HomeMy WebLinkAboutMiscellaneous - 21 CHERISE CIRCLE 4/30/2018• MAP # LOT
PARCEL # STREET
• �ONSTRUCTI.laN_APPR .__-.,._...
HAS PLAN REVIEW FEE .BEEN PAID? YES NO
PLAN APPROVAL: DATE � /� APP. BY _
DESIGNER: PLAN DATE:_��21�
CONDITIONS
WATER SUPPLY: TOWN WELL
WELL PERMIT DRILLER
WELL TESTS: M L DA I E
BACTERIA, I DAIS fIPPRUVED
BACTERIA II DA1-E
COMMENTS:
FORM U APPROVAL: APPROVAL TO IS5UL"YES NO
DATE ISSUED _BY_��! ...--...._..._..._......_..__._.. _--
CONDITIONS:
FINAL APPROVAL:.
ALL PERMITS PAID NO
WELL CONSTRUCTION APPROVAL Y.ES—. NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL,- NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DAT-E:/r_Z)i h�BY:
�PTI
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`�j(., . .� -` .:1 _.• •., . ,i.
AT ;�C^
+A' JS 'THEINSTALLER LICENSED? `� ` ���
NO
— r `'
'REPAIR
TYPE OF CONSTRUCTION: ? NEW
_ ,
.;'. NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW_ -
NO
�._ CONDITIONS OF.,APPROVAL YES
NO
ftp s t FROM FORM U)
' —ISSUANCE OF DWC
NO
•PERMIT._
= DWC PERMIT N0. r T b INSTALLER: T^Ni AG4t/!t
_ BEGIN INSPECTION '
:EXCAVATION.INSPECTION: :NEEDED:
PASSED BY
CONSTRUCTION INSPECTIONS NEEDED:
AS BUILT PLAN SATISFACTORY:
APPROVAL TO BACKFILL: DATE: BY
FINAL.GRADING APPROVAL: DATE BY
r . DATE: l/ Z BY
' FINAL CONSTRUCTION APPROVAL.
e,6,0
CONSTRUCTION APPROVAL
HAS PLAN REVIEW FEE BEEN PAID? YES\ NO
PLAN APPROVAL: DATE7 /v2z, Ci APP. BY
DESIGNER: �/�irc'//�. �iU PLAN DATE:-
CONDITIONS
A fE;_CONDITIONS
WATER SUPPLY: OWN WELL
WELL E RM I T DRILLER._...____.___ ___..__._.. ___ .._..._._
WELL TESTS: CHEMICAL DAIS
B RIA I DATE f1PPRUVED
BACTERIA II DAZE APPROVED__ _
COMMENTS:
FORM U APPROVAL: APPROVAL TU ISSUE YE5 NO
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
DAl"E:........
...._..._ ...BY:.._.. .
DATE: BY
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�..r� .
...: ,�,/;:.y.: :4. �� t�
1 IS THE INSTALLER LI CENSED a `
? '+ �� �f
YES NO
..TYPE OF CONSTRUCTIONa ; -
NEW REPAIR'
a ..•
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW
YES NO
CONDITIONS OF.. APPROVAL =
YES NO
(FROM FOR_ M U)
1: .� ilk 'i .l 1 .. . •!: �>�:. '..
,
—ISSUANCE OF DWC PERMIT
YES NO
_ _
I
• DWC PERMIT N0. :; `•' INSTALLER:
-
_BEGIN INSPECTION YES N0:
:.EXCAVATION.INSPECTION: :NEEDED:
- t^.
PASSED ' •HY
:-.- CONSTRUCTION INSPECTION: ::; NEEDEDt
11
AS BUILT "PLAN SATISFACTORY: YESS -
=
APPROVAL TO BACKFILL: DATE: HY
'
FINAL.GRADING APPROVAL: DATE BY
DATE: BY
I
1
TOO M
DATE:
TO:
FAX:
FROM:
RE:
G.H. RICKER, INC.
P.O. SOX 2011
R50 HIGHLAND STREET S. HAMILTON, MA 01982
(978) 468-4055 FAX (978) 458-7820
e mail: GHRICKER@AOL.COM
June 1, 2005
North Andover Board of Health
978-688-9542
Judy Harrigan
Title 5 Inspection -21 Cherise Circle
RECEIVED
JUN 0 12005
'We are iransmiltino a total of 12 pages) including this cover
sheet. If you do not receive the indicated number of pages,
please call us as soon as possible.
Any questions, please call. Thank you.
6.k!V ; y
9-/1 71 /. &2) 03'/
XVd 55:1T 9009/TO/90
'D
ali
Page 1 of 11 � ,rYr' Vj
TITLE S
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 21 CHEIM CIRCLE, 14 ANDOVER RECEIVED
Owner's Name II.ME TAYLOR
Owner's Address: 21 CHffiNSE CIRCLE, N. ANDOVER
JUN 4 12005
Date of Inspection: S/17105
TOWN OF ORT DEPARTMENT Name of Inspector: DANIFL B. JOHNSON
Company Name: DOMESTIC SEPTIC DESIGN, INC.
Moiling Address: P.O. BOX 331, OSTERVQ.LE, MA 02655
Telephone Number. (503) 477-9909
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was perforsoed based on my
training and experience in the proper fimctio n and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000). The system:
X Passes
_ Conditionaally Passes
_ Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: S~ 3! r) S
The system inspector shall submit a copy of this ' on report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection_ he system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sem to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments:
***:This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future ander the same or different
conditions of use.
zoo YVA 99:TT 400Z/TO/90
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Ad&vw.. 21 CMRISE CIRCLE, N. ANDOVER
Owner. HIM TAYLOR
Date of Inspection: $47/05
Inspection Summary: Check AAC,D or E / ALWAYS complete all of Section D
A. System Passes: YES
X I have not found any information which indicates that any of the f lure criteria described in 310 CMR 15.303 or
in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System ConditionaAy Passes: N/A
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.
The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the _ for the following statements If"not determined" please
explain.
* The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound,
;tidbits substantial infiltration or a diltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health)
broken pipes) are replaced
_ obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipes) are replaced
obstruction is removed
ND explain:
COOT) XVd 99:TT 9002/TO/90
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 21 CMMISE CIRCLE, N. ANDOVER
Owner: nXft TAYLOR
Date ofbspection: MUS
C. Further Evaluation is Required by the Board of Health: MA
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health, safety or the environment.
L System will pass micas Board of Health determines in accordance with 310 CMR 15-MXIxb) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
____ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fad unless the Board of Health (and Public Water Supplier, V any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone i of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria
and volatile organic compounds indicates that the well is fru from pollution from that facility and the
presence of ammonia nitrogen and tutrate nitrogen is equal to or less than 5 pptu, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form_
3. Other:
60011 XVd 99:TT SOOZ/TO/90
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 21 CHERME CIRCLE, N. ANDOVER
Owner: RENE TAYLOR
Date of Inspection: 5/17/05
D. System Failure Criteria applicable to all systems:
You mint indicate 'des" or -no" to each of the following for diospections:
Yes No
X Backup of sewage into fadity or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is lea than 6" below invert or available volume is less than''/: day Sow
X Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number
of times pumped _
X Any portion of the SAS, cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool.or privy is within a Zone I of a public well.
_ X Any portion of a cesspool or privy is within So feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. ['Phis system passes if the wee water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that fadity and the pnmm of ammonia
nitrogen and nitrate niftnen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the anadpsis most be attached to this form.)
NO (Yes/No) The system faU I have deternuned that one or more of the above failum criteria exist as described in
310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure -
E. Urge Systems: N/A
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd
You must indicate either `jres' or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
— _ the system is within 200 feet of a tributary to a surface drinking water supply
— the system ii located in a nitrogen sensitive area (interim Wellhead Protection Area - IWPA) or a mapped
Zone ii of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or
answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered
a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department -
soon YU 99:TT 50oZ/TO/90
Page 5 of I l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKL ST
Property Address: 21 CHERISE CIRCLE, N. ANDOVER
Owner. ILENE TAYLOR
Date of lospection: 5/17/05
Check if the following have been done. You most indicate "yes" or "no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner, occupant, or Board of Health
X Were any of the system components pumped out in the previous two weeks ?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up ?
X _ Was the site inspected for signs of break out ?
X _ Were all system components, excluding the SAS, located on site ?
X Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
X _ Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems 7
The size and toeation of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
X _ Existing information. For example, a plan at the Board of Health.
X Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (3 10 CMR I5.302(3)(b)j
900@1 XVA LS:TT 500Z/TO/90
i
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Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 21 CHERISE CIRCLE, N. ANDOVER
Owner: ILENE TAYLOR
Date of inspection: 5/17M
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 3 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 GPD (SEPTIC PLAN)
Number of current residents: 4 -
Does residence have a garbage grinder (yes or no): NO
Is laundry on a separate sewage system (yes or no): NO [if yes separate inspection required]
Laundry system inspected (yes or no): NIA
Seasonal use: (yes or no): NO
Water meter readings, if available (last 2 years usage (gpd)): N/A
Sump pump (yes or no): NO
Last date of occupancy: PRESENT
COMMERCIAM"USTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (sews/persons/sgft etc.)
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: SPRING/SUMMER 2004 (OWNER)
Was system pumped as part of the inspection (yes or no): NO
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained
from system owner)
_ Tight tank _ Attach a copy of the DFP approval
_ Other (describe):
Approximate age of all components, date installed (if known) and source of information: 1995 (AS-BUELT PLAN)
Were sewage odors detected when arriving at the site (yes or no): NO
LOO XFA LS:TT 90OZ/TO/90
Page 7 of 1 i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 21 CHERLSE CIRCLE, N. ANDOVER
O+waer: ILENE TAYLOR
Date of Imtpe da: 5/19/05
BUILDING SEWER: YES (locate on site plan)
Depth below grade: 18" (EST.)
Materials of construction: _ cast iron X 40 PVC other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEWER EXISTS THROUGH BASEMENT FLOOR
SEPTIC TANK: YES (locate on site plan)
Depth below grade: g"
Material of construction: X concrete _ metal _ f fiberglass _ polyethylene _ other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: 10'L X S'W X SO" H (EFFECT.)
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scam thickness: 1/2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: SEPTIC MEASURING POLE
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as
related to outlet invert, evidence of leakage, etc.): NO NEED TO PUMP TANK INLET AND OUTLET PVC
TEES IN GOOD CONDITION. LIQUID LEVEL AT OUTLET INVERT. TANK APPEARS TO BE IN GOOD
CONDITION. NO SIGNS OF LEAKS.
GREASE TRAP: NONE (locate on site plan)
Depth below grade:
Material of construction: —concrete _metal fiberglass _polyethylene other (explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendatioma, inter and outlet tee or baffle condition, structural integrity, liquid levels as
related to outlet invert; evidence of leakage, etc.):
900@1 %v3 LG:TT 9009/TO/90
Page 8 of t t
OFFICIAL IHBPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: n CHERIS)E CIRCLE, N. ANDOVER
Owner. RINE TAYLOR
Duh of is speetion: SA7/05
TIGHT or HOLDING TANK: NONE (tank must be pumped at time of inspectionklocate on site plan)
Depth below grade:
Material of construction: concrete metal _fiberglass _polydbyk w other(explain):
Lai,1t1"TIT 1 1I
capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Conamems (cation of alarm and float switches, etc.):
DISTRIBUTION BOX: YES (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0"
Comments (note if box is level and dowbution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out ofbox, etc D BOX LEVEL WITH EVEN DISTRIBUTION. NO OBSERVED SLUDGE IN
D -BOX. SLIGHT SCUM AT LATERALS (REMOVED AFTER THE INSPECTION). D -BOX APPEARS TO BE
IN GOOD CONDITION (SLIGHT CRACK IN SIDE WALL). NO SIGNS OF LEAKS.
PUMP CHAMBER: NONE (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.):
600 1 Yva 99:TT BOOZ/TO/90
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property'Address: 21 CHERISE CIRCLE, N. ANDOVER
Owner. ILENE TAYLOR
Date of Inspato: 5/17/05
SOML ABSORPnON SYSTEM (SAS): YES (Locate an site p1m es avation not required)
If SAS not located explain why:
Type
_ leaching puts, number:
_ teaching chambers, number:
teaching galleries, number:
ung tri. number, :
X leaching fields, munber, dimensions: 1 AT 45'L X 20'W (AS -BUILT PLAN)
_ overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): NO SIGNS OF HYDRAULIC FAIIARE OR PONDING. VEGETATION ABOVE SAS APPEARS
NORMAL. SAS VENTED.
CESSPOOLS: NONE (cesspool must be pumped as part of inspectionxiocate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comment.. (note condition of soil, signs of hydraulic faAue, Level of ponding. condition of vegetation, etc.):
PRIVY: NONE (locate on site plan)
Materials of construction
Dimensions:
Depth of solids:
Comments (sate condition of soil. signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
0101M XVA 8S:TT 900Z/TO/90
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No................_....__
THE COMMONWEALTH OF MASSACHU
BOARD OF. HEALT
f�11%]A/ of A111214 ANAn
Applirtttiun for Bispogttl Murky Tonstrmtion Permit
Application is hereby made for a Permit to Construct (>Q or Repair ( ) an Individual Sewage Disposal
System at:
................�N 15 ....4..1 . 1...e. ................... _.._..._.. ..... r._6_...i!!�Kl. �.rcN. ....�..�..
Location - Address or Lot No. L. . .
SciT cc��S�u cl iu!�....?a....�t�.x .... 1 z...�K�_...E....N.A14!?i(,A?�.....
Owner Address
...................................................................................................................................................................................................
Installer Address
Type of Building Size Lot........( 11.1A/.....Sq. feet
Dwelling — No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures,..}................................................................ ..
.....................................................................
Design Flow ............... ��!......................gallons per person per�day. Total daily flow..: .................. �?�'��............ gallo ns
Septic Tank — Liquid capacity.l..�-�...�gallons Length..f ..
A..... .... Width..6t--�.... Diameter ..... :-:........ Depth..,..---.......
Disposal T-r�cla-- -&. J -`j .... Width.....1.s.�....... Total Length ..... 66........ Total leaching area....�.i�i
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................sq. ft.
Other Distribution box ( L, -f Dosing tank ( )
Percolation Test Results Performed by..... C tif2�Sit1 NSl �J S 126.1. (¢1 G, Date ..LW-I-�_9-,�, .. SJ! � 14-
P - It Test Pit No. l ..... �–........ minutes per inch Depth of Test Pit ....... U.'1 f ..... Depth to ground water....�� �t............
►�-1L Test Pit No. 2...::�'....._..ntinutes per inch Depth of Test Pit.......gk........ Depth to ground water .....4L.............
Descriptionof Soil........`/�ly.......................................................................................................................................
............................................................................................._.........................................................................................................
................................................................................................................................................................•-••-...................................
Nature of Repairs or Alterations — Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...............................•-•-•---..............-•-------•....................... ..........................
Date
ApplicationApproved By................................................................................................_ ........................................
Date
Application Disapproved for the following reasons: ................................................................................................................
........................................................................................_............._.........................................................................................------
Date
PermitNo ................................................... ___ Issued. .....................................................
_
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... OF ........ . ......................................
T of irtt#r of Tom.plittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
by...............................................
) or Repaired ( )
..............................................................................................................................
Installer
at.............................................................................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated .................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........................................................................•-••... Inspector ....................................................................................
No.......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Dispouttl Vork,5 Tonitrurtion Permit
Permissionis hereby granted.............•--•-----.........................---....................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
Fn........................
........................ ................•---............................................................................ _ .......................
Street
as shown on the application for Disposal Works Construction Permit No ..................... Dated..............:...........................
......................................................................................................
DATE.................................
.............................................. Board of Health
PORM 1255 A. M. SULKIN, INC., BOSTON
CHRISTIANSEN & SERGI, INC.
PROFESSIONAL ENGINEERS AND LAND SURVEYORS
160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830
July 27, 1995
Ms. Sandra Starr
North Andover Board of Health
120 Main Street
North Andover, MA 01845
(508) 373-0310 FAX: (508) 372-3960
Re: Lot 6, White Birch II
Dear Ms. Starr:
In response to your letter of disapproval dated July 17, 199 , ease find the enclosed
revised plans for your review. A list of our responses to your reasons for disapproval are as
follows:
1) No benchmark within 50 feet to 75 feet of the system. An appropriate benchmark
has been added to the plan.
2) System within 50 feet of buffer zone for PRD. Please show proof of approval from
planning. I spoke with Kathleen Colwell about this issue and she said that unless the septic
system was shown in the buffer zone on the approved Definitive Subdivision Plan, it cannot be
placed in the buffer zone. As indicated on the enclosed revised plan, the leaching field has been
reconfigured to a size of 45'X 20' in order to relocate it entirely outside of the buffer zone.
3) Please check breakout; should be 128.16 to top of stone. The revised leaching facility
has a top of stone elevation of 129.16'. The breakout grading indicated on the revised plan has
been verified as complying with the grading requirements.
4) Leaching area not 35 feet from the foundation drain. The proposed invert elevation
of the foundation drain is 131.0'. Since this is higher than the top of the proposed leaching
facility, the setback distance may be reduced to 25' according to Town of North Andover Board
of Health Regulation 4.18.7.
5) Primary area must be 5 feet to groundwater. The leaching field has been raised by
1 foot to comply with the 5 foot separation from groundwater.
I trust that this information sufficiently addresses the issues raised in your letter of disapproval.
Please call me if you have any questions.
Vxy Truly Yours
Daniel J. O' onnell
Encl.
c.c. Dan Betty
Town of North Andover
Community Development and Services Division
Office of the Health Department
400 OSGOOD STREET
North Andover, Massachusetts 01845
Susan Y. Sawyer, REHS/RS
Public Health Director
Date:
Address: ,2 l S� , North Andover, MA 01845
Re: Application for:
ela
Dear: Iq !'5 1 /0)"-
Your
v✓Your application for /to (-'g-TC 6kq
Department. The application was denied on,
(978) 688-9540 - Phone
(978) 688-9542 - Fax
at �' has been reviewed by the Health
2WSfor the following reasons:
1. ❑ Missing information
2. Q"' Passing Title 5 inspection of septic system required
3. ❑ Location of structure not acceptable
4. ❑ Undersized septic system
To address the problem(s):
If #1 is checked, please supply:
a. Floor plan of existing and proposed addition - all rooms
b. Certified plot plan showing house, septic system and proposed project in scale
If #2 Is checked:
/a. ) Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it >s operating properly: OR
b. Tie-in to municipal sewer
If #3 Is checked:
a. Relocate the project
If #4 is checked:
a. Provide additional information proving that the existing septic system meets current capacity
requirements. Please consult an engineer to determine the flow capacity of the septic system.
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
��(/ GSC �(% ✓1 v �" '
P7 ;auLAI_)1
Reviewer
Cc: Building Department
File
11 )ARI) UP APPI AIS 688-9541 RUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
f NORTH
too
A
4
40
•;7d ,.� #
SACMUSE
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
9.
� 19-9.S--_
tr
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Test No.
Site Location LUT G LA -1 12.E Ba j—, —1C
Reference Plans and Specs.Q' \.�s ti 'ti �D �—c�
ENGINEER DESIGN y DATE
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
Fee LO ' Site System Permit No. 3
BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
July 17, 1995
Christiansen & Sergi
160 Summer Street
Haverhill, MA 01930
Re: Lot #6 Cherise Circle
Dear Phil:
TEL. 682-6483
Ext23
This is to inform you that the proposed plans for the site
referenced above have been disapproved for the following reasons:
1) No benchmark within 50 feet to 75 feet of system
2) System within 50 feet of buffer zone for PRD. Please
show proof of approval from planning.
3) Please check breakout; should be 128.16 to top of stone.
4) Leaching area is not 35 feet from foundation drain.
5) Primary area must be 5 feet to groundwater.
If you have any questions, please do not hesitate to call the
Board of Health Office at 688-9540.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
PLAN REVIEW CHECKLIST
ADDRESS CA ENGINEER
GENERAL tt
3 COPIES STAMP LOCUS NORTH ARROW SCALE
.I
CONTOURS �� PROFILE_Z SECTION jf BENCHMARK %C SOIL &
PERCS ELEVATIONS / WETS. DISCLAIMER �l WELLS & WETS
WATERSHED?�1 DRIVEWAY -)(Elev) WATER LINE 1/ FDN DRAIN J/-
SCH40 / TESTS CURRENT? ✓ hI _ SOIL EVAL
SEPTIC TANK
MIN 1500G_J/ .17 INVERT DROP GARB. GRINDER(+200% EDF)
25' TO CELLAR MANHOLE ELEV GW # COMPS.
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET j 00 - OUTLET l �_ 71 �3 ( 2 " OR . 17 FT) TEE REQ' D?
LEACHING a Pj k F
MIN 660 GPD? RESERVE AREA 611'
4' FROM PRIMARY? f/ 2% SLOPE
100' TO WETLANDS 100' TO WELLS i--' 4' TO S.H.GW (5'>2M/IN)
35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP L/
4' PERM. SOIL BELOW FACILITY MIN 12" COVER (/ FILL? ',c) (25'
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 gpd SLOPE (min .005 or 611/1001) SIDEWALL DIST. 3X EFF.
W OR D (MIN 61) RESERVE BETWEEN TRENCHES? IN FILL? MUST
BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501)
BOT + SIDE X LDNG = TOT
(L x W x #) (DxLx2x#) (G/ft2)
Copyright m 1995 by S.L. Starr
(L x W x #) (DxLx2x#) (G/ft2)
PITS
MIN 660 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT
GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE
BOT + SIDE x LOAD = TOTAL
(L x W x #) (2x(L+W)xD x #) (G/ft2)
CHAMBERS
MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT
MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005
BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT
BOT + SIDE X LOAD = TOTAL
(L x W x #) (2 x (L+W)xD x #) (G/ft2)
FIELDS
MIN 660 GPD 900 ft2 BED �� GW MIN 4' BELOW BOTTOM OF FIELD
PIPE ENDS JOINED? 4" PEA STONE?_P DIST LINE SLOPE .005?
>3'COVER-VENT SCH 40 MIN 12" COVER
RATE J, Ff f Y LDG 74, X -0 1 0 (7 X � -= TOTAL C� 6
G/ft2 REQ�D (ft2) LXW
DOSING TANKS AND PUMPS
DIMENSIONS X X = PUMP CAPACITY gpm
L W D Vol.
DISCHARGE SIZE DISCHARGE RATE
gpm
MANHOLES TO GRADE ALARM SEP. CIRC.
inlet) HWL LWL CHECK VALVE
OP. SWITCH
Copyright 0 1995 by S.L. Starr
DISCHARGE TIME
GW (Min. 1' below
BLEEDER HOLE MANUAL
FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary -;,.4.
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: _ SC07y7s�— C't��J .) - ,4j1 C . Phone __7/ y' O 0-7 Y
LOCATION: Assessor's Map Number Parcel
Subdivision Wr) �� Lot (s)
S�reet St. Number Zl
************************Official Use Only*****************x******
RECOMMENDATIO OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Town Planner
Comments
Food Innsp/ejctor-Health
Septic Inspector -Health
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved �.
Date Rejected
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector
Date
y�y
7�
rQ:
i
Town of North Andover, Massachusetts Form No. 2
MORTh BOARD OF HEALTH
s
♦ w
:^o•'
• -=-�: �F* DESIGN APPROVAL FOR
CH SOIL ABSORPTION SE AG OSAL SYSTEM
Applicant Test No
Site'Location
Reference Plans and Spe .
EN 1 EER DESIGN DATE
Permission is granted for a indi idual soil absorptin sewage disposal system to be installed
in accordance with regulations Board of Health.
--CHAIRMAN, BOARD OF HEALTH
CSV
Fe (90 Site System Permit No. s
PLAN REVIEW CHECKLIST
ADDRESS T G, d%laf581- Ole ENGINEER
GENERAL
3 COPIES C,-' STAMPS
CONTOURS ''-' PROFILE
PERC INFO ELEVATIONS
WETLANDS WATERSHED?
LOCUS c-� NORTH ARROW SCALE-�
'0 BG
SECTION BENCHMARK SOIL &
WETS. DISCLAIMER WELLS &
DRIVEWAY c---(Elev) WATER LINE
FDN DRAIN L,-- SCH40 c/ TESTS CURRENT? /993 g -/99q
SEPTIC TANK
MIN 1500G (,-' .17 INVERT DROP GARB. GRINDER(+200% EDF)
25' TO CELLAR t-�
D -BOX
SIZE
MANHOLE TO GRADE ELEV Q L GW D/—'
# LINES A FIRST 2' LEVEL STATEMENT
INLET ��Q •�/� - OUTLET/,'9, %� _
'17 ( 21' OR .17 FT) TEE REQ: D? /t/d
LEACHING /
MIN 660 GPD? C/ RESERVE AREA4' FROM PRIMARY? 61 / 2% SLOPE 4�
100' TO WETLANDS f/--100' 0 WELLS—'4' TO S.H.GW c�--
35 TO FND & INTRCPTR RAINS �ti 325' TO SURFACE H2O SUPP ,--�
4' PERM. SOIL BELOW FACILITY �MIN 1211 COVERC""" FILL?C�725'
if above natural elev; 101if below) BREAKOUT MET? t- ---
TRENCHES
MIN 660 gpd V1 SLOPE (min .005 or 6"/1001) - >3'COVER?-VENT—
SIDEWALL DIST. 2X EFF. W OR D (MIN 61)L----- IS RESERVE BETWEEN
TRENCHES? '`"� IN FILL? C/—MUST BE 10' MIN. C/ 41 -'PEA STONE?
BOT lig X LDNG+ SIDE X LDNGIIL TOT
(L x W x #) (G/ft2) (DxLx2x#) (G/ft2)
Copyright O 1993 by S.L. Starr
BOARD OF HEALTH
120 MAIN STREET TEL. 682-6483
NORTH ANDOVER, MASS. 01845 Ext23
May 11, 1994
Christiansen & Sergi
160 Summer Street
Haverhill, MA
Re: Lots #3-9 White Birch II
Dear Phil:
I have briefly looked at these plans and find that most of
them do not have sufficient test holes in the system. In
addition, there will be changes in light of the testing done
today.
Would you please review these plans keeping in mind the
criteria I recently sent you, add the new tests and re -submit the
designs.
Sincerely,
Sandra Starr, R.S.
Health Administrator
cc: Karen Nelson, Director, Planning & Comm. Dev.
Jim Grifoni
File
DESIGN REVIEW SHEET
LOT 6 CHERISE CIRCLE
PERMIT # 735 REC'VD 6/8/95
APPLICANT: DAN BETTY
ENG: CHRISTIANSEN
160 SUMMER ST., HAVERHILL
PLAN DATE: 4/27/95
DISAPPROVED
,04 NO BENCHMARK WITHIN 50' TO 75' OF SYSTEM
dig. SYSTEM WITHIN 50' BUFFER ZONE FOR PRD. PLEASE
�OW PROOF OF APPROVAL FROM PLANNING.
3. PLEASE CHECK BREAKOUT; SHOULD BE 128.16 TO TOP
OF STONE.
4. LEACHING AREA NOT 35 FEET FROM FOUNDATION
DRAIN.
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FOUNDATION LOCATION PLAN
CLIENT: FIRST ESSEX SAVINGS
THIS CERTIFICATION IS MADE AND LIMITED
TO THE ABOVE CLIENT.
LOCATION: NORTH ANDOVER,MA.
LOT 6 CHERISE CIRCLE
SCALE: I" = 40' DATE: OCTOBER 19,1995
CHRISTIANSEN �, SERGI PROrESS
LANDIONAL ENGINYORS ERS
160 SUMMER ST. HAVERHILL.MA. 01830 TEL. 508-373-0310
@1995 BY CHRISTIANSEN & SERGI INC.
I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO
THE HORIZONTAL SETBACK REOUIREM£NTS OF THE LOCAL
APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED.
(THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER
RESTRICTIONS SUCH AS COVENANTS, WETLANDS,EASEMENTS,
ORDERS OF CONDITIONS,ETC.)
THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY
PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE
WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC.
FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY
OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE
IS PROHISITED.CHRISTIANSEN & SERGI TAKES NO RESPONSIBILITY
FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR-
MATION CONTAINED HEREON.
BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN
IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA
FLOOD INSURANCE RATE MAP.
COMMUNITY NO.: 250098 0005C DATE:6/2/93
DRAWING No. 93067016
gra.
�-/
�s I
TOWN OF NORTH ANDOVER -
SYSTEM PUMPING RECORD
DATE '7
SYSTEM OWNER & ADDRESS
Babb
'Il Ch Brise,
A)0, 0rvz0ooev�,, Ma .
---
SYSTEM LOCATION
DATE OF PUMPING_ '7 %'1lo QUANTITY PIMPED
CESSPOOL NO YES SEPTIC TANK NO YES14
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLID CARRYOVER
FULL TO COVER
BAFFLES II f LACE
LEACHFIELD RUNBACK
-
FLOODED
OTHER EXPLAIN
SYSTEM PUMPED BY �tJ ycrQ--/97-7,,,
COMMENTS:
CONTENTS TRANSFERRED TO _0)
No......................... Fun..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....TOWN...........OF....................NORTH ANDOVER
........................................................................... .
Application for Diqoottl Worlt')5 Ton.6trttrtilait runtit
Application is hereby made for a Permit to Construct ( x ) or Repair ( ) an Individual Sewage Disposal
System at:
CHERISE CIRCLEr0
....................................................................................................................................................................................................
Location • Address or Lot No.
..........Ix.0......................... 1.2.... O RS...RD....,....NAVERHILL.....MA..................
Owner Address
....................................................................................................................................................................................................
Installer Address
Type of Building �••••-••••••......• q•
Size Lot...21l. °!b S feet
Dwelling —No. of Bedrooms............. 6+............................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures......................................................................................................................................................
Design Flow...........................................gallons per person per day. Total daily flow..............0............................. gallons.
Septic Tank—Liquid capacity.UQ.gallons Lengthl,0,t,-6„tWidth.6.'.-8.". Diameter................ Depth.5,'.-6",
Disposal Trench — No... 2............... Width ..... 2.1 .......... TotalLength............ Total leaching area....�04:.....sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( x ) Dosing tank ( )
Percolation Test Results Performed by..... C H R,I.S T I A N S,E N.., &....
.. SER G II N CDate..... IN6.`�i..... �.�4. �........
Test Pit No. 1...... Z...... minutes per inch Depth of Test Pit....�%b..`.�...... Depth to ground water .... 45 11.........
Test Pit No. 2...... Z..... minutes per inch Depth of Test Pit..JfJ..6.11...... Depth to ground water .... (06_.'...........
......... ..r
.................................................
..........................................•..................................... ..................
Description of Soil .........0. `.�. ..1.Z?I° 04 ... 4 .... $S:l!� wx.....................................................................................................
q6i.....SANO................................................................................................................................
........................................................................................................................................................................................................
Nature of Repairs or Alterations — Answer when applicable................................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed......................................................................................................................
Date
ApplicationApproved By................................................................................................................................ I.........
Date
Application Disapproved for the following reasons: .................................................................. .............................................
...........................................................................................................................-•-•-----.........----........................................................
Date
PermitNo .........................................................
Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ....................................................... I .................... I ........
Tntif iratr of Toutpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by....................................................................................................................................................................................................
Installer
at......................................................................................................................................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... datcd ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................---.............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No............................,..,.....,..........,..,.........,..OF...................................................................................., F$II........................
Biopowd luvrhil T111115trurtiait vlat tut
Permission is hereby granted................................................
..............................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo..........................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No ..................... Dated ..........................................
...................................................................................................
Board of Health
DATE.......................................................................•---•-.--
FORM 1255 A. M. SULKIN, BOSTON
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Quantity Pumped:
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40 Ilk. i
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vehlcle'ucen
�1. 60�wq of Hi oill
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UMPIng Rec4M Page 1