HomeMy WebLinkAboutMiscellaneous - 20 ROCKY BROOK ROAD 4/30/2018 (3)S
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LOT & S�REET (� L MAP/PARCEL_
CONSTRUCTION APPROVAL
HAS PLAN REVIEW FEE BEEN PAID? YES NO
PLAN APPROVAL: DATE APP. BY
DESIGNER: ,� 1(,,(� 5� PLAN DATE / /
CONDITIONS
WATER SUPPLY: TOWN WELL
WELL PERMIT
DRILLER
WELL TESTS: CHEMLCAL DATE APPROVED
BACTERIA I 'DATE APPROVED
BACTERIA II DATE APPROVED
PLUMBING SIGNOFF WIRING SI
COMMENTS:
FORM U APPROVAL:
DATE ISSUED
CONDITIONS:
FINAL APPROVAL:
APPROVAL TO ISSUE
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
_YES NO
o -z__ NO
CYES'-
NO
YES NO
YESNO /
DATE . l ,l , BY
A
SEPTIC SYSTEM INSTALLATION
IS THE INSTALLER LICENSED?
NO
TYPE OF CONSTRUCTION:
EW
REPAIR
C,
X55
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW
EY
NO
CONDITIONS OF APPROVAL
YES
NO
'(• �5 0, v
(FROM FORM U)
er
ISSUANCE OF DWC PERMIT
DWC PERMIT PAID?
DWC PERMIT NO._ �l .
BEGIN INSPECTION YES NO:
EXCAVATION INSPECTION: NEEDED:
60 NO 'C9Jw
ES NO
INSTALLER: 4, 9"
PASSED ZZ,;/j BY��
CONSTRUCTION INSPECTION: NEEDED:
i
AS BUILT PLAN SATISFACTORY: UYES
Z�� �6
APPROVAL TO BACKFILL: DATE: Z��� BY
FINAL GRADING APPROVAL: DATE
FINAL CONSTRUCTION APPROVAL:
BY
DATE:
6
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
5/12/00
This is to certify that
the individual subsurface disposal system
constructed (X ) or repaired ( )
by
Peter Breen
at
Lot 24B (20) Rocky Brook Road
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
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AS -BUILT CHECKLIST
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
/ WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
V
— DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
_ ORIGINAL STAMP & SIGNA
V I OUS AREA - DRIVEWAYS, RIVEWAYS, ETC.
NORTH ARROW .
4000 LOCATION & ELEVATIONS OF BENCHMARK USED
LOT NUMBER, STREET NAME
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
_. OF SYSTEM,
INCLUDING RESERVE
WELLING, VAMPS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
r /
V
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
/ WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
V
— DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
_ ORIGINAL STAMP & SIGNA
V I OUS AREA - DRIVEWAYS, RIVEWAYS, ETC.
NORTH ARROW .
4000 LOCATION & ELEVATIONS OF BENCHMARK USED
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System (x) constructed;
(
)repaired;
located at so l o � � � 6 r6
�, T Z y
was- installed. in conformance with the North Andover Board of Health approved plan,
System Design.Pe.,nit " , dated
, with an approved design
flow of..- - gallons per day. The materials used
were in conformance with those
speciaed on. the approved plan; the system was installed in accordance with the provisions
of 310 CTMBZ 15.000, Title 5 apd local regulations,
and the fnal 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: 4/1 4/0o
��N.,-� -y„`
Engineer Represenzative
Final inspection date: 4/19 4j28
.yy`
Engineer Representative
Installer: Lic.m:
Date:
Design En-ineer: � � _�, ;,,�
Date: 5/4/00
r
INSPECTION CHECKLIST FOR SEPTIC SYSTEMS
A. Bottom of Bed
1. Excavation to proper depth
2. With trenches, sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation, etc.
Comments:
NO Initials
/ �''c�✓�3A J
B. Retaining Wall
1. Wall height and width as specified Gl Lot
2. Waterproofed j�l/ L�� s X
3. Wall minimum 10' to leaching facility `I' r �! ` Ap- . _.;'a 4 0-
4. Wall meets specifications of plan
Comments: v
C. Building Sewer
1. Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Watertight joints
4. Inlet to tank cemented
5. Slope minimum 0.01 or 1/8" per foot minimum
6. Pipe properly set on compact fine base
7. Pipe laid on continuous grade in straight line
8. Cleanouts precede all change in alignment and grade
9. Manholes at any 90° change
10. 10' minimum offset to water line
Comments:
D. Septic Tank
1. Level
2. 1,500 gal minimum
3. Gas bale present on outlet
4. Manhole to grade
5. Manholes over center and each tee
6. 3-20" manholes
7. Inlet tee minimum 12" under invert
8. Outlet tee minimum 14" under invert
9. Outlet line cemented
10. Air space 3" above tees
11. 2" - 3" drop from inlet to outlet
12. Pipe set
13. Compact base with 6" of 1/4" crushed stone under tank
14. Tank is watertight
Comments:
PV
Yes NO
E. Pump Chamber
1. If separate from tank, compact base with 6" of 1/4" stone underneath
2. Minimum 2" pipe to d -box if gravity system
3. 20" access manhole
4. Tank level
5. Watertight
6. Tank size agrees with plan specification
7. Manhole to grade
8. Check valve and bleeder hole present
9. Alarm in building on separate circuit
10. Alarm functions
11. Manual operating switch
12. Pump delivers liquid to d -box
Comments:
F. Distribution Box
1. D -box level
2. Minimum 0.1T' (2") drop from inlet to outlet
3. Minimum 6" sump
4. Outlet pipes show equal distribution
5. Compact base with 6" of stone beneath box
6. Box is watertight
7. All lines cemented with hydraulic cement
8. Schedule 40 pipe
Comments:
G. Soil Absorption system
1. All stone double -washed - % 1 %z"
- pea stone
Bucket test done?
2. Minimum 2". of pea stone above distribution lines _
3. Minimum 6" stone beneath pipe _
4. Distribution lines capped or connected together _
5. Grading meets 3:1 slope _
6. Minimum of 9" of fill graded over system
7. Toe of slope stops minimum 5' from edge of property; if not, then swale.
Comments:
H. Leach Trenches
1. Minimum 2 trenches
2. Length of trenches agree with plan. (Max. length 100')
3. Width of trenches agree with plan - Minimum 2'; maximum - 4'.
4. Vent present if <50 feet or specified
5. Distance between trenches minimum 4' and maximum of 6'
6. Minimum distance between trenches 10'
7. Pipe slope minimum 0.005 or 6" per 100'
8. Depth of trenches below outlet invert minimum of 6".
aM
9. Pipes set on stable base.
Comments:
1. Leach Field
1. Maximum length of field 100'
2. Pipe slope minimum 0.005 or 6" per 100'
3. Separation between pipe 6' maximum
4. Pipes connected at end
5. Separation between adjacent fields 10' minimum
6. Pipes set on stable base
7. Maximum 4' separation from edge of field to first line
8. Minimum two distribution lines
9. Maximum perc rate 20 mpi
Comments:
J. Leaching Pits
1. Minimum inlet pipe 4"
2. Pits of concrete
3. Sidewall between 12" and 48" wide
4. Access manholes on each pit
5. Pipes cemented with hydraulic cement
Comments:
K. Final Grade
1. Slope over soil absorption system minimum 0.02
2. All system components covered by at least 9" soil
3. Cover soil free of stones larger than 6"
4. Grading slopes away from dwelling
5. No areas over system that may pond
Yes NO
SEPTIC PLAN SUBMITTAL FORM
LOCATION:
NEW PLANS: YES $125.00/Plan Z/
REVISED PLANS: $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES
DATE:2�
DESIGN ENGINEER: p
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans to Port
Engineering.
When the submission is all in place, route to the Health Secretary.
SEPTIC PLAN SUBMITTAL FORM
LOCATION: �° c y ,� 177
NEW PLANS:
REVISED PLANS:
YES
YES
SITE EVALUATION FORMS INCLUDED
DATE: / 2 Z 5
DESIGN ENGINEER:
DATE TO CONSULTANT:
$125.00/Plan
$ 60.00/Plan
YES NO
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans to Port
Engineering. i — - - ---
SCAM F g:E AL -CH
When the submission i also in�place, route to the Health Secretary.
S 2 31999
SEPTIC PLAN SUBMITTAL FORM
LOCATION:
NEW PLANS: YES $125.00/Plan
REVISED PLANS: YES $ 60.00/Plan
SITE EVAL/UATION FORMS INCLUDED: YES NO
DATE:
DESIGN ENGINEER: 5�e v'e
DATE TO CONSULTANT: q
*If you want your plans expedited, please submit four plans and included a stamped
envelope with the correct amount of postage to mail plans to Port Engineering.
When the submission is all in place, route to the Health Secretary.
SEPTIC PLAN S
LOCATION:
NEW PLANS: YES
REVISED PLANS:
FTAL FORM
46Z
$125.00/Plan
$ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES NO
DATE:
DESIGN ENGINEER::]
DATE TO CONSULTANT:\~`
When the submission is all in place, route to the Health Secretary. `
Town of North Andover, Massachusetts Form No. s
NORTh BOARD OF HEALTH
O � 19
� D %
DESIGN APPROVAL FOR
as�CHU SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applican
Site Location
Reference Plans and Specs
est No.
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of .Board of Health.
CHAIRMAN, BOARD OF HEALTH
Site System Permit No.
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 4,
L,5—
CURRENT INSTALLER'S LICENSEm
LOCATION:
LICENSED INSTALLER:
Yes
Ll_�
No
Foundation As -Built?
Yes
SIGNATURE:
No
TELEPHONE -44 2 % ,
L%
CHECK ONE:
FIDIX&J"r
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
575.00 Fee Attached?
Yes
Ll_�
No
Foundation As -Built?
Yes
No
Floor Plans? es ✓ No
Approval Date: /
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Nov -15-99 08:41A Paul D. Turblde, PE/PLS 508-465-0313 P.02
November 15, 1999
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MAO] 845
RE: Title V fourth review for Lot 24a Rocky Brook Road
Dear Sandra,
Enclosed find the "Checklist for North Andover Septic System Plans" for the fourth
review of the above-mentioned site. I find that this revision adequately addresses my
previous concerns.
As a minor note, the invert table in the upper right corner of page 2 shows the garage
floor as having elevation 142. The plan view on page 1 shows the garage floor and
grading of the driveway to be for elevation 139.5'. This does not affect the system
design, but I bring it to the attention of the owner.
If you have any questions or comments please feel free to contact me.
Sincerely ,
Carlton A. Brown, PE/PLS
Rockybrooklot24a4. doc
PORE'
ENGINEERING
Civil Engineers &
Land Surveyors
One Harris Street
Newburypert, MA
01950
(978)465-8594
-26-99 09:17A Paul D_ Turbide, PE/PLS
PORT
ENGINEERING
Civil Engineers &
Land Surveyors
One Harris Street
Newhuryport, MA
01950
(978)465-8594
October 26, 1999
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MA 01845
508-465-0313 P.02
RE: Title V third review for Lot 24a Rocky Brook Road
Dear Sandra,
Enclosed find the "Checklist for North Andover Septic System Plans" for the second
review of the above-mentioned site. The following is a list of all the `Problem' areas
and deficiencies Port Engineering has found.
❑ The leaching bed should be raised by 0.7'. In the upper right box of sheet 2 is the
design showing that the bottom of the field is to be 4' above ESHW. The existing
grade for the high end of the system is given as 142.2' (a reasonable elevation).
Next is stated that groundwater is 32" below the ground (GW,, 32) and the design
elevation of ESHW is given as 139.0'. This is in error as 142.2' minus 32" is
139.5'. Also, it appears that Test Pit 96-3 should be used to determine ESHW, and
ESHW was observed to be 30" down, not 32" down. This would mean that ESHW
probably should be 139.7'. The bottom of trenches should be 4' above this, or
elevation 143.7'. The plans show this bottom elevation as 143'. Thus the system
should be raised 0.7'. (Note that this would require the retaining walls to be made
higher, and that the slope encroachment on the southerly side would be more.)
❑ The proposed fill for the south side of the leaching bed is encroaching onto abutting
land shown on the plan as being owned by "No And Rlty Tr". The encroachment is
minimal and the abutting land is also presently owned by the owner of Lot 24a and
thus perhaps this slight filling over the line could be allowed. Other alternatives
would be to create a slope -fill easement or to continue the retaining wall around this
lot line to contain the fill.
❑ The northerly retaining wall is shown to have a top elevation of 145.0'. 250 CMR
15.255(2)(f) requires that the top of wall be the same elevation as the "breakout"
elevation which for the design shown would be about elevation 146'
If you have any questions or comments please feel free to contact me.
Sincerely
Carlton A. Brown, PE/PLS
Rockybrooklot24a3.doe
Sep -24-99 02:49P Paul D. Turbide, PE/PLS
September 24, 1999
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MA 01845
508-465-0313 P_02
RE: Title V second review for Lot 24a Rocky Brook Road
Dear Sandra,
Enclosed find the "Checklist for North Andover Septic System Plans" for the second
review of the above-mentioned site. The following is a list of all the `Problem' areas
and deficiencies Port Engineering has found.
u The proposed fill for the south side of the leaching bed is encroaching onto abutting
land shown on the plan as being owned by "No And Rlty Tr". It appears that the
retaining wall must also run along this lot line.
o The retaining wall design is not shown directly on the plans, however the plans do
state: "Ret wall: See Neve Plan". A one page design (on 8 t/2" by 11" paper) was
included that was stamped and signed by Charles Quigley III, PE. It is not clear to
me whether a Professional Engineer as required in the regulations has designed the
specific retaining wall shown on the design. The Quigley design was apparently
prepared for TKO Development Inc. which is neither the applicant (Flintlock Inc)
nor the design engineer (Steve Durso). Thus it appears that the one page retaining
wall design may have been for another site and was just xeroxed and included in
this filing. This is further supported by the plan stating that the retaining wall
design is shown on a plan prepared by Neve.
❑ There are actually two retaining walls required for this design: one is a 2 to 3 foot
high retaining wall on the east side of the system by land of Whitmyer. The other is
a 12 -foot high retaining wall by the proposed driveway. The one page retaining
wall design specifically states that the retaining wall design is only for a maximum
of 2 feet high. Thus the design is inadequate for the conditions shown on the plan.
❑ The length of the proposed retaining walls is not shown on the plan.
As a general comment, the proposed foundation sill is at elevation 150, while the garage
ODW
floor is proposed at elevation 135. Thus there is a 15 foot difference between the two.
It is unknown whether the homeowner will want to have a garage that is 15' high, but
itI
he or she should be aware that this is what is proposed.
ENGINEERINGIf
you have any questions or comments please feel free to contact me.
Civil Engineere &
Land Survevors
Sincerely
One Harris Street
Carlton A. Brown, PE/PLS
Newburypurl, MA
01950
Rockybrooklot24a2.doc
(978)465-8594
Town of North Andover NORTH
OFFICE OF 3? 0; t" . o ° ,4, oma
COMMUNITY DEVELOPMENT AND SERVICES A
27 Charles Street : �9
North Andover, Massachusetts 01845 �9ssACHus�t�y
WILLIAM J. SCOTT
Director
(978)688-9531 Fax(978)688-9542
August 11, 1999
Steven D'Urso
22 Lilly Pond Road
Boxford, MA 01921
RE: Lot 24A Rocky Brook Road
Dear Mr. D'Urso:
This letter is to inform you that the proposed septic plan for Lot 24A Rocky
Brook Road, North Andover has been disapproved for the following reasons:
1. Septic tank missing manhole to within 6" of final grade. (310 CMR 15.228(2))
2. Septic tank and d -box missing six-inch stone base. (310 CMR 15.221(2)).
3. Septic tank tees do not extend 6" above the flow line. (310 CMR 15.227(1)).
4. Septic tank inlet tee does not extend minimum of 10" below flow line. (310 CMR
15.227(6)).
5. Septic tank outlet tank does not extend minimum of 14" below flow line. (310
CMR 15.227(6)).
6. Soil tests were performed more than two years ago. (NA 7.05)
7. Street number, map and lot number missing from plan. (310 CMR 220(4)(u)).
8. Names of abutters missing. (NA 8.02j)
9. Distances from system components to property line missing. (NA 8.03b)
10. Toe of fill slope must stop 5' from the property line or a swale must be installed.
(310 CMR 15.255(2)).
11. Leach area less than 4' above ESHW adjusted for high point of existing grade.
(310 CMR 15.212). Highest elevation 144.2'. ESHW 30" down. Thus elevation of
bottom of leach area should be 1457.
Please do not hesitate to call the Health Department at 978-688-9540 if you have any
questions.
Sincerely,
Sandra Starr, R.S.
Health Administrator
Cc: D. Kindred
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Aug -11-99 10:04A Paul D. Turbide, PE/PLS
PODRT
ENGINEERING
Civil Engineers &
Land Surveyors
One Harris Street
Newburyport, MA
01950
(978)465-8594
August 11, 1999
508-465-0313 P.02
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MA 01845
24A
RE: Title V review for Lot 29a Rocky Brook Road
Dear Sandra,
Enclosed find the "Checklist for North Andover Septic System Plans" for the above-
mentioned site. The following is a list of all the `Problem' areas and deficiencies Port
Engineering has found.
❑ The septic tank must have a manhole brought to within 6" of the final grade 310
CMR 228(2)
❑ A six inch stone base must be placed under the septic tank 310 CMR 221(2)
❑ A six-inch stone base must be placed under the dbox. 310 CMR 221(2)
❑ The septic tank tees must extend 6" above the flow line. 310 CMR 227(1)
❑ The septic tank inlet tee must extend a minimum of 10" below the flow tine 310
CMR 227(6)
❑ The septic tank outlet tee must extend a minimum of 14" below the flow line. 310
CMR 227(6)
❑ Deep test pits were performed more than two years ago. NA 7.05
❑ Street number and map and lot number must be on the plan. 310 CMR 220(4)(u)
❑ Names of abutters must be on plan. NA 8.02j
❑ Distances from septic tank, leaching and reserve areas must be shown to the
property line. NA 8.03(b)
❑ Toe of the fill slope must stop 5' from the property line or a swale must be installed.
310 CMR 255(2)
❑ The leaching bed is not four feet above ESHW adjusted for high point of the
existing grade over the bed. The elevation of the high point of the existing grade
under the proposed leaching bed is about 144.2'. ESHW is 30" down. Thus
elevation of ESHW at the high point is about 141.7'. Bottom of the leaching bed
must be four feet above ESHW or elevation 145.7'. The proposed design has a
bottom of bed elevation of 142', which would only be a 0.3' separation. Thus it
appears that the leaching bed must be raised by 3.7'.
If you have any questions or comments please feel free to contact me.
Sincerely
Carlton A. Brown, PE/PLS
Rockybrttoklo t24 a. doc
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street
North Andover, Massachusetts 01845
W LLIAM J. SCOTT
Director
January 7, 1997
Steve D'Urso
22 Lilly Pond Road
Boxford, MA 01921
Re: Lot 24A Rocky Brook Road
Dear Steve:
This is to inform you that the proposed plans for the site referenced above have been
disapproved for the following reasons:
,to ,
1. Foundation drain missing. (N.A. 6.02V)
2. Gas Baffle/Deflector required on tank outlet. (3 10 CMR 15.224)
3. Statement: First 2 feet of pipe from D -Box to be level. (3 10 CMR
15.232(c))
4. Final Grade over SAS doesn't show 2% slope for drainage. (3 10 CMR
15.240(10,11))
5. Note: Excavation of top & subsoil must extend 6 inches into parent
material. (N.A.2.18)
6. Note #3 concerning fill should be updated to reflect 310 CMR 15.255.
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
l
Sandra Starr, R.S.,
Health Administrator
SS/cjp
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALI-d 688-9540 PLANNING 688-9535
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
FEE: 40 PERMIT ## DATE RECEIVED IZ-16 (,
APPLICANT 7�rIbV-�,e- _L-/U�, MAP PARCEL
ADDRESS��B �3% �, RNLI uP,re LOT # STREET ##
ENG. %GLiG "Le, -6 STREET`QGCY
ENG. ADDRESS
PLAN DATE. /��C��C REV. DATE
CONDITIONS OF APPROVAL
APPROVED DISAPPROVED
REASONS FOR DISAPPROVAL:
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Com. A)67�5-��
SEPTIC PLAN SUBMITTALS
LOCATION:
NEW PLANS:YES $60.00/Plan
REVISED PLANS: YES $25.00/Plan
DATE: Z Qi
DESIGN ENGINEER:
When the submission is all in place, route to the Health Secretary
c
Town of North Andover, Massachusetts Form No. 2
O� MO oTq, BOARD OF .HEALTH
o �
4 DESIGN APPROVAL FOR
ws SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant_. Test No.
Site Location Qx) Ce" &L ' Z l
Reference Plans and Specs.
GINEER
`.Permission is granted for an individual`soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
0
Fee Lo
CHAIRMAN, BOARD OF HEALTH
Site System Permit No.
�ORTH
O� at`E° '6.gti0
Applican
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 1
APPLICATION FOR SITE TESTING/INSPECTIO
r er)rlPP TFIFP
Site Location `- 9-2�r-�� &A - f e—J
Engineer q-- -'b
NAME `ADDRESS TELEPHONE
Test/Inspection Date and Time
AIRMAN, BOARD OF HEALTH
Fee � � � -'� Test No.
(CO
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
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CHRISTIANSEN & SERG1, INC.
PROFESSIONAL ENGINEERS AND LAND SURVEYORS
160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508). 373-0310 FAX: (508) 372-3960
606417701,1 -SOP- hYSTS, l�€arO9ME- 1�Ir4 i`i �3 v/c
F9ANr, J�IA/UCCo ON COT- Z4/4 / �IJ IEZ4)
N7F� l B�POO,�
\ \ EALTY TRUST
3
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\ \\ \ \ \ X900 l NIF ROCKY BROOK
REALTY TRZIS7
el 1130
TP
BENCHMARK \
O \ T9NK AIL
" �70P SC/BSO/L
TO BEREMOV \ N
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z LOT Z3.4
ROCKY
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.. ,FORM 11 - SOIL EVALUATOR FORAI
Page 1 of 3
No. Date:
Commonwealth of Massachusetts
/leo JvA , Massachusetts eN0 NO -" ' H
Soil SuitabUio Assessment for On-site Sewage Ditstaasal
'-Z-�;' . Cta
102 Date:
Performed By.
Witnessed By:
L=Ama Address Of Owrcr's Nurc.
LAI 0 Address, and C—
&ay
n Eq- e air ❑ tl",6
t,
ew Constructia M
Office Review
Published Soil Survey Available: No ❑ Yes
Year Published �Publication Scale y"�G.G7 Soil Map Unit
Drainage Class Soil Limitations . . ................
Surficial Geologic Report Available: No ❑ Yes ❑
Year Published Publicatic i Scale
GeologicMaterial (Map Unit) ........................................ .................. --..................................... .... ...._.........................
.............................
.__..... . _... ...... —
Lan lOrm
Flood Insurance Rate Map:
Above 500 year flood boundary No ❑Yes
Within 500 year flood boundary No lJYes ❑
Within 100 year flood boundary No 6yes ❑
Wetland Area:
National Wetland Inventory Map (map unit) ....................... ............................................ .....__......................
P Ma (ma unit) .............. :.................................................. I ................. I ............
_
Wetlands Conservancy rogram p p
Current Water Resource Conditions (USGS): Month
Range :Above Normal 2Normal ❑ Below Normal ❑
Other References Reviewed:
DEB APPROVED FORM - 12/07195
a
f
• FORM 11 - SOIL EVALUATOR FORM
Pagc ? of 3
Location Address or Lot Ivo. '2 /49 /a
On-site Review
_r
Depth from
Surface (Inches)
Deep Hole Number Date:
Time:
Location (identify on site plan) A.��l�✓C
Land Use Siope (°'o)
Surface Stones
Vegetation
Landform iYy�'�f%lfiYt�
Position on landscape (sketch on the back)
��L
Distances from:
Open Water Body feet
Drainage way,>/L90 feet
Possible Wet Area �1100 feet
Property Line ie feet
Drinking Water Well /11A feet
Other
Weather
DEEP OBSERVATION HOLE _OG�
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
I Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders. Consistency, %
I Gravel)
a -
FS'L
7�-�12`f
..... .......... ... .. . ...� .. ..v...r.. r. • v • r•.. . •v• vJ•.v v•J� VJnL MnCM
Parent Material (geologic) Depthto8edrock: Z
Depth to Groundwater: Standing Water in the Hole: �'1 Weeping from Pit Face: _
Estimated Seasonal High Ground Water:
kiDEP APPROVED FORM . 12/07/95
Percolation Test*
Date: Time:
Observation Hale ,4,
Depth of Perc
Start Pre-soak
LO 05
End Pre-soak
Time at 12
Time at 9"
d ..'
34,
Time at 6"
Time (9"-6")
Rate Min./inch
7
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed Site Failed ❑
.., ............... ... .. .... . ........................ ... .... ............ . ............ I ........................ ..................
Performed BY:
Witnessed By:
Comments:
1ADO XFMOY= rORM
COMMONWEALTH OF MASSACHUSETTS
�' /", Massachusetts
Percolation Test'
Date- Time:
Observation Hole
Depth of Perces
Stan Pre-soak
End Pre-soak
t9q
Time at 12"
Oq
Time at 9"
Time at 6"
Time (9"-6")
Rate Min./inch
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed 2She Failed El
.................
Performed BY:
Witnessed By:'
Comments:
Do Amoy= rORM - Ulvlgj
FORUM 11 - SOIL EVALUATOR F+QZ,1'�1
Page 2 of 3
Location Address or Lot Ivo. Z A
On-site Review
Deep Hole Number 96 .z Date: Time:. Weather
Location (identify on site plan)
Land Use Use Si pe (°'o) Surface Stones Yes
Vegetation
LandformyC�
Position on landscape (sketch on the back)
Distances from:.
Open Water Body feet Drainage wayfeet
Possible Wet Area 2l00 feet Property Lines feet
Drinking Water Well A11A feet Other
DEEP OBSERVATION HOLE _OG'
Deoth from
Surface (Inches)
( Soil Horizon
Sod Texture
(USDA)
I Soil Color
(Munsell)
Soil
Mottling
I Other
(Structure, Stones, Boulders, Consistency, %
I{
Gravel)
a-
A
goy/24f3
Fs z
Parent Material (geologic) ` v"V� L �--^ v vV`y V 1J' v DepthtoSedrock: Y6 17
Depth to Groundwater: Standing Water in the Hole: y Weeping from Pit Face: _
Estimated Seasonal High Ground Water: ��—
lx .AFi x..-�_i_,_E�1: �„9..rrani six:.zci+.'x i++ xrY'- •,„„4 ".`cw .a, a.R r r t+...
xd*erd2r.T-tir"`� �d'P �'���,ka3"a. ' s" z .,} �a+?4 a•• 2 - s-
RINI
..f�^+z^'� �y.�.'���' � t•••�Alr_e..•r'a:� .Nl'�^C.-,�rs a �>..t.y 4, . a._�t•*��" `^-�. ,- ^�yrs�' a .� ' -c- 4 �... 2 a a T ar . _ ,
�c� h, "" _- FOR.�1 11 'SOIL FVALL�TOI2
Locatlon_ddress pt_Lot- vo,. _
On-site Review
--
Deep :Hole 'Number ; Date.' Time: Weather`
.__-.
-- Location (identify—6n site plan)
Land Use Siope (o!o) Surface Stones
Vegetation
Landform
Position on landscape (sketch on the back)
Distances from:f
Open' Water body , " fest Drainage way feet
Possible Wet Area ` S� feet Property Line ems*
Drinking Water Well. /I/A feet Other
-DEEP OBSERVATION HOLE
I
i
Deoth ;ram
Surface Ilncnesl
Soil Horizon
I
Soil 'exture
(USDA)
Soil Color
(Munselq
Soil I Other
Mor -cling (Structure, Stones. Boulders. Consistency, 'ro
Gravel)
d.- ..:
A:_
.�bw
B 410Y
,{ %
HOLES REQUIRED
A I EVERY
PROPOSEDI l ARPA
Parent Material (geologic) —7—/ L_ L__ OepthtoBedrock: /0V
Q i
Oeoth to Groundwater: Standing Water in the Hole: If Weeping from Pit Face: 1910 _
Estimated Seasonal High Ground Water:
30 `r
DEF APPROVED FORAM • 1=/07195
03-21-1996 14:36
517 932 7615
OEP NORTHEAST REGIONAL P.02
FORM 12 - PERCOLATION TEST {
Location Address or Lot No..
COMMONWEALTH OF MASSACHUSETTS
i Massachusetts
Percolation Test'
Date: -_ Time:
Observation Hole x
Depth of Perc
Start Pre-soak `
I
Erid Pre-soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate Min./inch
* Minimum of 1 percolation test must be performed in both the primary area AND.
reserve area.
Site Passed ❑ Site Failed ❑
.................. ............__.................. ..... ... .................__.....................................................
Performed By:
Witnessed By:`..
Comments: ___._..:..... ,.._ . _.
osa xFMOvm rows . UM/92
FORM I1 - SOIL EVALUATOR FORM
Page 3of3
Location Address or Lot No. 9142`1-9
Determination ,for Seasonal High Water Table
Method Used:
t.
epth observed standing in observation hole inches o
H�Pi6pth weeping from side of observation hole'- inches.
d
Depth to soil mottles .3& M inches 1 ,30
❑ Ground water adjustment ....... feet
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 al aeras
observed throughout the area proposed for the soil absorption system?
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on l/ (date) I have passed the soil. evaluator examiriation
approved by the Department of Er-Mirorimehtal 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 J2 Date 1112 9
/9'�'/
DEP APPROVED PORN - 11/07/95
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FORM U LOT RELEASE FORM
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 or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION*********************** I
APPLICANT R&ME KAY
x11**1(:;5 PHONE -5_?= $(o
LOCATION: Assessor's Map Number 9014 PARCEL—DO-3,?
SUBDIVISION LOT (S)q
STREET o ��� ST. NUMBER 90 1
************************************OFFICIAL USE ONLY***********************************
RECENMENDATIONS,OFTOWN AGENTS:
/ CONSERVATION
COMMENTS J)F
TOWN PLANNER
COMMENTS
F.
DATE APPROVED .5jg O ®3
DATE REJECTED
a
4a- e)LAK.',L h(6 / hu
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH
DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR -HEALTH
DATE APPROVED b
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECT
Revised 9\97 im
C
TE
SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 2'
Workers Compensation Insurance affidavit must be completed and submitted
in the denial of the issuance of the 'building permit.
Signed affidavit Attached Yes ...... No ....... 0
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building ❑ 1 Repair(s) ❑
this application. Failure to provide this affidavit will
Alterations(s) ❑ I Addition t
Accessory Bldg. ❑ I Demolition ❑ I Other ❑ Specify
Brief Description of Proposed Work:
�'piY� 2 L11(� C�►sAR�r�••�rC `tom (Z� � [% X t.� � �,�.Iz �-
1 SRC'TFON 6 - Ti.iTTMATF-n !Vl1NCTT?TT! TTnN �ncmc
Item
Estimated Cost (Dollar) to be
Com leted b rmit a licant
(a) Building Permit Fee
Multiplier
1. Building
C 6
2
Electrical
(b) Estimated Total Cost of
Construction
3
Plumbing
Building Permit fee (a) x (b)
4 Mechanical HVAC
5 Fire Protection
6
Total 1+2+3+4+5
Check Number
aia�AV111Vi\1LJL111V1\ 1V DL' l,VD7.rJUr11 EV Wt1lA I
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, -.5'4Y'd411 , as Owner/Authorized Agent of subject -property
Hereby authorize to act on
My behalf, in all matters r wo�rk authorized by this building permit application,
Signature of Ovaifr Z Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
Li
Print Name
of
6 — 12,q
a
Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TINMERS iST 2 ND 3RD
SPAN
DIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHDANEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
• pl`! � �DDr� �`�
I
TOP OF WALL EL. VARIABLE.--,
1" CHAMFER
BOTH SIDES.
FINISHED GRADE.
3/4"-
2 3/4"
MIN.
TYP.
2'-0"
M kx.
c '
v c
B�pPE•. � I, !�!6
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P�N�SN�O
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- I —�" �A�KkI 1 b R 15 Ptl SIY T� R� UDR N�ENTS: '1 I
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-
S ITABLE \# 41S
32"8.C. % j/\
BROW %
/IN 12" LIFTS. -7 i / \
j
#/4-S (a� 16' ,LENGTH VARitS f O'M�Ef \' j\ `
%WALL HEIGHT AND COVER REQMT,!S.,\;
MATE IAL` / AS SHOWN. SUITABLE/
BORROW ! \V IGINALMAfE211
COMPACTED
4--0-,s IN 12'�LIFTS.
N.
\ \/ \��/j ✓ 4 v 110a c 2�4""X 8" ANGLE @ 16" O E
. / MAX. /
\\/� \� / REINFORCED CON CRETE \ •;;i�\��\\� \
RETAINING WALL. v
fc' =;4,000 ps.L Thin.
F,,y'140,000 ps:f min.
LONG. TRP AND BT//
,2 X 4 KEYWAY. 24"'6'Oi
.
\ \ \
# 4'S
\
¢4�INIllIAL,CQINP GEED 70 95°T MIN ,D�2Y hDEAN
RETAINING WALL SECTIONcy ` v
TKO DEVELOPMENT INC. "
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SCALE: I"=
f.
i{ 0" 6" 1'-0"
THE ROBERT CHARLES GROUP
160 WINTHROP SHORE DRIVE, WINTHROP, MA 02162 (617) 846-0144 DATE:
s