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Miscellaneous - 205 FOREST STREET 4/30/2018
N C N l SIL Lot & Street FOreS T— S�rte Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: NO Permits Q I?� " 1oL Plan Approval: Date: %d/7/�� Approved by: Designer: C {9 (05606L , J�—Plan Date: Conditions: Water Supply- _ Town Well Permit: ` Driller: Well Tests: Chemical Date Approved Bacteria I Date -Approved Bacteria H Date Approved---- Plumbing Sign -Off: _ -Wiring Sign -Off: Comments: Form "L"' Approval: Approval to -Issue: Date Issued By: Conditions: YES NO , Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO 1 Certification? YES NO 'r Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: r r DATE: APPROVED BY: t r SEPTIC SYSTEM INSTALLATION Is the installer licensed? O Type of Construction: NEW NO New N� New Construction: .__Certified Plot Plan Review YES NO -Floor Plan Review YES NO _ Conditions of Approval from Form U YES NO _Issuance of DWC permit:- NO _DWC Permit Paid? -- <�, NO - DWC_Permit #-j/�= Installer: - BegfiiInspection:_ _ NO - Excavation Inspection: Needed - Passed: By:_.. - --Construction Inspection: Needed: As -Built -Plan Satisfactory: YES.- Approval ES:Approval of Backfill: Date: 7 By: -Final Grading Approval: Date:/9L7 By: Final Construction Approval: Date: / By:/ Certificate of Compliance: Approval:- ', OA Date: LA!L19 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 M V• t5form4.doc• 06/03 EIV JUL 31 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left /igh rear of hous Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address a D s fioc-eS+ 5�- .� w r- City/Town State _ Zip Code 2. System Owner. �-b Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingDa? uantity Pumped: Gallons F 3. Type of system: ❑ Cesspool(s) ;/Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: f M Q v -e 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G. Ej SW Lowell Waste Water -7 - n e Haule Date System Pumping Recons • Page 1 of 1 Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumping Record System Owner System Location Type: Emergency Routine w (� Cesspool: IVo (/ Yes Septic taut: W =Yes Cate of Pumping: e!"I �' 03 Quantity Pumped: Gallons System Pumped By: Wind Riau Environmental, LLC Permit #: Contents transferred to: 1_., w."i 4 R it u r East FITIn'burg 1A1-,�� e {� . Plant, WP'", Plant, Contents Disposed at: Mi -k. MA. Cate: Pumper signature: Co clition of System/other Comments Dep Approved Form - 12/07/95 c;214Y4 mcy—tit o, FORM U LOT RELEASE FORM eyR4k3.e -Div �� t<c� .uW.v f --ACK . I2001H�Z•" INSTRUCTIONS: This form is used to verify that all necessarya rrhi Boards and Departments having jurisdiction have been obtaine. This does not rfromrelieve This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** APPLICAN� T_ ��✓ �f 6 f2�E'Sfi PHONE �/— r �39 LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET -,2&5 ST. NUMBE *****************************************OFFICIAL USE ONLY*********************************** LRECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMME NSPECTOR-HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED �s qAT E DATE 1� L._ 1-n 7-6 SS �/� �� cam. ' 'cz PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9\97 jm TE Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street. <: North Andover, Massachusetts 01845 �4ss "CH USwt" �y ACH Sandra Starr Telephone (978) 688-9540 Health Director Fax (978) 688-9542 October 1, 2001 William and Gail Tarbox 205 Forest Street North Andover, MA 01845 Re: Application for an Addition Dear Mr. and Mrs. Tarbox: The Health Department has reviewed your application for an addition at 205 Forest Street. The application was denied on October 1, 2001 for the following reason: The current septic system was upgraded in 1998 and a variance from the current Title V regulations was granted for the separation to groundwater. The variance allowed the system to be constructed 3' above the seasonal high groundwater table. Under the Title V regulations, no new construction is allowed to take place which utilizes a system that has this variance. The subsurface sewerage disposal system must be upgraded to comply with current Title V Regulations for any new construction. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, 10�e� an J. LaGrasse Health Inspector Cc: David O. West, 92 Lamoille Ave., Bradford, MA 01835 Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 WILLIAM J. SCOTT Director Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 30 School Street North Andover, Massachusetts 01845 October 7, 1998 Ben Osgood, Jr. New England Engineering 33 Walker Road North Andover, MA 01845` RE: 205 Forest Street Dear Mr. Osgood: Pursuant to our meeting earlier today, your request for a variance for a 3 foot separation to groundwater at 205 Forest Street has been granted. With this variance, the proposed plans for the repair of the septic system at this location are approved. Please call the office if you have any questions. Sincerely, Sandra Stair, R.S. Health Administrator �r Z 4 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 07/29/99 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X ) by Paul St. Hilaire at 205 Forest Street 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 as described in the Design Approval Site System Permit # 988-12 dated 10/07/98. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector Town of North Andover, Massachusetts BOARD OF HEALTH 7 199R DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant T k-- �� Test No. Site Location o2 D Reference Plans and Specs. ENGINEER SIGN r DATE Permission is granted for an individual soil absoprtion sewage disposal system to be installed in accordance with regulations of the State and the Board of Health. BOARD OF HEALTH Fee . ib Site S i.)- ystem Permit No. qUQ' - i.) vl JJ P.91• • t . t j 1 t • TO`4`VN O)FNORTE A NDO VER SEIV_aCrF,,D(SPOS I. c X\ -ST L TIOi`r CERTIFICATION �vTEi1,I , The urtdersisrned hereby ce 7L6r that the Sewage 1Disposzl Svste'n i' ) co::szr, ctc located aC 2 e),5r was insailed is contarruance wizh.ti;e North Andover Board of die: lEh approved plan. S,vsteri Design Per:ritM. o"aated 1D- , -q $ with an annro� desigt, rlow at . g;dlens per day The rnatenctis used were is cortiortnan - c - - ire se speciiieo on tl G apprr_. c';; plan; the system was instalicd in a,ccordarl;c t�tviirh the prc� isicns of 310 C�1� 1 . ;;c � an+d l,ocal regulations, and the Snai grading agrees substantially Tian, All wprk is accurazey represzazed Or, the As-buiit which has be -_,7 BoardO `'-lealth, Bed Final in,pcc,nFa-crce- Instz:rr: Design Engineer, �Poz-(- (f e- � Eat+ree„ Kepres �•------•,. Lic. .l31- 9 mate:AD v _ Dace: "gyp 7 I AS-BUILT CHECKLIST l� LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATION & DEMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA y LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION �\ LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM LOCATION OF WATER,-GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D-BOX / v STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. y NORTH ARROW FINAL CONTOURS l/ LOCATION & ELEVATION OF BENCHNLARK USED �/ LOCUS PLAN .1 i..;" • ^:•,,:1 �. -313 P. 03 c:1` A idcve, 'i;:ptic S,s - n plans" :'Or the above - r r,c e T'nt ! r.,; s a i,sc , a:i e'�e `f'rob!em' a Aar a+i ue*iciencies Port .i..)ns, ho>vevvi a 'Lillp _ . S'S ',e r«,, r r 1.006 ert) peering practicc 4. Ells is a small 5yster t ,_ ,;.IL rant co-,.arnr .iced, r ro requested 3., , ,� :jrrrr.e-'.+ �1 tree to conta-t us. '.3: , ,% APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: �,� - [�- c( `'� CURRENT INSTALLER'S LICENSE#_3l _tet LOCATION: aD S�r5 S 1. N , I�•,�v .Jew LICENSED INSTALLER: SIGNATURE: % TELEPHONE# 7�- 3 `t (� �d.Cf( CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes No Yes No Floor Plans? es No Approval Date: 16. / �' q ............................................ TO **« CD G N ° •'A'. Z `) o w y � O a � Z m " CD O a 77 O D � ° � D r, 0 a N Z C D� m m D t4 O m m l p r m O -, -0 3 2 o '*. O w m 0 0 0 °z 74 a APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE://— / .l 7? CURRENT INSTALLER'S LICENSE# LOCATION:4O.S r -r_5- 7_ S,T LICENSED INS A ER: ~�h� C en- SIGNATURE: c, - ELEPHONE# CHECK ON : REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes No Floor Plans? /Yes No Approval �_"CL/J Date: ���/ Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH `J,t '696 0 7 19 A '4 f--` CO ^b APPLICATION FOR SITE TESTING/INSPECTION Applicant�1:;O'XSC.-),A NAME ADDRESS TELEPHONE Site Location ACom— Engineer /V NAME / ADDRESS TELEPHONE Test/I nspection Date and Time `016A? c CHAIRMAN, BOARD OF HEALTH Fee �/ j ��� Test No.0!!24 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION \� nDR4 TED APP\i'�y Form No. 1 19 Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. 'a° , BOARD OF HEALTH 146 MAIN STREET TEL. 688-9 540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: q` z 3) q-7 LOCATION OF SOIL TESTS: ao5- Fo Assessor's map & parcel number: t o 6 ij i -a7- -45- OWNER: CS-cLd %l -box TEL. NO.: ADDRESS: 'a oS f�� r -es fi sf� IUGR. _r--.-kCW-it Al0 EvtGt •�.� E E2t.ne (,- ENGINEER:_TEL. NO.: CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial 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 $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of $75.00 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. 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. 0 9 17 O \Y T� CL L m h Q -n z Av O rt O v 0 n c o cD a O a o n D Q' O CD —� a1 �; 1 O m -s O_ O � rr Q• N O I � V rt � 1 3 7 3 Q (D I 'r 3 D 'D S fr J � t ♦' f E Q 3 rt 7 _ O 3 fy � 1 CL 1 � I 0 9 17 O \Y T� CL L m h Q -n -/x 111 s5 SIL Town of North Andover ot rORTh OFFICE OF?•�,••' ,•,+o°c COMMUNITY DEVELOPMENT AND SERVICES - * 7 30 School Street WILLIAM 7. SCOTT North Andover, Massachusetts 01845 �'SSAcHustit�y Director OUTSIDE CONSULTANT ESCROW AGREEMENT NORTH ANDOVER BOARD OF HEALTH Agreement is made this � QIM between the Town of North Andover and �(Yl �" �x 0 1 A A -IK -Q of for Soil Tests, Plan Review ----------------- c5 c KNOW ALL men by these present that the Applicant hereby provides the Town of North Andover with a check in the sum of $ >a5-4 , to be deposited in an escrow account for the Town of North Andover and has deposited in an interest- bearing account as designated by the Town Treasurer to be expended by the North Andover Board of Health to insure payment to any outside consultant(s)for Soil Tests, Plan Review for the above referenced project. This agreement shall remain in full force and effect until the specified project has reached completion, U' oard of Health Chairman or Agent _ g1 "9, Da®— -- Applicant NEW ENGLAND ENGINEERING SERVICES, INC, 53-7058/2113 SS 33 WALKER RD., ST&23--PH. 978-686-1768 887807675 2742 NORTH ANDOVER, MA . 01845 DATE PAY TO THE ORDER OF DOLLARSB IPSWICH SAVINGS BANK 1PSMCK KkSSACHUSErPS 01938 MEMO -� -7: 2 1 13 70 58 7�: 88 780 76 7 S11. R2 ---- No. e -.I-' FORM 11 - SOIL EVALUATOR FORM Page I of 3 Date: Commonwealth of Massachusetts 1ye. Massachusetts Soil Suitability AssessmentforOn-site Sewage Disposal Date: Performed By. ..... Witnessed By: .... .. ..... ...... . ................ .................................... ..................................... J,=tjon A6dre4S orOwner's Nam, 6,0e,,e— Lot I zo—r Address, and AV , Tcleptxw 1 94�5— New construction 0 Repair 10 Office Review Published Soil Survey Available: No El Yes Year Published 470V-...----. Publication Scale Soil Map Unit Drainage Class 09,4 Z- ...... Soil Limitations ..... .. ....... ........... ... Surficial Geologic Report Available: No KI Yes El - Year Published Publication Scale -...-.--- GeologicMaterial (Map Unit) .................................................................... .......................................... .. .. ..... . ........... Landform.......................................................................................................................................................................... ..... .......... Flood Insurance Rate Map: Above 500 year flood boundary No E]Yes Within 500 year flood boundary No El 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 nNormal 0Belau Normal ❑ Other References Reviewed: — WDEP APPROVED FORM - 12/07195 FORM 11 -SOIL EVALUATOR FORrvj Page 2 of 3 Location Address or Lot leo. On-site Review Deep Hole Number Z Date:. Time:./'!'J� Weae0f/'7- i Location (identify on site plan) ,P��f,�.•.!...•eT�' 3't- •••� �E . Land Use Slope M Z . Surface Stones 1 -41 - Vegetation.. -41- Y .... . Vegetation :. GD..... .....:... ......• . Landform Position on landscape (sketch on the back) Distances from: Open Water Body feet Possible Wet Area �'sb. feet Drinking Water Well .�1�'� feet Drainage way .�.� feet Property Line ....:. feet Other . ..�.................. DEEP OBSERVATION HOLE LOG* Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) s AO Novy :%L O - l0.2 0.►, vA/ 1'-2ex A91 / AV, - mi vgiiviuivi yr C riVLCJ nCLLu1nrU Mi LVGnI rnvr VOCV L/IJrVJML Mn LM Parent Material (geologic) Gioss!_T %%�- Z- DepthtoBedrock: ©,r Death to Groundwater: Standing Water in the Hole: � Weeping from Pit Face: _AS -4 Estimated Seasonal High Ground Water: .J.._ DEP APPROVED FORM - 11/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. On-site Review / v Deep Hole Number / Date: '�!3/gam Time: WeatherC� . � G'TI� - o fi Gly �1 L✓�ci� Location (identify on site plan)�.,.i?..:::....:...:......::. j.:..:.:.:.:..:.... ....:.:..:.::..,.......- ........_,.. . Land Use � s crrr, Slope M Z Surface Stones . IVi4Y Vegetation .. ld� ... �:...:.. :.:... ...:....:.:::... .... . : . Landform .. �� "� p Position on landscape (sketch on the back)' ..S! :. �✓!'`�. Distances from: Open Water Body y�� feet Drainage way. -b.. feet Possible Wet Area.Z-� feet Property Line . .... feet Drinking Water Well >/tea feet Other DEEP OBSERVATION HOLE LOG* Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) ^� —Q (2W 6616 v 8[ L.5 2S� sI3 � -y/Z Ig - vAim Ivlvlvl ur C nvLw nr-VU IInn cvTll 1 FV Cm f-nvrwcv W-WOML 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 - 12/07/95 -1 .4 FORM 11 - SOIL LVALUATOR FORM Page 3 of 3 Location Address or Lot No.Z 7Q6r.% Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole .................. inches ❑ Depth weeping from side of °bservation h le ........... .... inches ❑X Depth to soil mottles ....:::.".... inches' ❑ 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 all areas 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 (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 ' / Date - �3 DEP APPROVED FORM - 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 Date: -� / ?195 Commonwealth of Massachusetts Massachusetts Soil Suitability t for OnDisposal' Performed ..... Date:. . ................ .................................... .................. I ................... Witnessed By: Owner's Narm, Location Addrus of �7- Aftas, and Lot I > Tcfephm 1 5 ?;7 & pew construction 0 7Repair Office Review Published Soil Survey Available: No El Yes Year Published I'70Z ......... Publication Scale Soil Map Unit 1. ,6.e ........ .... Drainage Class 4�a,6 �:t ...... Soil Limitations 7 ?PXD ...... J'Z�- -- . . .... ...................................... ........... .. Surficial Geologic Report Available: No R1 Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) ............. I ...................................................... ............................................ .. .. .. . ............ Landform.......................................................................................................................................................................... ..... .......... Flood Insurance Rate Map: Above 500 year flood boundary NOE] Yes Q Within 500 year flood boundary No E]Yes 0 Within 100 year flood boundary No 0Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Non -nal ONormal NIBelci-iNormal El Other References Reviewed: aDEP APPROVED FORM - 12/07195 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot leo. ZZS �T. /Xv ,�Cll�sa On-site Review 2 �/ A� o Deep Hole Number Z Date:.%348 Time:. . %. Wea ef��"�� Location (identify on site plan)jj�....:..C'T Land Use Slope (%) Z. Surface Stones!% Vegetation�� Landform Position on landscape (sketch on the back) Distances from: Open Water Body �`�'� feet Drainage way o feet Possible Wet Area Z`Sb. feet Property Line ....:. feet Drinking Water Well feet Other. DEEP OBSERVATION HOLE LOG* Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) -1No'&5-' O X%L �O� s oMM P Ily i� ,ems/odd �,l1CT Mi1Viiviu1V1 Vr G rlWLCJ nr.VU1nCV Ml CVGnI �1�V�VJCV VIJ�VJML MnCM Parent Material (geologic) �PhIPAC% %�/� L DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: ,r Estimated Seasonal High Ground Water: .—.._ DE13 APPROVED FORM - 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. On-site Review v Deep Hole Number / _ Date: '� Time: �� Weath'erC��� . Location (identify on site plan) :..:....:...:..-........,..... . Land Use Slope M Z Surface Stones . IVIVY :..., Vegetation . :.:..::.:...........:..:... Landform ..loE��� Position on landscape (sketch on the back) Distances from: Open Water Body y�� feet Drainage way.... feet Possible Wet Area.Z-� feet Property Line .: .... feet Drinking Water Well >/tea feet Othei .......- ............:..... ......... ............. DEEP OBSERVATION HOLE LOG' Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) O — yQ �T �sYR � ' MINIMUM OF 2 HULLS KbUUlKLU A r tvtnr rhVt-UbtU uiarUbHL /antes Parent Material (geologic) —��Y%� % �LL- DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: — Weeping from Pit Face: Estimated Seasonal High Ground Water: _ kiDEP APPROVED FORM - 12/07/95 FORM 11 - SOIL EVALUATOR FORM - Page 3 of 3 Location Address or Lot No.'Z'r'-- 7Q;x� Determination ,for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole ................. inches ❑ Depth weeping from side of °bservation h le ........... .... inches ❑ Depth to soil mottles inches ; ❑ 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 all areas 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 6 Q� (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 '/ Date �3 DEP APPROVED FORM - 12/07/95 Y � r ' ON Page 1 of 5 $ j 9A - APPLICATION FOR LOCAL UPGRADE 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: ' G r,,7 T 1ba� Address: ZvS' GS�esf .0: Al, vt Phone #: 9 7v - 4�s ! - /B.37 Address of facility: 7 u- 2) Applicant (if different from above) Name: ' Address: k-L� Phone #: 3) Type of Facility: N Residential Commercial School Institutional (Specify) Page 2 of 5 4) Type of Existing System: _privy cesspools) conventional system other(describe) Type of soil absorption system (trenches, chambers, pits, etc.) Trenc4e f- 5) Design Flow Based on 310 CMR 15.203: a) Design. flow of existing system lV'o _:y�N -Fn gpd Approved: _yes Approval date: no Why: b) Design flow of proposed upgraded system gpd c) Design flow of facility gpd Why. 6) Proposed upgrade of existing system is: a) ✓Voluntary required by order, letter, etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback tances) Percolation rate of 30-60 minutes per inch (state actual perc rate) yO Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) eduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) �o m / �, 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 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: S c9 S�R� rL Evaluator's Signature: IYJ Date of evaluation: Z 3A 9 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: L 11 ell, .,IS 1_,/_ .,_. �0,_,_4- �.. b) Analternative system approved pursuant to /310 CMR 15..283-15.288 is not feasible. 7L— CcaS� OI Q'/L G7//c/`/l -een 4.- b�As, c— c) A shared system is not feasible. LL / Acc d) Connection to a sewer is not feasible. ���tiu rS o n- l<� 4 C� H 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? dyes v ----no 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/0 Facili e'Owner's Signa�� ,/ Date Print game Name ofPreparer Date - 5�7k- 6.9h - 76,8 33 /-T 2-3 ,y_ 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. 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: w,ll'a.,• �' GG,7 24,z k - Address: ,zk- Address: Phone #: Address of facility: s i-vrr s i St it/ t-<- 2) Applicant (if different from above) Name: Address: Phone #: 3) Type of Facility: �4 Residential Commercial School Institutional (Specify) 4) Type of Existing System: _privy cesspools) other(describe) Page 2 of 5 conventional system Type of soil absorption system (trenches, chambers, pits, etc.) Tre n c 4 e t 5) Design Flow Based on 310 CMR 15.203: a) Design, flow of existing system lVo �„ �n gpd Approved: _yes Approval date: no Why: b) Design flow of proposed upgraded system ____pd c) Design flow of facility gpd O 6) Proposed upgrade of existing system is: a) ✓Voluntary required by order, letter, etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback ,Aistances) Percolation rate of 30760 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) ! _,'Q I-CC-� fig. -9 3 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 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: Sq,," Sfja.2 Evaluator's Signature: /Yi /111JZEAAD Date of evaluation: S�5 8 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 Address Abutter Name Address Date notified Date notified 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: b) Analternativesystem approved pursuant to 310 CMR 15.283-15.288 is not feasible. 7L— - ))Ca[S� o� cln allc-nr c) A shared system is not feasible. 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? dyes v --*-no 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." i- el s Simat�/ ,/ Date Print Name Name o reparer Date 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. DATE: lo —c, — '� 7 LOCATION: 2,0 / 0--� �>� ENGINEER: BOH WITNESS: PERCOLATION TEST #cap ` BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: (At least 15 minutes long) TIME AT 12" TIME AT 9" TIME AT 6" OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: TIME AT 12" TIME AT 9" TIME AT 6" (At least 15 minutes) - � M WILLIAM F. WELD Govemo: ARGEO PAUL CELLUCCI Lt. Governor COMMONWEALTH OF MASSACPUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS C L'l b DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02108 617-292-5j00 9— TRUDY COXE Secretan• DAVID B. STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property AddressQO.SS '70f.244} !S -k_ K)CDC-Nkk Address of Owner. Date of Inspection: �►— Q *' of different) Name of Inspector: sl -k k J 1 am a DEP pproved system ins ctor pursuant to Section 15.340 of Title 5 (3 10 CMR. 15.000) Company Name: TG -IvkC-- Mailing Address: l l t 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 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 Nmeds Further Evaluation By the Local Approving Authority ✓fail Inspector's Signature: _ffiDate: _ If _Q The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. . COMMENTS: BI 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", ezplairt why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial Infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. 1 P (rsvissd 03 /25/97) Pagi 1 of 10 DEP on the world Wide web: http:1 www.magnetstate.ma.usidep t0 Printed bn Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: orkS6 iFoces-N--#-SIA-- P0r)A-\ Owner: Mc. W\ Date of Inspection:9— t1_47 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 Cl 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER 4 WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE f ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface Water supply or tributary to a surface water supply. I well. _ The system has a septic tank and soil atfsorption system and the SAS is within a Zone t of a public water SUpp y _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private Witer 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 .riot valid). 3) OTHER A. (revised 04/25/97) ?iqb 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: dog TC2S-V - �JCKI� "LJ" Owner: Date of Inspection: P( ct7k D) SYSTEM FAILS: You mjct'indicate either "Yes" or "No" as to each of the following: !/ I have determined that the system violates one or more of the following failure criteria as defined 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. Ye� No'-:— ,, Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. lV V-1--Discharge /Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. f/ 5 tic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS of cesspool. _ V 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). �mber of times pumped _. ny 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. ny 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 not acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water art*09 for` coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. I., I E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as 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 napped Zone'0 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revii*Q 04/25/97) Pato 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4o Fy`q� N �` Owner: { A(- UA (A } aAAA- �cu�ok Date of Inspection:Qr_ tri-�y7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes o Pumping information was provided by the owner, occupant, or Board of Health. ✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal '— flow rates during that period. Large volumes of water have not been introduced into the system recently or art of this inspection. / As built plans have been obtained and examined. Note if they are not available with N/A. _ f The facility or dwelling was inspected for signs of sewage back-up. V 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. N _ septic tic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for coAditii in of _ P 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of . / Sub -Surface Disposal System. VIA _V Existing information. Ex. Plan at B.O.H. IVIA (� Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distant* is unacceptable) [15.302(3)(b)] A� (revised 04/25/97) **** 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: d05 �'ps-� S�- w NCjK-,V A- 4et,_� Owner: Date of Inspection: ul� FLOW CONDITIONS RESIDENTIAL: Design flow: O a.P.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:15- Garbage grinder (yes or no):iO Laundry connected to sYslem (yes or no): %s Seasonal use (yes or no): Ivo Water meter readings, i1 available (last two (2) year usage (gpd): Sump Pump lyes or no): VC, Last date of occupancy: CJcf-kA,* QY-, W499 U. COMMERCIAUI N DUSTRIAL: Type of establishment: Design flow:gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: lyes or no)_ Non -sanitary waste discharged to the Title 5 system: lyes or no)_ Water meter readings, if available: Last nate of occupancy OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ^ Yt) �t 7 System pumped as pan of inspection: lyes or ho) ! If yes, volume pumped: Gallons Reason for pumping: TYPE OF SYSTEM i 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 6s'. 4d 0W W2A— Sewage odors detected when arriving at the site: lyes or no)p ,9- (revinod 0{/25/97) Digi S bf 16 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:`at.5 SSV .+ Owner: Rc��- Date of Inspection: q BUILDING SEWER: "[ (Locate on site plan) 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) It Depth below grade: t� Material of construction: _oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 6 / h -6- ti t Sludge depth: Q Disfance from top of sludge to bottom of outlet tee or baffle: �� bA0 Scum thickness: Distance from top of scum to top of outlet tee or baffle:�� Distance from bottom of scum to bottom of outlet ter or baffle: How dimensions were determined: ' �� F -- Comments: (recommendation for pumping, condion of inlet nd outl 4-t �e� or baffles, depth of Ii uid lev I in r integrity.eviden a of leaks tcJ �� ��.�%`=I' i k 4 g t _ .�ra ..� n... 'l a an— " 11* 142 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+ sttuctutal integrity, evidence of leakage, etc.) IP, (revised 04/2S/97) page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM ,I�N�F�jO.RMATION (continued) Property Address:CkS'-��Z�C�`'� c�� Owner: �lC. w� l/ljCi�vvG ��ljL��C Date of Inspection: 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 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: a" PUMP CHAMBER- 'L � (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.) A, (revised 04/25/97) paaii y bi t0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ACV (Zj ��(�� Owner: Date of Inspectionq_ ('7 SOIL ABSORPTION SYSTEM (SAS):— (locate on site plan, if possible; excavation tot required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:4JlA leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments:LL (not con rtion of soil, sign of by raulic failure level of pondi con of�vellgetal�ion,)�-- e% G �+ J �� a t CESSPOOLS: T\Q%o,& (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 (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: n0Ae— (locate on site plan) Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r•vissd 09/25/97) Pigs 9 of io Dimensions: L . C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) i . Property Address: gc s- � oc-� �;�� Dateo: p� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ik I = ll"iu t l0 /�--�0 fl-'2>vr = to F3-�o(:7--(r71 (zovited 04/25/97) Dago 0 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: H UJ\ GI I L!AA--, _�-}_U/� �C�C Date of Inspection. 1 Depth to Groundwater%A4= Please indicate all the methods used to determine High Groundwater Elevation: /Obtained from Design Plans on record V Observation of Site (Abutting property, observation hole, basement sump etc.) '� Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how ,you established the High Groundwater Elevation. (Must be completed) (rovimed 04/25/97) Page 10 of 10 TEL, (508) 475-1474 FAX: (508) 475-5451. BATESON ENTERPRISES, INC. Excavating - Water & Sewer Lines - Septic Systems & Pumping Service 111 Argilla Road . Andover, Mass. 01810 Title 5 Inspection Report Property Address: ag-�- �Dr'QQA- tiC. VA Mta� �h Owner:----------------------------- Date Of Inspection: q- <<-qq My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. . Neil J. Bateson Bateson Enterprises Inc: 11 of 11 Of NORTH, OFFICES JF: °m Town of 120 Main Street APPAI-S o ::= NORTH ANDOVER North Andover, L; BUILDNIG ';,'-^,::.�.'�g Mass ac:hr�5e;ttS c1 1845 CONSEfWATION 6g,°" ges DIVISION OF (617) (385-4775 HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NELSON, DIRECTOR August 8, 1988 s J7 �1 Tarbox 205 Forest Street North Andover, MA 01845 RE: Proposed Addition 205 Forest Street On July 12, 1988, we met at this address to discuss the proposed addition. The septic system appeared to be function- ing adequately and was not in the way of the addition so I am willing to allow the addition without requiring a new septic system. Sincerely, Mike Graf MG/vs (3,11 (Grp 205 Fa��5 T sT' �,-30-, � F - rG ac�), ?'lcvl - ��s cis s %� 12- di 1/lsrre� 5 /% ,_2- hnv5� GS �IaN,�d� Foorik - 5 W I �''!� ►'I �� `t-w'1� - "ew" S VGAi /GI�CG i`O J w,�T,1' • 4G@Jgs @LTg JO SGpTs ggoq uo pagsod SUSTs SuT:lapd ON • eT Lpauu>;Td 23uTaq ppOJ SSGOOP JGTggOue: sI •uOTgsGSUOD GToTTI@A 9q pa�lOOTq IOU ST qa@,Tgs 01,14 quilq aansua oq, u@-lpq aq TTTM suoTgnPoa•zd qugm 'PUG pp@p p ST g@@JqS MOTAJGAT�1 SV -TT LpapGau LIgpTM TUUOT4Tppp Gq4 JOJ uailpq aq TTTM OPTS 4Pgm ' pGuapTM aq oq 2uTo2 ST IGGJgs Gq4 JI *0T ON • asodand STLIq JOJ q@GJgs U Jo LIgpTM paaTnbaj aqq sT gpuM LSUTssud UT SJUO oMq Gqupoww000p oq g2noua apTM IaaJgs aLlg sI •6 -'W)J-)900j Ldn oO saxsq ano qugq os paspajouT aq sanTUA. puUT , sguapTSG-z OLlq T -CTM `UOT4UTTp4suT SIT J@Ij l ' LIT joJ Kud og p@su@JDuT Gq OI SUTOS soxeq KgJGdojd G<zd • L LwOJJ awoo SGuow Gq4 TTTM GJGgM `J�apssaOau ST SUTpunJ TuuOTgTppp JT • DIG `suuTd `SUOTquaUd@jd igioM agTs aLlg uo quads uaaq f'ppajTu ouq Sauow gaLIUI Moll ; Isoo qo@ roid 0141 TTTM qugM • 9 • saouds SuT�jjud J,9TTpaq TTP 0gPU-EWTT9 •OTTgnd @qq Sq ssaoop pagTwTT TIgTM JGATJ Oqq Oq SsaOOT: ri0110-2,10wa uMog ailq 9LITMOTT'e pagpgsuTaa aq uuTd TPUTSTJO @Ilq Iuq l gsanboJ sguGpTs@J Wil • �, -2UT�1,Tud UGTTUJ4 TTU agpuTwTTa oI paonpaa aq oI PGJU JOAO p@JJUq G1I4 Jo g4PTM aug quem GM L,�uM PUP IT pG`UUgD OqM •SuT:ljpd JGTTPJq Og PGSUU lO SUM UGJU STENT, 'DIG `saGMOTJ `sgnjgs `sa@dq LlgTM paduospupT aq oq puPTsT JDII-10-0 Gqq JOJ paTTpo uuTd TPUTST to ailq `GsPg3 TTugwTM Oq SUTPJOOOV •asn OTTgnd joJ SuT31jud J@TTPJq JOJ pGgpoOTTP soopds SUT)fjud GATJ Mou 0,7p @•T@qq 'lUgq GgUDTpL,IT H6T `TT DPW `,�ppsaup@M uO pTGTl :JUTgaaw uMog Gqq qp paquasaid OLIuTd 'tl •SuTgounPj JOJ JGATJ GLIB og uMog paTJJUD pupa aq pTnoo apo p Jo doq UO pGTJJUO GjaM qugq sgPOq qugq os JGATJ @q4 oI Jium XTum p g4TM sJUD xTS JO GATJ JOJ . 2UT),Ijpd GAUq og sum �gaadojd aqq Jo jagawTiad jagno aqj •. awj aqq puq guawgj-edap GUTJ 01-l4 PUP pa}IOoT aq oq spm -eGre ally •.RTuo sasodind RouG2aawa •zoJ pasn aq oq spm gounpT gpoq Gqq gpgq pagpgs o2u sxeai� OMg 0I1I09 pT@q SUOTssnosTp TpUTSTJO •� • dwpj quoq �ou,92jawa up Jo UOT4eTTpgSUT Gqq gULDJJ 3M og SSUTUMOJP JO squ@pTOOP Jo S@OupgsuT 04TS • z LJGATa Gqq JO aBpa Gqq SUOTU sung gUg4 p1;OJ Gqq Jo uOTgpTTUgSUT oqq Jo asodind oqq spm qugM . LpGZTTTgn aq paju sTuq q, upo SLIM • gaaJgS UTpW ugJoN 3o pua aLII gp paTTpgsuT aq dwuj q.poq Gql gpgq pags9SSns sguapTsaa ally •T •.z@AOPUlT TlgJOM Jo UMo,T, @LII Sq asn OTTgnd LIgTM dwPj gpoq „R0U@SJ@111@„ up JO UOTIpTTpgsuT 9qq Oq 53uTuTpq.JGd 896T `f3T SUN `�CppSOUPOM Ua IGO,I.I;; MOTnzanTTl J�? sgi.iapTs�>,l- ailq JO SuTgaaw p qu passnosTp ss s@IOU GiII Jo I�Xewwns u OT `3uTMO-LTOJ aLI,L HAWES, Dr. John A. Forest St. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION r _fi ` 4HEALTH DEPARTMENT - NORTH ANDOVER, MASS. ICJ I hereby make application for a permit for a sewage disposal installation at Forest St. . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of 1000 gal. in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of IS() lineal (agaare) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and,,the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE June 1, 1965 7r Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE June li 1965 7 • .,����'CRn.Cc�lw�� Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature o Inspecting Officer Percolation Test GRAVEL FILL* 3 min. Garbage Grinder No BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. 1. NAME~� \ 0'+� A w C' s DATE Z? t 2. ADDRESS i X13 ��' t? LOT NO. s TEL. j 3. NO. OF BEDROOMS 3 DEN YES NO__� 4. GARBAGE GRINDER YES NO 1" 0 j. SHOW DIMENSIONS OF HOUSE -�4 .4 d' 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM�� 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. a� BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL NAME OF APPLICANT Hawes, Dr. John A. LOCATION Forrest Street Address of lot no. BUILDING: Dwelling X Other, SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND high SUBSOIL: Clay PERCOLATION TEST 3 DATE May 22, 1965 Gravel Fill Sand minutes per inch. MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1,000 gallon capacity. LEACH FIELD 180 lineal feet of drain pipe. William J. Dri oll, Engineer Board of Health