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HomeMy WebLinkAboutMiscellaneous - 210 FARNUM STREET 4/30/2018 (2)3 Lot & Street J/6 Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid YES NO Permit# Plan Approval: Date: f!) -/V) Approved by:_ Designer: MPlan Date: —?// Conditions: Water Supply: Well Permit: Well Tests: Chemical Bacteria I Bacteria II Plumbing Sign -Off: Comments: Form "U" Approval: Date Issued Conditions: Final Approval: Well er: Date Approved_ Date Approved Date Approved Wiring Sign -off: roval to Issue: YES i By: All Permits Paid? Well Construction Approval? Septic System Construction Approval? Certification? Other? Any Variance Needed? FINALBOARD DATE: APPROVED-6Y: TH APPROVAL: NO ES NO NO YES <pJ YES NO e r � R'I � o -v CONDITIONS: Is the installer licensed? Type of Construction: New Construction: SEPTIC SYSTEM INSTALLATION Certified Plot Plan Review Floor Plan Review Conditions of Approval from Form L Issuance of DWC permit: DWC Permit Paid? DWC Permit # I) d Begin Inspection: Excavation Inspection: Needed: Passed: 12 -Z7/e,0 By.- Construction y: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Installer: N NEW YES NO YES NO YE6 NO Approval of Backfill: Date: By: Y Final Grading Approval: Date: % O/ By: Final Construction Approval: Date: / /i Z By: Certificate of Compliance: Approval: Date: 4� /V,Z- Commonwealth of Massachusetts W City/Town of North Andover .System Pumping Record Form 4 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. City/Town RECEIVE® JUL 13 2015 TOWN OF NORTH ANDOVER HEALTH DEPARTh"ENT ----------- -- - State State - - Telephone Number B. Pumping Record Zip Code Zip Code 1. Date of Pumping oat�� 2. Quantity Pumped:— Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank El Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important When filling out forms 1. System Location: on the computer, ��y w1 5( rl use only the tab V 1 Lf l key to move your _ Address cursor - do not North Andover use the return key., —---.--.- ---- City/Town 2. System Owner: Name --------------- rerun � Address (if different from location) City/Town RECEIVE® JUL 13 2015 TOWN OF NORTH ANDOVER HEALTH DEPARTh"ENT ----------- -- - State State - - Telephone Number B. Pumping Record Zip Code Zip Code 1. Date of Pumping oat�� 2. Quantity Pumped:— Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank El Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rm Commonwealth of Massachusetts City/Town of North Andover System Pumping Record Form 4 RECEIVED NOV 2 4 2008 DEP has provided this form for use by local Boards of Healp! %w(fAW#WAWbT, but the information must be substantially the same as that provideu 1 IVI V. LJVIVI'V U011 IV , 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 210 Famum Street Address North Andover City/Town 2. System Owner: Elizabeth Thurber Name Address (if different from location) MA State 01845 Zip Code City/Town State Zip Code 978-686-2646 Telephone Number B. Pumping Record 1. ©ate of Pumping Date 10/25/08 2• Quantity Pumped: 1.500 Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ® No 5. Condition of System: Good working condition 6. System Pumped By: Jason Elliott Name Jason Elliott Septic Pumping Company 7. Location where contents were disposed: Hauler Signature of Receiving Facility If yes, was it cleaned? ❑ Yes ® No L90-471 Vehicle License Number 11/10/08 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 TRANSMISSION VERIFICATION REPORT TIME 0610512007 10:25 NAME HEALTH FAX 9786888476 TEL 9786888476 SEP,.# 000B4J12O96O DATE, TIME 06,105 10:23 FAX [.10. 1N 817812246548 DURATION 00:01:58 PACE !'S 15 RESULT Ota MODE STANDARD ECM North Andover Health Department 1600 Osgood Street Building 20, Suite 2,36 North Andover, MA 01845 978.688.9540 Phone 978.688.8476 0 fox healthdeat tovunofnarthando_v_eyeco!m - E-mail WW.WjqWAqfMrthqq,4qvqrxqrn - Website Letter of Transmittal Page �_ of s CONFIDENTIAL . D' �Yy1to ,e � 40 a T0: DATA: (OMPANY: FROM: Pamela DelleChiaie, Health Department Assistant phone: RE: We are sending you: Q Copy of l etter J Plans 0 Other (fill in below) These are transmitted as checked below: > Q );- ®A AN uW COPY T0: �f7'�r,�,gamr�t C1You�t u > Oftbn a�aiesfor North Andover Health Department 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 — Fax healthdept(CD-townofnorthandover.com - E-mail www.townofnorthandover.com - Website Letter of Transmittal voe:of CONFIDENTIAL TO: DATE: COMPANY: FROM: Pamela DelleChiaie, Health Department Assistant Phone: RE: ` /� Fox: /W, We are sending you: O Copy of Letter O Plans O Other (fi// in below) These are transmitted as checked below: ➢ O ➢ Re�qued ➢ O.4sRegimd ➢ 0f-arAva d ➢ L7rrit*wva i&vwkw. ➢ 0rnrrarbm c,- ➢ OR&m&n t woksfbr ➢ L7&*,rt a:iai�slFiraFcl. REMARKS: COPY TO: COPY TO: SIGNED: COPY TO: TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 1/12/01 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X ) by Mike Reilly at 210 Farnum 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. 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 SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed-, ( repaired: by-- H I a 1%E I w`l' located at Z I ci% rA lZN) Ll --1 GJT was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # , dated , with an approved design flow of� gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bed inspection date: %Z—yf_ od e'2 Engineer Repre entative Final inspection date: /7,--/ 7 Engineer Representative r Installer: v Lic.#. Date: Design Engineer:eftuL—� Date:. ifn'" J 411-13-31 S0 1:37 ;1,q HRDStHRD, P. Fxv 111. 9786336188 P. 2 RESTRICTION The Restriction herein set forth shall apply and be appurtenant to the following described property located at 210 Farnum Street _, North Andover, Essex County, J� Massachusetts, being more particularly described as follows: V A certain parcel of land in North Andover, Essex County, Massachusetts, being shown as Lot�,on a plan entitled "Plan of Land tiNorth h Aodover, prepared for Old North Andover 12ealt Trust" recorded in North Andover District Essex Registry of Dees as Plan No. 5862. Said Lot 8 containing 45,230 square feet, more or less, according to said Plast. Being the same premises described indeed recorded with Essex North Dist»ct Registry of Deeds in Book 3223, Page 0008. I . Maximum Number of Bedrooms At all times subsequent hereto, unless connected to an approved municipal sewer. the property described hereinabove shall be limited to use as a single fare ly residence containing no more than three (3) bedrooms. This Restriction is being implemented due to the maximum capacity of the current septic system. 2. Enforceability These Restrictions may be enforced by the Town. of North Andover, by action in equity in any Court of competent jurisdiction. Witness our hands and seal this 8th day of January, 2001 Owners E. Narles Beliveau Owners S san J. Beliveau COMMONWEALTH OF MASSACHUSETTS Essex, ss January 8, 2001 Then personally appeared the above named OWNERS and acknowledged the foregoing instrument to be their free act and deed, before me, Mark Ford, Notary Pu lic My Commission Expires: May 26, 2006 N Ln v:. ,•,9C;.�s JAN -13-01 SAT 1:36 AM FiiRD&FORD, F. C. FAn l01, 9786838188 P. 1 ffit*FAX TRANSMISSION*w John P. Ford, ESQ Mark Ford, ESQ. Law Offices of FORD & FORD, P.C. 300 Essex Street Lawrence, MA 01840 Tel: (978) 686-0108 Fax: (978) 683-8188 To: IIIA Board of Health Fax #: r� _4��O Oo 8 " � � From: Mark Ford, Esq. Subject: BELIVEAU Restriction COMMENTS: ENCLOSURES. Maine Offices Post Road Center 62 Portland Road P.O. Dox 1028 Kennebunk, ME 04043 Tel: (207) 985-6561 Fax: (207) 985-2693 Date: January 11, 2001 Pages: 2, including this cover sheet. Statement of Confidentiality -The information contained in this fax is intended for the exclusive use of the addresses and moy contain confidential or privileged information. If you are not the intended recipient, you are hereby notified that any form of dimemtnation of this communication is strictly prohibited. if this f= was sent to you in error, please notify us by pP Mirnmedxately IF YOU 00 NOT RECEIVE YOUR COPIES CLEARLY OR NEED ASSISTANCE, PLEASE INFORM US IMMEDIATELY. THANK YOU. (978)686-0108 TOWN OF NORTH ANDOVER BOARD OF HEALTH 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 SANDRA STARR, RS., C.H.O. Health Director October 31, 2000 Mr. E. Charles Beliveau 210 Farnham Street No. Andover, MA 01845 Dear Mr. Beliveau: µ0R711 f 7�0 ��SSACHU`+�� Telephone (978) 688-9540 FAX (978) 688-9542 This letter is in regards to the issuance of a Certificate of Compliance for the repair of your septic system. Please be advised that before a Certificate of Compliance can be issued the Board of Health will need a deed restriction on file with our office. The deed restriction must state that the dwelling is limited to a maximum of three (3) bedrooms because of the size of the septic leach area and because a variance from depth to ground water of 4 feet to 3 feet was given. A sample deed restriction is enclosed with this letter. We suggest you contact your lawyer to set up the deed restriction. If you have any questions please feel free to contact our office. Sincerely, Sandra Starr, R.S., C.H.O. Health Director COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y t i TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: %ay12c/l� �� Ply Owner's Name: &-/—r Owner's Address: Date of Inspection: Name of Inspector: (please print) Company Name: Mailing Address: y S' Telephone Number: �271 " qS7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: tls Date: The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 in (d Co o e a/ te4 17 e e � 7 � Page 2 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / d Gd v< d •jj 5 -)- Owner: rOwner: �) ✓ /� / Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: v P S I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components/as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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): ND explain: broken pipe(s) are replaced obstruction is removed 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /� � ph U&14 S /— P- 0 -P-0 1 - Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a su_rface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ?/d 6 e Nv "r r S Owner: 1341 /i1 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool L Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,,,clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow `''JRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. f Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic .compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a trapped 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. f Page 5ofII OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /V. '49A, --lo p d -r Owner: 1--)7 y r Date of Inspection: Q f Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ✓ _ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks ? 4�-, _ Has the system received normal flows in the previous two week period ? v Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out ? Were all system components, excluding the SAS, located on site ? _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _✓ _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. _ ` Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)) 5 , Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: --91J 4 s/fin Owner: i> U /its -� Date of Inspection: '- /,F o 5'r FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: _ Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd)): Sump Pump (yes or no): Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: If Design flow (based on 310 CMR 15.203):_ gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the .Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection (yes or no): If yes, volume pumped: gallons - How was quantity pumped determined? % 0Qu c, c 44 t�{i Reason for pumping:'/t e c% '7,0 1,tle-o ST Q v cTur? -c TYPO'F SYSTEM _ Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: F Were sewage odors detected when arriving at the site (yes or no):v Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. C SYSTEM INFORMATION (continued) Property Address:. Q "vh ✓A SJ- Owner: l`Owner Date of Inspection: ! - BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: _cast iron Lo,40' PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of jointssventing, evidence of leakage, etc.): ( 14 6s/ra/T/4M SEPTIC TANK: ((S (locate on site plan) Depth below grade: /.•- " Material of construction: L--6ncrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: 16 ( c S �' Sludge depth: '` Distance from top of sludge to bottom of outlet tee or baffle: 3 7 v Scum thickness: Distance from top of scum to top of outlet tee or baffle: r, ; Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Q �� $'/'9'c_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): , 6'000 Col Di -►-IO J GREASE TRAP: _(lotate 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 recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /6 /.'a P, ► t' H4 .a - ANo uy10✓ Owner: 13 U �,� -'t!Date of Inspection: ,S- /y "0 r• TIGHT or HOLDING TANK:/(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX:'*5 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -g�v.a Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): h►o ra /-' l P PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 V Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .;2/Q f' vGj U S Owner: U brims �- Date of Inspection:�- / 9 QS SOIL ABSORPTION SYSTEM (SAS):/e5 (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: S 3 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.): Inti . t .� .o < IC16 ".1 i CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth- top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on-site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 0 Page 10 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Fa0-'?4U - . s rZ-e e I OW c ///J -r •C 044 6 . sib kC 10 13_ C r t„ b Page I 1 of 11 << OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: U $/ / A4 Ai iox vr-i Owner: Date of Inspection: SITE EXAM Slope ;z 4,1h, ew 0 Surface water H o N Check cellar p Q,�/ Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: 7 Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: C 6.- I 6 J-/ ffLf /N0/ C,$7'f5' / /fS� /l! c' vtf D02 `� /-1� to �-;''fir S �/ � w•v L, I System Construction Availability 9:45 - 12:00 PM 2:45 - 3:45 PM 9:45 - 12:00 PM 2:00 - 3:30 PM 9:45 - 12:00 PM ons that are made before g) will be inspected on that day. Al will be inspected the time as noted above. required inspections listed below )osed as per plan and a sample of the i� 14. Tank is watertight Comments: INSPECTION CHECKLIST FOR SEPTIC SYSTEMS A. Bottom of Bed Yes NO Initial 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation, etc. ;7 - Comments: Comments: B. Retaining W41----, 1. Wall hei t and specified %thas 2. Waterproofed 3. Wall minimum 10hing facility 4. Wall meets specifications o an Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe ✓ 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8" per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90° change 10. 10' minimum offset to water line Comments: D.. Septic Tank 1. LevelZ f / !� 0 2. 1,500 gal minimum _V L 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20" manholes 7. Inlet tee minimum 12" under invert S. Ouilet tee minimum 14" under invert U 9. Outlet line cemented / 10. Air space 3" above tees y / 11. 2" - 3" drop from inlet to outlet 12. Pipe set 13. Compact base with 6" of %" crushed stone under tank 14. Tank is watertight Comments: Yes NO E. Pump Chamber 1. If separate from tank, compact base with 6" of 3/4" stone underneath 2. Minimum 2" pipe to d -box ifgravity system 3. 20" access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specifi tion 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d -box Comments: F. Distribution Box 1. D -box level ✓ 2. Minimum 0.1T' (2") drop from inlet to outlet 3. Minimum 6" sump 4. Outlet pipes show equal distribution 5. Compact base with 6" of stone beneath box y 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double -washed -'/4" - 1 ''/z" - pea stone Bucket test done? 2. Minimum 2". of pea stone above distribution lines 3. Minimum 6" stone beneath pipe ✓ 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9" of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not, then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with pl . (Max length 100') 3. Width of trenches agree with plan inimum 2'; maximum - 4'. 4. vent present if <50 feet or specified 5. Distance between trenches minimum 4 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6" per 100' 8. Depth of trenches below outlet invert min maximum of 6' KIVU r Yeses- NO 9. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6" per 100' 3. Separation between pipe 6' maximum 4. Pipes connected at end 5. Separation between adjacent fields 10' minimum d 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: J. Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12" and 48" e 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9" soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond //��4,/- TOWN OF SYSTEM PUMPING RECORD DATE: L� SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: k-( — t U,&)L( QUANTITY PUMPED : CESSPOOL: NO YES SEPTIC TANK: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER `S_z2 GALLONS FULL TO COVER YES BAFFLES IN PLACE LEACMULD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: coNTENTs TRANsFERRED To: G.L.S.D Lowell Waste System Owner Fes" Commonwealth of Massachusetts A' `)��Massachusetts System Pumping Record System Location (0-S-4- Ftv�-� Date of Pumping: Quantity Pumped Cesspool: No 1.4 ------Yes I] Septic Tank: No System Pumped by: vctiedart Eit&M,64ma License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector - l�/`�gallons Yes [_4--- ori � 7 Conunonw alth of Massachusetts l � Massachusetts System Purnping Record System Owner .AuJPOAJ Date of Pumping: Cesspool: No [.. Yes U System Location Quantity Pumped: ` gallons Septic Tank: No U Yes r System Pumped by: Faredea gooey jed License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: r j-C.� urd O� R -, 0�RD O1= BOA HLAU H �t�•. --__ ; " �'. 12o MAIN S I REM �y NORTH ANDOVER, MASS. 018-x5 i, �SSACNus�t „I f 141, Mr. Phillip Riccardi 210 Farnum St. North Andover, Mass. TEL: 682-6483 Ext. 32 or 33 May 29, 1990 Dear Mr. Riccardi, An inspection of the premises on May 14, 1990 revealed that your septic system is malfunctioning. Sewage effluent was observed `i running on the ground over the leaching field. This condition mus be rectified immediately. Please contact me at the Board of Health 'I Office to discuss the options available to remedy the situation. Thank you for your cooperation in this matter. t NORTH 9 OEt"`o '° ti0 9 SAC US BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 Mr. Phillip Riccardi 210 Farnum St. North Andover, Mass. TEL: 682-6483 Ext. 32 or 33 May 29, 1990 Dear Mr. Riccardi, An inspection of the premises on May 14, 1990 revealed that your septic system is malfunctioning. Sewage effluent was observed running on the ground over the leaching field. This condition must be rectified immediately. Please contact me at the Board of Health Office to discuss the options available to remedy the situation. Thank you for your cooperation in this matter. Yours Truly, Michael Rosati Acting Health Agent .A y = APPLICATION FOR SEWAGE DISPOSAL INSTALLATION y i HEALTH DEPARTMENT - NORTH ANDOVER MASS. I hereby make application for a permit for a sewage disposal installation at —_ Lot #8 Farnum 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 200 ft lineal (square) 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. 2 feet gravel to be installed DATE Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE OA Signature of I pecting Officer Percolation Test 5 min Soil: Gravel & Clay Garbage Grinder BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. 31 1. NAME Oc cc; K s c4v yz /'' DATE 2 2. ADDRESS 7�i� rryt i� 77L- LOT NO. TEL. f 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 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. N BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL NAME OF APPLICANT LOCATION Address of lot no, BUILDING: Dwelling ?C Other SYSTEM: New K Repair GENERAL DESCRIPTION OF LAND "JA' SUBSOIL: Clay K G vel Sand PERCOLATION TEST minutes per inch, MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK. lfi��gallon capacity. LEACH FIELD 2-&V lineal feet of drain pipe. illiam J. Dr' co 1, Engineer Board of Health INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at '� 1. p frit �'1nu(� C� relative to the application of F R e� j 1 dated _-� c, for plans by VOC!6gi-nd dated with revisions dated q -I a I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed — generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to BOIL after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer A �_A�o Date: ► ®-� 1-,-> 31 Town of North Andover, Massachusetts Form No. 2 O�tNOoT:�h BOARD OF HEALTH / O X. , w F «^,r; DESIGN APPROVAL FOR SACMUS SQA SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM .&.cant.L:1 rte, Test No. Site Location Reference Pla Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee CHAIRMAN, BOARD OF HEALTH Site System Permit No.—//,? oL '' row cn co N.** a a ..e o. CD f9 ,� fD ,°°.'. N °a^ i ;ii+r c ot f�9 p Ln n Pi p7• Nva;< 'sem .nlroo? *,4w, t/1 GCD Q D � m CD W v_ V) w :3 N LA; O O =- n V) f O D � o O n W Z O O O > coCD O aq' D Z O `-° w. y y O m -� 7G m D � C IrD 'a N a DF- z o m n Ca Z w Q N D r,.. O C, D rn m J r o 0 m 3 O o 0 m w BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 1() -S i-00 CURRENT INSTALLER'S LICENSE#, LOCATION:­�� j. o"'S� . LICENSED INSTALLER: k p _ � \n + � S�c _ . SIGNATURE: TELEPHONE# q1 9 - CHECK CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes 'vell� No --Foumd"ation As -Built? Yes No Floor"Plans? Yes No Approval 1 v Date: so U oa NORTM q Town Of North Andover Community Development & Services 27 Charles Street North Andover, Massachusetts D 1845 9sS4CHU5Et Fax 978-688-9542 Board of October 13, 2000 Appeals (978) 688-9541 Bill Dufresne Building Merrimack Engineering Department 66 Park Street (978) 688-9545 Andover, MA 01810 Conservation Department Re: 210.Farnum Street (978) 688-9530 Health Dear Bill: Department (978) 688-9540 This is to inform you that the revised septic system plans dated 09/12/00 for the site referenced above has been approved for repair. Public Health Nurse (978) 688-9543 any If Y you have.questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Planning Sincerely, Department (978) 688-9535 i ' Sandra Starr, R.S., C.H.O. Health Director SS/smc cc: Beliveau File William J. Scott Director (978) 688-9531 �1,4 N DJ'�� G Sep -28-00 12:46P Paul D. Turbide, PE/PLS 978-465-0313 P.02 P ORT ENGINEIRIK Civil Engineers & Land Surveyors One Harris Street Newburyport, MA 01950 (978)465-8594 September 28, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School Street North Andover, MA 01845 RE: Title V review for 210 Fornum Street Dear Sandra, I find that the design plan dated September 5, 2000 with revisions on September 12, 2000, as prepared by Merrimack Engineering Services on behalf of Charles & Susan Beliveau adequately addresses the minimum design criteria as set forth by the Town of Andover and Title V regulations. For the purpose of clarification, the design plans should be modified to specify the location and identification of proposed and existing contours. Also, the septic tank detail should include a note requiring a minimum of 3" of air space over the tees and a minimum of 9" of air space over the flow line. If you have any questions or comments please feel free to contact me. S' Paul D. Turbide, P LS \\Server p\ NABH\P2884\FORNW STREET 210.DOC Sep -28-00 12:46P Paul D. Turbide, PE/PLS 978-465-0313 P.01 Facsimile Cover Sheet To: SANDRA STARR Company: NORTH ANDOVER BOH Phone: 978-688-9540 Fax: 978-688-9542 From: Paul D. Turbide Company: Port Engineering Associates, Inc. Phone: (978) 465-8594 Fax: (978) 465-0313 Date September 28, 2000 Pages Including This Cover Page: 2 Comments: Sandy, I have attached our review of the SDS Upgrade at 210 Fornum Street. Thanks, Paul Turbide PORT ENGINEERING Civil Engineers & Land Surveyors One Harris Street Newburyport, NLA 01950 (978)465-6594 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 Authoritymoard 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 151000. 1) Facility/System Owner: Name: 5L42A►.s i e,/A A f Le,- g Ei-j UzeFt! Address: 210 rA" u H cy,-�eT Phone #: & Uzi Address of facility: e7vr-A 6 2) Applicant (if different from above) Name: Address: Phone #: i T pe of Facility: Residential Commercial School Institutional (Specify) _eg 211E �t�v tG�E ' os,�STf�-I 4) Type of Existing System: _privy cesspool(s) other(describe) Page 2 of 5 /conventional system Type of soil absorption system (trenches, chambers, pits, etc.) 00ve, 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system -jA9 gpd Approved: y� yes Approval date: O no Why: b) Design flow of proposed upgraded system — c) Design flow of facility gpd Why 6) Propose("pgrade of existing system is: a) t/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: Co��i O�er� V��Ii1� Er-+�uT lam 6AL .. 5 PTIc TAnA,- qq2 15!f L-CACH- Fl Cs. PZAV(f�!r 4 V41 -OM c) Which of the following are applicable to the proposed upgrade? _Reduction of setback(s) (list setbacks to be reduced with propospd setback distances) S.a.s, 7O 159M) . Ft4d-d Zd 4,ol �'�TN�I!�-Zv F'OW /0' Ip -7' Percolation rate of 30-60 minutes per inch (state actual perc rate),, ,5. To F✓> -ti/_ 2d (fvfL T Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) duction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) 1 fv3/ 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 ;i feet As determined by: Evaluator's name: Evaluator's Signature: Date of evaluation: ?5 --&-Oco 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: 2tCTyl-4 N mrro si rZF' /2.14c- 12 1%� S� b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. Alli 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? yes ono Page 5 of 5 11) Certification 1, 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." • Facility Owner's] Signature Date ten- c 0 z'U v--,A�,j Print Name Name of Preparer Date Y72;� -35�;� 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. SEPTIC PLAN SUBMITTAL FORM LOCATION: NEW PLANS: S $125.00/P1an ✓ C. l� 5 I �7 REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: Y'ES NO DATE: q-1 I -oo DESIGN ENGINEER: - eat vVl2& 4A ti vt DATE TO CONSULTANT: *If you want your plans expedited, please submit tbrec plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. I m 4- I H la Location: Z!v Y't..ri�7�,..2, S`1F". Owner's Name: Map/Parcel:_ I0? 4 Address:/ Z/U Installer. Tel yLr '�C Sr ai New tsisol Repair r� /' ) Date: C/ Wetlands5e_ f/,'�a.one II Soil Symbol W —Soil 1Qame L✓Oa --�Soil Class G� Deep Observation Hole Logs Observat Depth of Start Pre Time at ] Time at S Time at E Time (911 Rate Min 11 Performed By - ham. Witnessed Bx-. - J Elevation Depth Soil Horizon Soil Te=htre Soil Color Soil Mottling b/o Gravel, Stones, etc: Zl S/ `� re m� a 3�` e fir! --Z4" 0, Si. *S �S Parent Material Depth to Bedrock "{ Standin.w Water in the Hole•. O" Yee ina pa „ from Pit Face �� � �GtiY; , ,�- Date . Percolation Tests N Parent Alaterial / LC Depth to Bedrock ' Standing Nater in the Hole --13y Welpin*. from Pit Face •` Observat Depth of Start Pre Time at ] Time at S Time at E Time (911 Rate Min 11 Performed By - ham. Witnessed Bx-. - J Zl S/ `� re m� a 3�` e Glc�i ss- --Z4" 0, Si. *S �S Parent Material Depth to Bedrock "{ Standin.w Water in the Hole•. O" Yee ina pa „ from Pit Face �� � �GtiY; , ,�- Date . Percolation Tests N Observat Depth of Start Pre Time at ] Time at S Time at E Time (911 Rate Min 11 Performed By - ham. Witnessed Bx-. - J I 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: 5 V--,, Address: Z10 rAtLaJUH � eT Phone #: & V7 Address of facility: ivy-lGf 2) Applicant (if different from above) Name: f7 Address: Phone #: i T pe of Facility: Residential Commercial School Institutional (Specify) 'VN �z1T `1nMQE i�sT1�-1 I 4) Type of Existing System: _privy cesspool(s) other(describe) Page 2 of 5 conventional system Type of soil absorption system (trenches, chambers, pits, etc.)�v� 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system 'jam' gpd Approved: _yes Approval date: 8 no why: b) Design flow of proposed upgraded system �gpd c) Design flow of facility r gpd Why 6) Proposed pgrade of existing system is: a) 7loluntary 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: 67 Pi MT -C' Ck i l,-Jbo 6W,,.. SPpric -F4njr- 120 � LCACH- Fl 91.j2 QnAVCZ:Y yYSTkm c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with propos d setback distances) S.A.5, To leiO . FJ10-a 2d 4V ! 15r'fate),�,A.,5. T Wk+ , Tv IrPW J01 0 ? Percolation rate of 30-60 minutes per inch (state actual perc To Wf�l- as �{�/.ti' Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) duction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) q i fy 3l Page 3 of 5 Other requirements of 310 CMR 15.00'0 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 :i feet As determined by: Evaluator's name: 'Z - 'Cj'!-(Q� Evaluator's Signature: _ Date of evaluation: 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 0I:ft'V bay sib Ma 72 b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. AA 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? yesno 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." Y Facility Owner's Signature Date �Z 0 -71V,,,) nn, c 1-krz� onn"y .t -t1 Print Name Name of Preparer Date Telephone No. & Address of Preparer cl7t;� -35z;� 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 uponissuance by the Board of Health and prior to commencement of construction. oc A ion, off- Lo _ 0 H 'IN i N= S Uy 'vim =COL i ICN i Tr/ICE 01 - Vr.(\. _ IS -"Ir, _ :C r. I 4 NORTH _ F 9 SSACMUSEt Date ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING { This certifies that-r'v,..... ! •: r ........ : z .............................. has permission to perform ........................................... wiring in the building of %` :,, .._:.................................................. at 57 �.... -r rr,, -...< ' ................... . North Andover, Mass. Fee .......................Lic. No O..'r ; f . ...................................... ELECTRICAL INSPECTOR Check # /U` 5311 THE C0jW0NTV LTHOFM4S,4C'HU.SE+7'1',5' Office Use only DEPARTA1EW0FPUBLICSAF= Permit No. 7 BOARDOFFIREPREVEMONREGUL<AHONS527CMR12.M ivy Occupancy & Fees Checked APPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) Owner or Tenant i G U 12 K Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building k i, - Ci Utility Authorization No. Existing Service COQ AmpsA7 rQT7 yYkolts Overhead Pr7runderground r-1 No. of Meters New Service Amps _Volts Overhead F�i-1 Underground M No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No. of Lighting Outlets No. of Hot Tubs ��- No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA round ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners No. of Ranges No. of Air Cond. Total FIRE ALARMS No. of Zones Tons No. of Disposals / / No. of HeatTotal Pumps,-' Tons Total KW No. of Dishwashers Space Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No. of �— No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP No. of Detection and Initiating Devices Nq. of Sounding Devices Na of Self Contained Detection/Sounding Devices LocalMunicipal Connections a Other THEI}� �►i�l9i µI IL UarMCoveiage. PtusitarittotheognmyrttsofMacmchisettsc-ate Laws avea�tLmblityykmo=PohcyiriclhemgCc)no Coveaageorilsatsu ialegtuvalat YES � NO avert>tnnitledvalidproofofsametotbe0ffimYES � Ifyouhawded<edYES,plea9 ndicethetypeofcovt�by �gthe ° bo. LL�M�� SURi6ff t (� BOND r7 OIC FkaseSpe*) NOW -G EstimatDdValueoflbchicalWbik $ Rough ��%/�//I l s' --D c/ Final IJa=No. C TO C� Signallm ._4;C __' �No BusinessTelNo. ta� _�! ,(3iCClj'Ir �� �� ,y��� ✓iG'�. l9 ��/fr.� / Alt. Tel No. T,UZ'SINSURANCEWATVET;IamawarethattheLocnsedoes nothavetheir>sur ncowngeorits&A-analeWvalentasreclmedbyNbssachusenGeneral Laws that my signatrue on this petrr it application waives this regtlirerr>ent :ase check one) Owner ® Agent 2 El Telephone No. PERMIT FEE $ t,V Signature oT Owner–or 7gent The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name: Address City: Phone #: . Insurance. Co. Policv # Company name: Address 1. Y City: Phone #: Insurance Co. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,506.0o and/or one 'years' imprisonment.aswell"as_civil.penaltiesin-the fnrmofa_STOPWOi KORDFR.amd_a.fine"of_(.$10-0,00.)-a-dayagainst,me. 1 4 understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. , Signature Date. Print name . P.hone # Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing EJ Building Dept ❑Check if immediate response is required n Licensing Board Selectman's Office Contact person: Phone #: Health Department Other BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: '7 - 1:a LOCATION OF SOIL TESTS: ZA6 Assessor's map & parcel number. 107A_I--IL, OWNER: eA-I�r�7 OgE�j p�ekLj_ TEL. NO.: ADDRESS:_ 2,10 ENGINEER: HE1 U }STEL. NO.: CERTIFIED SOIL EVALUATOR: Intended use of land: sidential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: ef8siy-. 66 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 1275.00 per lot forspew construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. 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 disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1'-100') shall be submitted to the Board of Health showing--acation of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. - F � v w m m OL m 0 (D 0 fD v n ao Z ;z O Z \ o � 'O tc of TOWN OF NORTH ANDOVEP, UA ft SYSTEM PUMPING UCOR-D Z SYSTEM OWNER R& ADDRESS --- S Y 5 TE M—LOCATION 20 4u -o -l -Q, a UATE OF PVMMNQ: .........----QUANTITY PlJMP6D:-_/.,5 SoPdc Tank: NU YES—/ NA ruRE OF SBRVICE: WvrINE.... UbSERVATIONS: 000D CONDITION PU W. TYJ CO V ISR HEAVY MAU BAFFLES IN PLACL ROM LEACFMP-LD RUNBACK 8xCess'lVE SOLIE)S,_.. FLOODED qnl TM CARR MAY 0 6 2005 TOWN OF NORTH ANDOVER DEPARTMENT I v Y Q FHER EXPLAIN systam ol� 6-1—se/ /I7a WIMMENTS. �.vN rtwrs rmwemo ru lio �s?5 o 44-14A \�A cocwic MewrcK ^O Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Applicant 11.� L44—Ir NAME Site Location cl, a Engineer Test/Inspection Date and Time O , Zai Z:6 �6�; C10 —"4,1,7 CHAIRMAN, BOARD OF HEALTH Fee / Test No. 57 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH F q Q S,IED Ib �Q 19 - : Ew° APPLICATION FOR SITE TESTING/INSPECTION QDRA TED 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. BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: LOCATION OF SOIL TESTS: -,74 0 Assessor's map & parcel number. — A '1, OWNER:614aP+.07 0E�j lfEj_ TEL. NO.: ADDRESS:_ DO FA2,,- ENGINEER: E IE121Z1 CERTIFIED SOIL EVALUATOR: F2I t- r Intended use of land: sidential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: 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 1276.OQ per lot forenv construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for Leoairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than V-100') shall be submitted to the Board of Health showircation of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. JUL. 14 r I` 6_0 c U= Of N N U C O �l « C N O C wQU k 114`C EQ 0 °Jp a °c'v m EoON O0d cv, vocv c N NN 7 O NN° 0 W_ UN J O �coE Z 3v°EpN° o � ac rE O 0r°OU ° °�w °~ 46 cV c° E 1001� Q v � ) 0 n.°® oofcum _ oN WQ7 ° d CO LL LL O Eb o E g�m I 3: cm E m a N 3� (na U. cc wm Wrncof iY :.. a Qr EM' o o° Tc �� x c U O o N N U E p ° cC O U c « c c V V o `� �Ecoo a�`EEN p �) aero zU� otdo oN m�cjjO�o .2 0'0 ~ c.0o�NSE \--c`�iE a 02M 0UN Zocc0 Z -c°°0, ►-y aci�>3 �c°o•N t X m LL 2T�=oc° EQ°�aci O rncLiy° _� Eca°o comp ~ O U) '0 rn o>�y Q ��ro3 F—Q v��cLn (� ��'� N V cmn 4 H= c c a `c Nva 3 U r_ a� cm w e N o cNa (-- E `° a iliai°�'Ncty.LM Nccc 00 Lo.0 FW—. EE°�cp Qa EC•°N—a iri 3: —0 �E D F- y d N L c0 tr H O Q Q N L y J ~ r C E (LD) Q O p C O y Q Z U F- Ti N O — 3 N O N Z ®❑ ❑ LL 0 N Commonwealth of Massachusetts W City/Town of ao System Pumping Record Form 4 �M 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. System Location: , \ on the computer, U use only the tab key to move your Addre s cursor - do not use the return key. City own 2. System Owner: VFO I I" 1` U bk Name renrm Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1 D of2. Quantity Date o Date Qua t ty P umped: allons 3. Type of system: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: rc-) 00C 6. System Pumped By: V�7Ln - Name Stewart's Septic Service Company 7. Location where contents were disposed: Vehicle License Number Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of ReceivinVFacility Date l� Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 No Andover J&S Development dba 1600 Osgood St Stewart's Septic Building 20 Suite 2-36 Andover Septic No. Andover, Ma 01845 58 South Kimball Street Bradford, MA 01835 Date Name & Address Gallons Comments 1-Maj'Patter reality 81 Sawmill Rd 1500 Good 2-May'Mulcahy 350 Sharpners Pond Rd 1500 Good {Greene 62 Willow Ridge Rd 1000 Good 3-MayIacross 259 Grandville 2500 Good 4-May�Rincohi 1.15 Sherwood Dr 1500 Xsolids HG 9 -May Callahn 540 Foster St 1500 Good 10-May''Melerim!,1444 Salem St 1500 Xsolids 15-MaytDira4e1'3 Brenkin ridge Rd 1500 Good L..Depari/175 Stone Cleave Rd 1500 Good 16 -May Martin 701 Forest St 1500 Good M rphy 16 Carleton Lane 1500 Good 18 --May Vandergraaf267 Old Cart Way 1500 Good ,S618no,2498 Tnok St 1000 Rh 21-May-Vomich0_115 Laconia Cir 1500 Good Reti 42 Cross Bow 1500 Good 24;MRtarbonell 1560 Salem St 1000 Good 29 May Thurber 210 Farnum St 1500 Good C31=May,Clearyt105 Winter green Dr 1000 Good T CVVN 0I NOR-rH ANDA\irk HEALTH DEPARTMI=NT