District: - -- - P - --- - - - - - - - -- -- - - - - - Use: - land U 101 `Pro osed Use Detail- Subdivision Description Soil Testing _] estingComments: of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health YELLOW FLAG BHJ-2003-0115 8/13/04-Cert form received from NEES. Still needs to be signed by John Soucy. As Built also received. 7/13/04-Final Inspection 7/1/04-Bed Bottom 6/17/04-DWC Application received from John Soucy. 12/8/03-Plan Approval 11/14/03-Resubmittal of plan to address the reduction in separation distance between the bottom of the leach trenches and the groundwater. Sent to consultant. 11/13/03-Request to be on the 11/20/03 BOH Agenda to: "Allow a reduction in the offset distance between the bottom of the stone in the leach trench from 4 feet required by Title 5 section 15.212(a)to 3 feet." 10/16/03-Plan Review completed 8/21/03-Forwarded to Consultant. Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: DWC-System Repair BHP-2004-0450 Jun-22-2004 SIGNED OFF JS-2004-0214 Repair-Complete Plan Review BHP-2003-0352 Oct-16-2003 DENIED JS-2004-0214 Plan Review Revised Plan Review BHP-2003-0384 SIGNED OFF JS-2004-0214 Plan Review GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Page 1 of 2 191 GRANVILLE LANE JS-2004-0214 Project Detail Report Printed On:Fri Aug 13,2004 Soil Testing-Repair BHP-2003-0253 Sep-05-2003 SIGNED OFF JS-2004-0214 Soil Testing Inspection History Inspection Type: Permit Type: Permit No: Insp Date: Status: Inspector: Project No: Comment: Final Inspection DWC-System Repair BHP-2004-0450 Jul-13-2004 SIGNED OFF Dan Ottenheimer JS-2004-0214 Bottom of Bed Inspection DWC-System Repair BHP-2004-0450 Jul-01-2004 SIGNED OFF Susan Sawyer JS-2004-0214 GeoTMSO 2004 Des Lauriers Municipal Solutions,Inc. Page 2 of 2 NUMBER COMMONWEALTH OF MASSACHUSETTS BHP-2003-0253 North Andover FEE $360.00 Board Of Health BERLIND, DAVID A --------------------------- --------------------------------------------------------------------------------- NAIVE 191 GRANVILLE LANE ----------------------------------------------------------- - - ----------------------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Soil Testing This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires-------_-___September 05,2005------------unless sooner suspended or revoked. ---------------------------------------------------------------' September 05,2003 Board Of ------------------------ .E► Health ------------------------- -----��h ---------------------- r1 1 BOARD OF HEALTH NORTH ANDOVER, MASS. 01845 ` 978-688-9540 APPLICATION FOR SOIL TESTS DATE:_ l Z�. 03 MAP&PARCEL: A LOCATION OF SOIL TESTS: ,t" CS-,'�h yr - i-N OWNER: A t n ; ( 1042FAZ TEL.NO.: ADDRESS:--Iqi 1,(�✓ �'�{ �� = Z ov^, �'l.' nr D ca.� ENGINEER:ll9r✓w �,v L L..�,t,D t r.t,>1 /�� —TEL.NO.:_ X78 - F��[�. �7c CERTIFIED SOIL EVALUATOR: � Intended use of land: Residential Subdivision Single Family Home Commercial Is This: Repair testing �_ Undeveloped lot testing Upgrade for addition In the Lake Cochichewick Watershed? Yes No- THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership(Tax bill,deed,or letter from owner permitting tests) 2. Plot plan 3. Fee of$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 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass.Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing,a scaled plan(no smaller than 1"-100')shall be submitted to the Board of Health showing the location of all tests(including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval. l� p Date Received: Check Amount: Check Date: 6—d- &—'*�� M i s 0 � + LOT 15 r� 45 738 SF; � D Ey TN G \ y � i 1000 GAL l� ` SEPriC l-EACO i nth IQ.t , Vo ;; r� r ( C� rf PE - �►u Ki L D�:,v Or I ---r hk-rr�i ,; Af ",rte ' Fi`�'t~ / ��•r�4�}-�a�l�I.�.J.. .......-_—._.._ . .. .__....- _.�,.. • .._ _�-_.�.. •-..i..y,.. .-. ' _.._ ...w+....F-_._ _. ai_. ♦..._as—_..^_�... _..r ._... ..:�... w -.r..-� «.J+{+... + . ~ > d e �q +yip s 3 e' r. 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'... e.x .�',., -tA' '• ', IOU COMMONWEALTH OF MASSACHUSET'1,0 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y _ - 3 2003 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS-- - --� SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 01 GmM U I l e L 0C N o Al2 10n,ye-r Owner's Name: Pie r l-nd D Owner's Address: Date of Inspection: b' 2(--03 Name of Inspector: (please print) , f}-n'1 _ Company Name: -Q t-4 is Mailing Address: ac) ,50/1)/// 5t, u;3rc,4 / q Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved 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 ails Inspector's Signature: 4�4Date: 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. 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6f-0 to 1i I I IP- n� A)o A0&r--f Owner: P—)Q(-1\nd Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.`/System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or duo to a broken,settled or uneven distribution box. Systemwill pass inspection if(with approval of Board of Health): 7 broken pipes)are replaced obstruction is removed distribution box is leveled or replaced NO explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Flee 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11� I 6--►rwy/U ik e h n P No f1+ca4ae� Owner: 15 9 r I„ Date of Inspection: ( -,�h -� C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will.protect public health;safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system 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 i "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 nitrdgen4and 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. C 3. Other: 3 r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 1 7 fG � � tq n e'. Owner: 4,f 1, 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 c6sspoo] Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 'fLiquid 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 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. i�j 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.] ?S (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 16,000 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 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 Il 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. 4 Page 5 of 11 I f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: pl YCa r��l „f (� lco c Owner: bf( 1 rA Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health ere any of the system components'pumped out in the previous two weeks? ✓� Has the system received normal flows in the previous two week period? f Have large volumes of water been introduced to the system recently or as part of this inspection? V 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: Y. s no j y f _ 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)[3 10 CMR 15.302(3)(b)) 5 Rage 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: q \ (�_YG( \ 1e IC04Z l � Owner: 6P( � 1 Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual) DESIGN flow based on 310 015.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no),� Is laundry on a separate sewage system(yes or no):Yd [if yes separate inspection required] Laundry system inspected(ye or no): f + Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): �� Sump pump(yes or no): �S 1 Last date of occupancy: Q C Cc- COMMERCIAL/INDUSTRIAL vCOMMERCIAL/INDUSTRIAL Type of establishment: /r 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: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP�OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): U 6 Fage 7 of 11 w O OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Q` , (a k �e �C�1 Owner: Date of Inspection:--Q BUILDING SEWER(locate on site plan) Depth below grade: 3 Materials of construction:_�t iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:_concrete_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) , „ /C `' Dimensions: f G 't 5- Sludge Sludge depth: U it G 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: r Distance from bottom of scum to bottom of outlet tee or baffle: / I/ , How were dimensions determined: 0 Al S /T r Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: (locate on site plan) /y 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.): 7 Page 10 of 11 ate, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: `q� Y 6 i-� f e l( e 1011c 1 V 47 Owner: Oe r I"y, Date of Inspection: —,,2b, c.,3 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. a f _ ,( 10 P4411 of 11 s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART C SYSTEM M INFORMATION(continued) Property Address: 1-G1 r'Yl (e.. No 1411 rxv� Owner: ►'yc Date of Inspection: 4- h L SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water_ feet ti Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: Wc A 1T 17U1!r® (Gt/ f Pv ff ' r i 11 LOT 15 455738 SF W Ns 1 EY, S71K, Lo T� 15 ss r 1000 GAL G t j 1.,6 C a n y� SEPTIC TANK LEACH INC ys BEC 0, /Vv vo GSA' To eam L�1V. Pi;?F— p_4a� __114,_�� F— - � N . ANDOVER GEORGE FAR > 1Z 1�f$b G.