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HomeMy WebLinkAboutMiscellaneous - 212 HAY MEADOW ROAD 4/30/2018 (2) 212 HAY MEADOW ROAD 1 210/104.6-0077,0000.0 , r � `\ 1 a i Lot & Street Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: Approved by: Designer: Plan Date: Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: N. SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? YES Type of Construction: NEW REP New Construction: Certified Plot Plan Review YES NO Floor Plan Review . YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: YES NO DWC Permit Paid? YES NO DWC Permit# /a a Installer: - 0XJjA Begin Inspection: YES NO Excavation Inspection: Needed: - _�, Passed: By: Construction Inspection: Needed: As Built Plan Satisf ctory: YES:— b�= �V Approval of Backfill: Date: By: Final Grading Approval: Date: By: �' �bC Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: COMMONWEALTH OF MASSACHUSETTS • EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS > DEPARTMENT OF ENVIRONMENTAL PROTECTION F TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 212 Haymeadow Road_ _North Andover_ w ® Owner's Name:_Steve Macrides_ REC Owner's Address: 212 Haymeadow Road_ —North Andover,MA 01845_ APR 13 2005 Date of Inspection:4/8/2005_ Name of Inspector: Neil J.Bateson TOHEALTH DEPAR M ORTH ANDOVER Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ 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: X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa' Inspector's Signature: Date: 4/8/2005_ 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 212 Haymeadow Road_ _North Andover_ Owner:_Macrides_ Date of Inspection:4/8/2005_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_212 Haymeadow Road_ _North Andover— Owner:_Macrides_ Date of Inspection:4/8/2005_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance_ "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 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 212 Haymeadow Road_ _North Andover — Owner: Macrides_ Date of Inspection: 4/8/2005_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'h day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No Any portion of the SAS,cesspool or privy is below high ground water elevation. _ _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ 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.] _No_(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 mapped Zone 11 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_212 Haymeadow Road_ _North Andover— Owner:_Macrides_ Date of Inspection:_4/84/2005 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes Were as built plans of the system obtained and examined? Yes Was the facility or dwelling inspected for signs of sewage back up? Yes Was the site inspected for signs of break out? _Yes_ _ Were all system components,excluding the SAS,located on site? Yes _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the n dimensions depth of liquid,depth a and depth of of sludge condition of the baffles or tees,material of construction, p Q eP g scum? _Yes Was the facility owner( P_ _ 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 _Yes_ _ Existing information. _Yes_ _ Determined in the fieldan if of the failure criteria related to Part C is at issue approximation of ( Y distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_212 Haymeadow Road_ _North Andover– Owner:_Macrides_ Date of Inspection:_4/8/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_440_ Number of current residents:_4 Does residence have a garbage grinder(yes or no): Yes_ Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): _ Seasonal use:(yes or no):_No Water meter readings: Yes,019866Ft3_ Sump pump(yes or no): No_ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment:__ Design flow(based on 310 CMR 15.203):___Md 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: Pumped last year,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/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:–4 years old,8/22/2001 as built plan_ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 212 Haymeadow Road_ _North Andover — Owner:_Macrides_ Date of Inspection: 4/8/2005 BUILDING SEWER_X_ (locate on site plan) Depth below grade:_5'_ Materials of construction: X_cast iron _X 40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): 4" Cast iron thru foundation, 3"PVC in house,no leaks visible_ SEPTIC TANKS: X Depth below grade:_4'_ Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth —211_ Distance from top of sludge to bottom of outlet tee or baffle: 25"_ Scum thickness:_2"_ Distance from top of scum to top of outlet tee or baffle:_8"_ Distance from bottom of scum to bottom of outlet tee or baffle:_19"_ How were dimensions determined:,Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)_Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert. No evidence of leakage._ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART C SYSTEM INFORMATION(continued) Property Address:_212 Haymeadow Road_ _North Andover_ Owner: Macrides_ Date of Inspection:_4/8/2005_ 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: X Depth of liquid level above outlet invert: _0"_ 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.):—D-box level&distribution equal.No evidence of leakage.No evidence of carryover._ PUMP CHAMBER: X (locate on site plan) Pump in working order(yes or no): Yes_ Alarm in working order(yes or no): Yes_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_Pump cycled on then off.Alarm has both visual&audible. •Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_212 Haymeadow Road_ _North Andover_ Owner: Macrides_ Date of Inspection: 4/8/2005_ SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required) If SAS not located explain why: i Type _ leaching pits,number:_ — leaching chambers,number:_ leaching galleries,number: leaching trenches,number,length: X leaching fields,number,dimensions:_1 field 15'x 60'_ 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.):_Soil oL Vegetation oL No sign of ponding to surface._ 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 sludge 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.): Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 212 Haymeadow Road_ _North Andover — Owner: Macrides_ Date of Inspection:_ _4/8/2005_ 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. i Driveway House Water Meter A B —LZ Deck A to Tank=82'8" A to Pump Tank=9016" A to D-Box=9717" B to Tank=82' B to Pump Tank=93'4" B to D-Box=9312" Septic Tank Pump Tank ® D- box Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_212 Haymeadow Road_ _North Andover— Owner: Macrides_ Date of Inspection: 4/8/2005_ SITE EXAM Slope Surface water Check cellar Shallow wells ted depth to ground water 4 Estima ep gr _ _ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_11/7/2000_ 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:_As per design plan._ I Summary Record Card generated on 4/8/2005 1:33:06 PM by Lisa Warren Page 1 Town of North Andover Tax Map # 210-104.8-0077-0000.0 212 HAY MEADOW ROAD MACRIDES, STEPHEN 212 HAY MEADOW ROAD N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.09 Acres FY 2005 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until MACRIDES, STEPHEN Payor 212 HAY MEADOW ROAD N.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 2829.0- 212 HAY MEADOW RD Last Billing Date 4/6/2005 3180141 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE•ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 64.86 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 13242668 a Active ERT HH METE METE w Water 0.63 0.63 0 Date Reading Code r Consumption Posted Date Variance 3/10/2005 191 a Actual 22 4/5/2005 -8% 12/15/2004 169 a Actual 22 1/14/2005 -67% 9/28/2004 147 a Actual 90 10/8/2004 139% 6/15/2004 57 a Actual 19 7/30/2004 9% 4/23/2004 38 a Actual 38 5/17/2004 0% Wd F.E I - — ,.:SS tt 03 to 'd VTL'V0i 3A 9" oF!- � O » ;`� aw a � aro ase -s a . 1 1177�� I ` i SUM) _ f.Y SSI 0145 F 1 6' 5X5]'u? 3 I 13 Crr.Wlt7> c ��/ /,-w " -Py,Y j i !611 '16 a 'o .7 V% C% k:WO, �k�� 'WAX/, UTC ,. ylwi ,2 � n�rq��ih �yyir1vK�� 'J 04 ."�21� �iW4i . �r vl t`.M//��51 Uc—cnm �1, M '.6X.7 ='� ss v i),I r�-37 J4 41T `7. r 'S r r S ;' e r y[i Jai% �� --�55:�1r�C �'..�i$���i i1 ' 'T r�rl? 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"l `l Y �yTfJ�7 7''1 T '��/ "Jx., ,. �)l `� a}Al�FC4�2. ¢1'.'LAdl IRllf:rllI �S3J?-'���IJl.,0) T T .M�47�f IV -C)I.\�� :31 )S DILLY;,; 'a��STlk�� ri -19 g',)331-I rT TI ;7': 'l IT' 1w,i }l I �1�`r.7° y':rr :)'b_F �?t CAlIll JGiI�Zi��J}J �Yr"3} t Feld CC:T 1 x TC T'OT WZi3AO�J "mai i au°u a ra -s a n a .r O unS fi mol -.. iem Ifs �S a Ras Mori I ! F r F 4 If I'Ll !b') ifn .! h ry PZ' T 4 •, IlLiTOWt'S tit, �f� ' ��) - _ -- - - W WTI* : 1 Tel: (978)475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 212 Haymeadow Road, North Andover Owner: Macrides Date of Inspection: 4/8/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street oA'ATFD���AI North Andover,Massachusetts 01845 Sandra Starr Telephone(978)688-9540 Public Health Director Fax(978)688-9542 TOWN OF NORTH ANDOVER BOARD OF HEALTH I CERTIFICATE OF COMPLIANCE DATE.OF COMPLIANCE 10/18/01 This is to certify that the individual subsurface disposal system constructed O or repaired (X) by John Soucy at 212 Hay Meadow Road i 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. i ' I B an J. LaGrasse Board of Health Inspector E y"� I BOARD OF APPEALS 658-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 r TOWN Or NORTH ANDOVER Sri AGE, DISPOSAL S��S`�'E\-i I\S � E•TALLA-rIOCRTIFICATIOiN The unce:sismed here.,v ceriiv that the Sewaee Disposal System 1` ? cor.su;lctcd; (�C) recaired : by located ai _----- was installed in conrc.-mance with the 'North Andover Board of He:.ith a-fprovec plan, System Deslan Permit,;-7' dated: _. :vim an arcroved desi-ii [low of Gallons per day The mate: a:s,usec were in coniormarc2 with those specified on the approved plant; the system was installed in accordance vvith the previsions of 3 10 CNfR 15.000, Title 5 and local repalatiors, and the anal gradin.; agrees substantially with the approved plan. Ail work- ;s accurateiv_ represented :)r, the As-built %vhich has been subrr:itted to the Board e Health. Eed inspection date: — Engineer R:ar:se :sti�e. Final inspect:cn cp I - Cc7 --- -- L-nsir-ec: Represe::tat:-.e Instal:er: s i:c T. Date: _10-1-7-01 CesJUM Ens_i 4ee : Date- %k ate: N^ — ar` RIZHARD tiG c C. TANGARD 0 9 0 BcwncQ=t' ' '\ SSIpNAI �. ..� 3; OCT 1 2.2001 } i 2-1 Z �4ti /A t,-jo\0 j AS-BUILT CHECKLIST LOT NUMBER, STREET NAME �J ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES &PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM f TOP OF FDN ELEVATION J� LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM o_ LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE �J DISTANCES FROM CORNERS OF HOUSE TO CENTER OF JTANK&D-BOX ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW J LOCATION& ELEVATIONS OF BENCHMARK USED Project Request Record Town of North Andover Date: fil 7 Q Client Id:ToNA Card Id:ToNA Client/Company Nam :Board-'Health 1�JrCard�rTr�ue=. 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CUM! d' �!t�,,,r,a;.r, ,,,�. r+r Rhone: ,Fax:� ..... r r ! J li,1!r(trl�lltlJ('tlll+jfir7l�tlj/rf1!(�/+(j !1 J Addr+ ess r+ 1 ,r•.- +i, , rr .+lr 1 f� r + 1r Email: +J r1rlf»Fr�Il+�i)f++.j/Fl/t F(/1lIGr{1�. Notes: �T10lwn ( ,-J.. Fr ,N.Jrll�lrr'rlfilJl�(lff!F/tlil��firfr'�t 1S to a api ode Jllu(rf!•;n;ifG; ll(,IflG,ff%/!J 1 t ++1!�+ .�r -..fr+rl'1�1`- 1 r (!f r..:rt�irilllJ/Il�/ll�fl�/AJ��II�/Il�l,�1/1 Protect: I. Project Id: 1770 Project Title: Town of North Andover.Board of Health (JOB NO) (PROJECT NAME&STREET ADDRESS) Manager:NOW Billing Group: © Billing Cod :Fixed Fee Qp Jir rr r. + +r•rril' A: 1 1 '�ContractiLnfofFPEojecVDescnptiory or,each,bilhn :group, ': + r y �rBG/1 '` rr F Applicant ! , .G� "Y � � �J U��%✓ Ol�• r f r F Jrl r 11(lrf�!J��l( r 'J/Asse'sSOrs lyTaDF>Q9 L.ot, 117 7 Street:..-Z /2 17`�t���`��,pd cJ a r 'dii I:ih!j%i;�rjO'Zzl ll 111! f IIJTypetof,service! �:'. ✓� Qcc S�—�i/ c_ S YS.7 �'`'r r t(1 ++1 rj1F�� '1 r,iF ' +lr frlJil'flfffJf!!I(())r .�. ..1., , rl r . r r ( r n 1. ..a��•;;,1C{IfFtllrfrl�ri TOWN OF NORTH ANDOV ER 80ARD OF LT HEA r H _ 2 5 2001 _J Officeofforms,ijbrqutona .1 N&M Job number 1770/ 9-1-4 1 i . TOWN OF NORTH ANDOVER INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Site: 'Z l.' AYAY/ham POOV I°C Final Date: Installer: —J fly N 50 U eTel: �JS —G/8--:53� 95'"' Date Yes No Initials A. Bottom of Bed 1, Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. Comments: (Use back of sheet for diagrams.) B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10'to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Inlet to tank cemented 4. Slope minimum 0.01 or 1/8"per foot minimum 5. Pipe properly set on compact firm base 6. Pipe laid on continuous grade in straight line 7. Cleanouts precede all change in alignment and grade 8. Manholes at any 90°change 9. 10'minimum offset to water line Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to w/in 6"of grade 5. Manholes over center and each tee 6. 3-20"manholes 7. Outlet line cemented 8. 2"—3"drop from inlet to outlet 9. Pipe set 10. Compact base with 6"of'/4"crushed stone under tank 11. Tank is watertight 12. Tees 12"off side of tank N&M Job number 1770/ I � i Date yes No � Comments: Initials i E. Pump Chamber 1. If separate from tank,compact base with 6"of/a"stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole ' 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade — A 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 f 2. Minimum 0.1T'(2")drop from inlet to outlet FP CJt/` 3. Minimum 6"sump �o - 4. Outlet pipes show equal distribution 72 5. Compact base with 6"of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe 9. First 2'from box laid level Comments: G. Soil Absorption system 1. All stone double-washed–3/a"– 1 %" -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. Toe of slope stops minimum 5' from edge of property; 5a. if not, then swale. Comments: N&M Job number 1770/ Date - Yes No Initials- H. Leach Trenches i L Minimum 2 trenches ' 2. Length of trenches agrees with plan. (Max. length 100') 3. Width of trenches agrees with plan Minimum 2';maximum-4'. 4. Vent present if>50 feet or specified 5. Minimum distance between trenches 10' 6. Pipe slope minimum 0.005 or 6"per 100' 7. Depth of trenches below outlet invert minimum of 6". 8. Pipes set on stable base. Comments: i I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' 3. Separation between pipes 6'maximum 9�! 4. Pipes connected at end&vent end raised ,� 1S 5. Separation between adjacent fields 10'minimumGn N� OWIT71 6. Pipes set on stable base �� rarrC.Fed 101fe 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines Comments: We I&7,- J& A- I'2 r� ��i � PLS O-✓ J azo�v.s` � �S? �-�''�"� J. Leaching Pits I. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement 6. 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 t may pond 6. Grading meets 3:1 slope 7. Minimum of 9"of fill graded over system Town of North Andover, Massachusetts Form No.3 t tORT11 BOARD OF HEALTH � p f 41 AT Ko DISPOSAL WORKS CONSTRUCTION PERMIT . �SSACY1USEt Applicant NA j DRESS / TELEPHONE J Site Location Permission is hereby. granted to Construct ( ) or Repair (1 an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD-OF HEALT Fee �� D.W.C. No. I I BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: 1 � LICENSED INSTA ER: o �, SIGNATURE: T LEPHONF?1�7 CHECK ONE: REPAIR: I NEW CONSTRUCTION: IF NEW CONSTUCTION,PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only °�vu4 t'' � °`t �' w �` , $75.00 Fee Attached? YesMAY 2 2 No 2001 it [ .., .. Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: 4z/ � - - INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at relative to the application of '1 0 COO ,dated <--9,9k—cJ 1 for plans by E .. .Oiv►d(, and dated 10—(9-00 with revisions dated I understand 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 Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 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. Undersign e L' ensed Septi staller Qv4C Date: Disposal orks ConstruC on Per NEW ENGLAND ENGINEERING SERVICES INC October 20, 2000 Sandra Starr,Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 212 Haymeadow Rd.,North Andover, Septic system design Dear Sandra: Enclosed are the following documents concerning the above referenced property. 1. 5 sets of design plans, one with an original signature. 2. Soil evaluator forms. 3. Application for approval. 4. Check to cover the fee. If you have any questions please do not hesitate to contact this office. Sincerely, Be`n? � C. Osgo , Jr.,EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-764.5,FAX(978)°685=1099 FORM 11 - SOIL EVALUATOR FORM Page I of.3 No. Date./- co:in Mon wealth of Massachusetts Massachusetts -SUM , asmenr&URMsOn-site Sglfflge Val Performed By: .... .... .. Date:........... Witnessed By: ................... ....,4r. ............ ....................................................... LOWIM Afttu or10 oww's Narm. Addros.W vewconstructlon EIRepair Fk1 Office Review Published Soil Survey Available: No ❑ Yes Year Published .......... Publication Scale Soil Map Unit ............... I - Drainage Class ........... Soil Limitations ....... ...................................... Sufficial Geologic Report Available: No 10 Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) .......................................................................................................................... ............ Landforrm ............................................................................................................................................................................................ Flood Iniurance Rate Map: Above 500 year flood boundary No El Yes Ej Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ❑Yes F1 Wetland A National Wetland Inventory Map (map unit) ........................... ................................................. Wetlands Co=rvancy Program Map(map unit) ...........I.................................................................. 41— Current N�ater Resource Conditions (USGS): Month Range :Above Normal KINormal FlBelcwNormal ❑ Other References Reviewed: i. DEP"MOVED FORM-12/07193 20 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No.119/cz A/ On:s to Review �I i c Deep Hole Number f... ....• Date:... Weather- 60 Location (iden ify on site pian) °a 7wMw........:...... . w......._.��. Land Use Surface Stones .. - . .. :.....!�!.�,�."l.-�G,. Slope {%) . ...-"- -......... Vegetation . .. �,s ..,... �. . . .. ._ : ,.. ...... .. .. Position on landscape (sketch on the back) .. � . .•. �� ... .... ..., . Distances from: Open Water Bodv-00� feet Drainage.way feet Possible Wet Area `'��... feet Property Line ...-�'�...�.. feet Drinking Water Weil ... ... feet Other : ..._:.......�,,:....... DEEP OBSERVATION HOLE LOG` Depthfrom Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, % Gravel) YZ C Y14 Z)IS d, � 1Ti fCr I I MINIMUM OF 2 HOLE$REQUIRED AT EVERY PH L AREA Parent Material(geologic) ©�rLU�sIZ _ DepthtoBadrock: Death to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Es)Imated Seasonal High Ground Water: .S�O DEP APPROVED FORNS-12107/95 FORM n - SOIL: EVALUATOR FORM Pagc 2 of 3 Location Address or Lot No.- �A �`! Gr/ '�., ,�,c/000 497- _4n--site. ,Review Deep Hole Number Data:.�'� �� Time%.•,�►/S Weathe i '�-gyp Location (identify on site plan) � >� 7 Land Use Slope (%) . ... .. . Surface Stones Vegetation `-J ~ Landform Position on landscape (sketch on the back) .. . ..��7� ...., � Distances from: ^M y Open Water Body-2��feet Drainage way 4� feet Possible Wet Area .., feet Property Line .... feet Drinking Water Well .. . ... feet Other - DEEP ther :DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Texture Soil Color Soil .� Other Surface(Inches) (USDA) (Munsell) Mottling, (Structure,Stones,Boulders,Consistency, % Gravel) 751 4' Rw i Parent Material(geologic)— rel j�t� _ DeptMogedrock: r Depth to Groundwater: Standing Water In the Hole: _ Weeping from Pit Face: _ Estimated Seasonal High Ground Water: �i i DEP APPROVED FORM-12107/95 4- FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 'Location Address or Lot No. o2442- /�yy��Q,�/ j le ,DvA� determination Qr Seasonalih Water Table Method Used: ❑ Depth observed standing in observation hole................... inches ❑ Depth weeping from side observation hole.................. inches ® Depth to soil mottles ..,w.,._.. . inches ❑ Ground water adjustment .................. feet Index Well Number .................. Reading Date .................. Index well level .................. Adjustment factor ................... Adjusted ground water level .........-_-............................. Depth of Naturally Occurrinq Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? .5' If not, what is the depth of naturally, occurring pervious material? Certification I certify that on 4 �S (date) 1 have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience It described in 310 CMR 15.0 7. It Signature Date ®n i DEP APPROVED FORM-22/07/95 v Town of North Andover, Massachusetts Form N0.2 • f HORT�y BOARD OF HEALTH 6. DESIGN APPROVAL FOR ' ,'SS4CMUSftA SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. Site Location l� Reference Plans and Specs. NGIN R ( 7X el DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed r, in accordance with regulations of Board of Health. 1 HAI RMAN,BOARD OF HEALTH r Fee Site System Permit No. f3 i � I May-27-99 12 : 45P Not-th Andover, 'Com. Dev . 508 688; X9542 P O1 SEPTIC PLAN SUBMITTAL FORM LOCATION:_ 12 IntAA Me,,,ov.,,, VEW PLANS: YES $125.00/P1an_._....- REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: Y`ES NO DATE: t DESIGN ENGINEER: A I 61 2uu G— DATE TO CONSULTANT: *If you want your plans expedited, please submit three plans and included a ! stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. I i I 20 � r May-27-.99 12 : 45P Not�-th �Andover Coral Dev . ; 508 688 9542 P_ ©l i SEPTIC PLAN SUBMITTAL FORM r LOCATION: Z I Z I-lt� , ►�t ._ __.. NE�w' PLANS: YES $125.00/111an_ REVISED PLANS: YES S 60.00/flarn SITE EVALUATION FOR AS INCLU ED: YES NO DATE: 1 OD DESIGN ENGINEER: J L /UPS✓ t'.r2t N s- -�1' cJ DATE TO CONSULTANT: *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. I f 8i L ��4 7`d � � . Zo/xfr- f-e-6)l n ca d,..e-Flc-I e()c e5 Nov-06-00 11 :33A Paul D_ Turbide, PE/PLS 978-465-0313 P.02 October 30,2000 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 SDS upgrade at 212 Haymeadow Road Dear Sandra, Enclosed find our review of tae"Checklist for North Andover Septic System Plans" for the septic system upgrade at the above-mentioned site. The following is a list of technical deficiencies that Port Engineering has found. o Buoyancy calculations for the proposed pump chamber are not provided as required by 310 CMR 15.221 (8). In addition to this technical deficiency,we also recommend that the existing septic tank be inspected for tees and a gas bale since it is proposed for re-use. If you have any questions or comments please feel free to contact me. Sincerely Paul D.Turbide, PE/PLS PORT ENGINEERING Civil Engineers& Land Surveyors One Harris Street Newburyport,MA 01950 (978)465.8594 \\Setver PWABH\P288AHAY[vIEADOW 212.DOC �aORTN Town Of North Andover p William J. Scott Community Development & Services Director 27 Charles Street (978)688-9531 North Andover, Massachusetts 01845 9ySACHUSEt Fax 978-688-9542 November 6, 2000 Board of Appeals (978) 688-9541 Ben Osgood, Jr. New England Engineering Building 60 Beechwood Drive Department No. Andover, MA 01845 (978) 688-9545 Re: 212 Haymeadow Road Conservation Department Dear Ben: (978) 688-9530 referenced above have This is to inform you that the proposed laps for the site Y p P p Health been disapproved and have technical deficiencies as followed: Department (978)688-9540 1. Buoyancy calculations for the proposed pump chamber are not provided as Public Wealth required by 310 CMR 15.221 (8). Nurse (978) 688-9543 If you have any questions, please do not hesitate to call the Board of Health Planning Office. Department (978) 688-9535 Sincerely, -' Sandra Starr, R.S., C.H.O. Health Director cc: Quinn file NEW ENGLAND ENGINEERING SERVICES INC November 8, 2000. Sandra Starr,Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 212 Haymeadow Rd.,North Andover, Septic system design Dear Sandra: Enclosed are the following documents concerning the above referenced property. 1. 5 sets of revised design plans, 1 with original signatures. 2. Submittal form for revised plans. 3. Check to cover the fee. i I The following changes have been made to the plan. 1. The buoyancy calculations for the pump chamber have been added. If you have any questions please do not hesitate to contact this office. Sincerely, Benjamm C. Osgood r.,EIT - - - ni President C01 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 Town of North Andover a �°aTII O Office of the Health Department Community Development and. Services Division William J. Scott, Division Director p�gAteo "`Ry 27 Charles Street �ssncaaus�� Sandra Starr North Andover,Massachusetts 01845 Telephone (978)688-9540 Health Director Fax (978)688-9542 November 9, 2000 Ben Osgood, Jr. New England Engineering 60 Beechwood Drive No. Andover, MA 01845 Re: 212 Haymeadow Road Dear Ben: This is to notify you that a variance to the distance to wetlands from a leach area has been granted for 212 Haymeadow Road. The variance is for no less than 51 feet. With the granting of this waiver, the septic plans dated 11/9/00 are approved. If you have any questions,please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Health Director I SS/smc cc: Quinn File _95 ;s 95 BOARD OF APPE.iL,S 688.�-lI BUILDING688-9545)�45 CONSERV.TION 638-953a FI7=;AI,TI4688 9540 PL.AtiNIIvG 688 9,.,5 Town of North h Andover � tloRTh q 2 g`S LED\ Yti�O �. Office of the Conservation Department 3 b F A Community Development and Services Division William J. Scott, Division Director 27 Charles Street 4sS�cHus�t Brian LaGrasse North Andover,Massachusetts 01845 Telephone 978 688-9530 Interim Conservation Fax(978)688-9542 Administrator November 16, 2000 To: Robert Nicetta, Building Commissioner Alison Lescarbeau, Chairman,Planning Board William Sullivan, Chairman, ZBA From: Brian LaGrasse, Interim Conservation Administrator At our Conservation Commission meeting held on November 15, 2000 the following decisions were approved: _ 242-1044 428 Winter Street This NOI was for the construction of a replacement septic system and associated grading within the Buffer Zone of a BVW. The Order of Conditions was approved as drafted for this project. 242-1046 314 Rea Street This NOI was also for the construction of a replacement septic system and associatedradin within th g g e Buffer Zone of a BVW. The Order of Conditions was approved as drafted for this project. 242-1049 659 Forest Street The Order of Conditions was approved as drafted for this NOI which was for the construction of a septic system and associated grading within the Buffer Zone of a BVW. 242-104712 Haymeadow Road This NOI was for the construction of a replacement of a failing septic system and associated grading within the Buffer Zone of a BVW. The Order of Conditions was approved as drafted for this project. If you would like a copy of the Order of Conditions please contact the Conservation Department. CC: Scott Masse, Chairman, Conservation Commission Heidi Griffin, Town Planner ,/Sandra Starr Board of Health Administrator BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 FORM U .- LOT RELEASE FORM i INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION"""-**" APPLICANT PHONE LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT(S) STREET &A q LIP`0—C, 0 ST. NUMBER /` *****************************************OFFICIAL USE ONLY*********************************** RE PONS OF TOWN AGENTS: ZZ C ERVATION ADMINISTRATOR DATE APPROV5D g DATE REJECTED �J COMMENTS �� 1 �' CD.^J�'�.c f�d� �I`c� TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS i PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 jm Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH Q��SLEO 16�tiO . 19- 0 A �0 °°°°1��ew,. APPLICATION FOR SITE TESTING/INSPECTION TED SSACHUs���y Applicant — d!60 cv NAME ADDRESS TELEPHONE Site Location C� Engineer NAg ADDRESS 0 TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. BOARS Ol•.,HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR SOIL TESTS DATE: �� 7 o MAP &PARCEL: ft%11 127 LOCATION OF SOIL TESTS: 2 t Z t o wt ��c �•.w. OWNER: TEL. NO.: ADDRESS: ':Z ) 72- /U - -4,r ENGINEER: Near•., t�C�L 1+-1n �-A)(j A;C E 0 u' G TEL.NO.: q79 6B6--1769,, CERTIFIED SOIL EVALUATOR: e:� �h���' �t �� 1d A-a i C< i `4AJ l,,4,dj3 Intended Use of Land: Residential Subdivision mgle Family Home Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No 1� THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax.bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$275.00 per lot for new 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 the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. o Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: I I I _\I �OI �OL i ICON i_�i = _ l IiNl= r- . I CvE1-:;VIC:r �0,=. 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