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Miscellaneous - 236 SUMMER STREET 4/30/2018 (2)
I T I i i 1—' 4 O N 4 w -� o c rn G) 'n O '� 4 � n rn rn 0 —+ L�, t I H Lot & Street ,506 5aiwylL-k- Map/Parcel A))8" CONSTRUCTION APPROVAL Has plan review fee been paid: NO Permit# Plan Approval: Date: !?4 Approved Designer: PlanDate:_ y Conditions: Water Sup`piy_z Town__-_ ---- - WelI. Well Permit: -..Driller: Well Tests: Chemical Date Ap rived – Bacteria I Date -Approve 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? NO Well Construction Approval?ts� NO Septic System Construction Approval? NO Certification? NO Other NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION Is the installer licensed? YES NO Type of Construction: NEW _ p 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: - S NO -.DWC Permit Paid? -- YES " NO . --DWC_Permit Installer: Jr If�Uol�C _BegimInspection:_ YES` _ES � NO -- _Excavation Inspection: –Neyed"7e�d. [/✓ L'/ G. ✓' /Yl� �r'7CJ ...G� j..11. %• �d i' �� �G���I�L ( L/ [( C l'��I^V��! 12 — Passed- 7 /�: tz_-_ _ By: _Construction Inspection: Needed: As-Built_Plan Satisfactory: V,,'r-ba) g��y YES: _ Approval of Backfill: Date:. By- ---Final Grading Approval: Date: o0 By: Final Construction Approval: Date: / D ; By:� _ —Z Certificate of Compliance: Approval- Date: =_— Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. QW 4 Commonwealth of Massachusetts t '� 5 V - Title 5 Official Inspection Form v� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2 236 Summer Street 1 Property Address Emily Hoffman Owner's Name North Andover MA 01845 05/21/13 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: John J. Souc Name of Inspector Soucy's Sewer Service, Inc. Company Name 78 North Broadwav Company Address Salem City/Town 603-898-9339 Telephone Number B. Certification NH 03079 State Zip Code 13397 T�-- License Number I tail T`MI OF NORTH ANDOVER HEALTH D PgRTMENT I certify that I have personally inspected the sewage disposal system at this �a'ne��rra-tir-� 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: ® Passe ❑ Conditionally Passes ❑ Fails E21eds Furth Evaluation by the Local Approving Authority nature 05/23/13 Date Thetem inspector shall sutAt a copy of this inspection report to the Approving Authority (Board of Hs Ith 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. ****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. t5ins • 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VL ff e- Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner's Name North Andover City/Town MA 01845 05/08/13 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: John J. Soucy Name of Inspector Soucy's Sewer Se Company Name 78 North Broadwa Company Address Salem City/Town 603-898-9339 Telephone Number B. Certification Inc. NH State 13397 License Number MAY 11 6 2013 TO-WROF NORTH ANDOVER 03079 Zip Code 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 El Fails F-1Ne s F her Evaluation by the Local Approving Authority Date TJ�e system inspector shall sub/it a copy of this inspection report to the Approving Authority (Board df Health or DEP) within 30 d s 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. ****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. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 7 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 05/08/13 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 r '+ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover page. City/Town B. Certification (cont.) MA 01845 05/08/13 State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. j B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): "D" box replaced- See attached oermit- ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner's Name North Andover MA 01845 05/08/13 City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: 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 ❑ ® 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 % day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °,M ,.•y''v 236 Summer Street Property Address Emily Hoffman Owner Owner's Name Information is required for every North Andover MA 01845 05/08/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El® Any portion of the SAS, cesspool or privy is below high ground water elevation. E] ® 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. E]® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El® 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. 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 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. l5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover MA 01845 page. Cityfrown State Zip Code C. Checklist 05/08/13 Date of Inspection 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? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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: ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 550 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 • 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover page. City/Town D. System Information Description: Number of current residents: MA 01845 State Zip Code 05/08/13 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Recommended removal of qarbaqe grinder. See attached -water meter readin Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) 4 ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 ` Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover MA 01845 05/08/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Current Date Owner/Soucv's Sewer Service 2010 1500 gallons Gaae and sludae tool Maintenance and Inspection ® Yes ❑ No Type of 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts H w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover MA 01845 05/08/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1985• (upgraded 1999) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: e0t Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.) Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 14" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 1 ' Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) State 01845 Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 38" 3" 6" 14" 05/08/13 Date of Inspection How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins - 3/13 Date Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code 05/08/13 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 C I f mmonwea t o M oassachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) State 01845 Zip Code 05/08/13 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): 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 in very poor shape, cracked. and corroded Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Type MA 01845 State Zip Code 05/08/13 Date of Inspection ® leaching pits number: (9) shallow ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hvdraulic failure. 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 ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover MA 01845 05/08/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover MA 01845 05/08/13 - - - - - — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately ELEVA TIONS REEW I AS—B"l INV. OF PIPE AT SEPTIC TANK .OUTLET 213.05 212.96 INV. AT D—BOX INLET'..- 210.77 210.4E /NV. OF PIPE AT :O-BOX-.OUrLET . 210.60 210.32 INV - AT END OF DISTRIBUTION PAPE 1 210.45. 210.23 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is required for every North Andover MA 01845 05/08/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 6' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record ■'' If checked, date of design plan reviewed: 7/1999 Date 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: Duq hole with auqer in low drop off area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts N r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 236 Summer Street Property Address Emily Hoffman Owner Owner's Name information is North Andover MA 01845 05/08/13 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 5/21/2013 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Repair of D -Box By: John Soucy At: 236 Summer Street Map 38 Lot 173 orth Andover, MA 01845 of thisTV�ca e 'shall not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health, 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 236 Summer Street MAP: 38 LOT: 173 INSTALLER: John Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 5/21/13 D -BOX DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port Comments: Only one outlet pipe. The flow was slow. I asked him to put speed leveler on outlet pipe. (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits -❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX X Installed on stable stone base X H-20 D -Box X Inlet tee (if pumped or >0.087foot) X Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: Only one outlet pipe. The flow was slow. I asked him to put speed leveler on outlet pipe. Commonwealth of Massachusetts Map -Block -Lot 038.00173 BOARD OF HEALTH ----------------------- Permit No North Andover -20 -07 BHP 201318 ----P-3-07------ FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT L. John Souc Permission is hereby granted -- ---- -- -- y — r "V to (Construct) an Individual Sewage Disposal System. i M, at No 236 SUMMER -STREET --------------------------------------------------------------------------------------------------------- ------------------------------------ - --- - -- as shown on the application for Disposal Works Construction Permit No. BHP -2013-071 Dated --- ----------------------------------------------------------------- Printed On: May -15-2013 BOARD OF HEALTH Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ray re� t Application for Septic Disposal System d1l, /n Construction Permit —TOWN OF '!' A RTH ANDOVER, MA 01845 $ 250.00 — Full Repair / $125.00 - Component / AgmIlcation is hereby made fora permit to: FI Construct a new on-site sewage disposal system* ❑pair or replace an existing on-site sewage disposal system* t(? Repair or replace an existing system component — What? � l J (J)e-- A. Facility Information or tot # 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump VGravity (choose one) ***If pump system, attach copy of electrical permit to application"* 4conventional System (pipe and stone system) ❑ Infiltrator or Blodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. Owner Information ' I& LAoKnYA n flame I co An- Jr w I L above) �/� , � City/Town (�J �ni(o/!� tate Zip Code diA 9.339 . Telephone Number 3. Installer Information 7 1(1 �DL)w"'— '�ix.�'I.0 �,/,C YUrL-e- , Nam^ d1 n ` Name of Com any /o��State /, _ Zip ode Telephone Number (Cell Phone # if possible please) a. Designer Inform ion Al Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 6y -V Application for Septic Disposal System NOrtTH I% �10 Construction Permit - TOWN OF TODA 'S D AT ORTH ANDOVER, MA 01845 $ 250.00 -Full Repair °•:'..0 qac $125.00 - Component SA KU /'s y PAGE2OF2 A. Facility Information continued.... 5. 'Pepe of Bullding:esidential Dwelling or []Commercial E. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site seWoe disposal system in accordance with the provisions of Title 5 of the Envirmonpleqfal Code, as well as the Local Subsurface Disposal Regulations for the Town of NoVISSIZ er, and not to p e the system in operation until a Certific a of Compliance has beeby this Boar of ifealth. zgz 11 me Date pprov By: (Boar4f6f Health Representative Date aperTedor the following reasons: For Office Use Only: L Fee Attacbed? 2. Project Manager Obhgatron Form Attached? I Pump System? If so, Attach copy ofElectrical Pe. -mit 4. Foundation As Built. (hew construction ronly). (Same scale as apptoved plan) 5. Floor Plans? (hew construction only). Ye&Z No_ Yes No Yes No 0 s No Application for Disposal System Construction Permit • Page 2 of 2 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director (978) 688-9531 April 30, 1999 Mr. Phillip Christiansen Christiansen & Sergi 160 Summer Street Haverhill, MA 01830 Re: 236 Summer Street N. Andover, MA 01845 Dear Mr. Christiansen: 27 Charles Street North Andover, Massachusetts 01845 This is to inform you that the proposed septic plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/sc cc: Peter Hoffman File Fax(978)688-9542 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 -64:- 53:3 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT ' DATE: J' CURRENT INSTALLER'S LICENSE# LOCATION: CA VVI VAell AJ, r1 LICENSED INSTALLER: G� SIGNATURE: CHECK ONE: REPAIR: l� ONE# NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative.Use Only $75.00 Fee Attached? Yes LZ No Foundation As -Built? Yes No Floor Plans? Yes No Approval Date: �C Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director (978)688-9531 March 10, 1999 Christiansen & Sergi 160 Summer Street Haverhill, MA 01830 RE: 236 Summer Street Dear Mr. Christiansen: 27 Charles Street North Andover, Massachusetts 01845 6%D , Fax(978)688-9542 The purpose of this letter is to inform you that the proposed plans for the septic repair at 236 Summer Street have been disapproved for the following reasons: • The 2" of 1/8"-1/2" double washed stone over galleys is not specified. (310 CMR 15.247(2)) • The end of the perforated pipe of the galley is not specified as being capped. • There are no soil tests within the system boundaries. The statement that soils are typical across the entire site is not proven since only one acceptable test hole was excavated. Also, additional deep holes are required to determine the absence of construction debris. (3 10 CMR 15.102(2)). • Trenches are to be used whenever possible. Why are galleys proposed here? (3 10 CMR 15.240(6)) • Please explain why system is designed with groundwater at 203.33, since it was determined to be around 201.34. Please feel free to call the Health office with any questions you may have. Sincerely, Sandra Starr, R.S. Health Administrator Cc: Hoffman File -BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830-6318 March 19, 1999, 1998 Ms. Sandy Starr, R.S. Health Administrator North Andover Board of Health 27 Charles St. N. Andover, MA. 01845 Re: ssds repair at 266 Summer St. Dear Ms.. Starr: (978) 373-0310 FAX: (978) 372-3960 7i3� , € OARD OF HEALTH [MAR 2 21999 We are in receipt of your letter dated March 10, 1999. In response to the issues raised in said letter, the system was designed as submitted for the following reasons: 1. Two (2") inches of stone was not specified above gallery. (310CMR 15,.247(2)) states "to prevent intrusion of fine textured soils into the system". It was our interpretation that the concrete top of the chamber prevents this intrusion and therefore stone is not required. .2.,.We will.change the plan to include a note that specifies "end of pipe to be capped" . 3. The system was moved up gradient from test pit 98-1 to meet break out requirements. The abandoned, as well as historical test pits done on 5/15/84 by Mike Rosati and Mike Graf, indicated uniformity of soil profile across the lot. Construction debris was observed in the pit @ approx. grade 206. The system was located below the existing tree line. The presence of these 40' tall pine trees indicated to us that this soil was deep and probably undisturbed. 4. Trenches were initially designed requiring retaining walls on both the driveway and Summer St. side of.the system to meet break-out requirements. (310 CMR 15.102(6)) states " When trenches cannot be used because of area limitations, other soil absorption system configurations may be proposed for substitution. 5. Test pit 98-1 established E.S.H.W.T. @ 32" (see soil log). Existing grade at the high point of the chamber is approximately 206 (see profile A -A and plan view) thus establishing the water table at the designed 203.33. Per our phone conversation we will await your further review and incorporate revisions that you require in light of this response. Should you have any further questions in the above matter, we are available at your convenience and can be reached by phone at, 978-373-0310. cc: Hoffman File 98651 Mar -09-99 09:13A Paul D. Turbide, PE/PLS I March 9, 1999 Sandra Stan: North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for 236 Sumner Street Dear Sandra, 508-465-0313 P.02 Enclosed find the "Checklist for North Andover Septic System Plans" for the above- mentioned site. The following is a list of all the `Problem' areas and deficiencies Port Engineering has found. • 2" of 1/8" —'/2" double washed stone must be placed over the leaching galleys ,(247(2)). (This layer is shown by symbol on the "Profile" and "Profile A -A', but is not labeled). • The end of the perforated pipe of the galley should be capped. The following are items that must be checked during construction • The existing septic tank is to remain and be used. Either new pvc tees should be installed on the inlet and outlet side, or the existing baffles should be checked for structural integrity. Also a gas baffle is specified, which must be installed if it is not already part of the septic tank. • Construction debris was found within 15' of one end of the proposed leaching galley. The plan states that there probably is no debris under the proposed bed because of existing large pine trees. During construction, care should be taken that no construction debris exists under the leaching bed. The following are general observations about the proposed design: • The existing grade at the high end of the proposed leaching bed is at elevation 204'. If ESHW is assumed to be down 34" (as found in the test pit) then the elevation of ESHW at the high end of the system is 201.33'. The system design has ESHW at 203.33'. Unless there are other circumstances not shown on the plan, I would suggest lowering the proposed elevation of the leaching bed by 2 feet. This will require less fill and be less expensive to build. Also, by lowering the system the leaching bed can be moved closer to Summer Street, away from the buried PORT construction debris and closer to the perc and deep tests. (Also, it is within the power of the Board of Health to grant a variance for groundwater separation from 5' to 4', which would also lessen the amount of fill required.) ENGINEERING • The design loading rate was based on Class R soils. The soils (loamy sand) are in fact Class I. Thus the loading rate is 0.74 gpd instead of 0.6 gpd. Thus the system Civil Engineers & could be made smaller. Land Surveyors One Harris Street If you have any questions or comments please feel free to contact me. Newburyport, MA 01950 (978) 465-8594 Sincerely 'CAL Carlton A. Brown, PE/PLS FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 No. Date: /o 20qt Commonwealth of Massachusetts No r+ , "ve/u , Massachusetts Soil Suitability. Assessment for On-site Sewage Disposal Performed B 7R; fin Ch. ............ Date: WitnessedBy:.. c�t......... 5 ........... .... _....... .......................................... .... ............. L.oniion Address or Owner's Name. Lot, ?-3(, Sam %nom V + Address, and Z�� �Lt �m �y� Teiephorc ! CAS J Ass:°ssrs�t� 28 %73 C�/fi'J New Construction Repair Office Review Published Soil Survey Available: No ❑ Yes Year Published %.f.......... . Publication Scale Soil Map Unit �C Drainage Class Vert �/� .::. _ toil Limitations _ ...�..��-�.��............... _ .... ......... .. . __...... . Surficial Geologic Report Available: No % Yes ❑ Year Published Publication Scale Geologic Material (Map Unit).................................................................................................................... ............. ............... Landform. ............................................... _ ................... ............................................................................................................................ Flood Insurance Rate Map: ,?,5-00 9,S' Above 500 year flood boundary No 17 Yes Within 500 year flood boundary No Pfes ❑ Within 100 year flood boundary No ;�Y-es ❑ Wetland Area: National Wetland Inventory Map (map unit) ........................................................................... ...... Wetlands Conservancy Program Map (map unit) .................................................................... 1.......... Current Water Resource Conditions (USGS): Month Range :Above Normal []Normal ❑Beit,•. Normal ❑ Other References Reviewed: hiDEF APPROVED FORM • 12/07/95 FORM 11 - SOIL EVALUATOR FORI11 Page I of 3 Location Address or Lot i\io. t?.36 SUl`Ytyn&I On-site Review Deep Hole Number l '— / Date: i�2��� Time: /to" ®d Weather (��/��3�.✓ Location (identify oan) Land Use LAVn sjte plSlope (% 0-3 Surface Stones /7b Vegetation OaK 1x4pt- 1 IV Landform Draw( (v Position on landscape (sketch on the back) B� ( 7-0A j Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line feet Drinking Water Well feet Other DEEP OBSERVATION HOLE _OG' Oeoth Irom Surface (Inches) Soil Horizon I Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other I (Structure, Stones, Boulders, Consistency, % Gravel) 61^"d&r Ve ,'a l-- 5'. Ua m rnal"y roofs 3tN�q -21 F.ne- 6-12 ���_(�v Poufs C,omme-o S.Coc=rM z J.1- 33 rY►.e to \1K� YR �r,6 , l0-lSl S.Loprm 578' A A C �s e yr� 33-7-1 "a v�eC jr S .MM � , �er,L! : �ih� ad 1Y► a ss; rrP 10 —if c iaysc— Z 7a -9 Z Med t7�� �%�, Sum MCtSSi� TirL��G f0 7v gra. Parent Material (geologic) De thtoBedrock: �� ! Depth to Groundwater: Standing Water in the Hole: n ® Weeping from Pit Face: / / n o Estimated Seasonal High Ground Water: 347 11 DEP APPROVED FORrt - 1:/07195 FORM 11 - SOIL LVALUATOIZ FORM Pafge3of3 Location Address or Lot No. o?36 SiA.M-I ell Ste' Determination -for Seasonal .high Water Table Method Used: Depth observed standing in observation hole ...... inches J Depth weeping from side of observation hole inches Depth to soil mottles 3,3. inches _ Ground water adjustment .........:........ feet index Well Number .................. Reading Date ................. Index well level .. Adjustment factor ............. Adjusted ground water level ....... _ . . Dente of Naturaliv Occurrino Pervious Material Does at least flour feet of naturally occurring -pervious material exist in all reas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? �1prtification I certify that on. 10 z (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature �/Lez —W-4- � Date DEP APPROVED FOP -M . 12/07195 k�" 1 vim. .v... 1- ,amu , v _ r . va FORM 12 - PERCOLATION 'PEST Location Address or Lot No. :;7-3A6 5 U M M E /Z ST - COMMONWEALTH OF MASSACHUSETTS i' MOV -H AN0 J t -_f _ , Massachusetts Percolation Test$ Date: ��/��/ Time: Observation Hole # / Depth of Perc / Start Pre-soak %0 PS -3 End Pre-soak Time at. 12" Time at 9" �� S Time at 6" Time (9"-6") Rate Min./inch a n7;n • Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed 2' Site Failed ❑ Performed By: �J Witnessed. By:`S M6" Comments: r.. s✓+ apt �►rntov� ro� • urv►m �©F-Fl�-Wr) r-urbe,5 6o X -(or (LN%,lp S M,v<, 5e wry dG cSSu Gv�tc��= SS r5 0U? r t Tie �J 5 - ��C�i�T�015 SVS Io�S���� proms Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 APPLICATION FOR SITE TESTING/INSPECTION Applicant I NAME Site Location 1.3 G Engineer Test/Inspection Date and Time `L CHAIRMAN, BOARD OF HEALTH Fee Test No. .97-2- S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. LOCATION NEW PLANS SEPTIC PLAN SUBMITTAL FORM 294 SUM M9- REVISED PLANS: YES SITE EVALUATION FORMS INCLUDED . f1 0,61VEZ. $125.00/Plan $ 60.00/Plan YES NO DATE: DESIGN ENGINEER: DATE TO CONSULTANT: *If you want your plans expedited, please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. SEPTIC PLAN SUBMITTAL FORM LOCATION: 07 3 NEW PLANS: YES REVISED PLANS: +YES SITE EVALUATION FORMS INCLUDED DATE: �&" v j C'X 2 $125.00/Plan r101A1N cF N0. TH AP:JOVER/ $ 60.00/PlanM u APR 2 0 1999 YES NO—� DESIGN ENGINEER: DATE TO CONSULTANT: *If you want your plans expedited, please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. I Town of North Andover, Massachusetts Form No. 2 NORrM BOARD OF HEALTH �19- 1P 9- ' DESIGN APPROVAL FOR s`CM°5� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant ';�'24E��65-e &661 294X 2 Test No. 3 7-2-1 Site Location_ ':7?36 c501LIM16-4 15% Reference Plans and Specs. ENGINEER '/c 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. /06"' TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 4/13/00 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X ) by John Soucy at 236 Summer 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 AINDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The. dersigned hereby certify that the Sewage Disposal System ( ) constructed; ( repaired; `'�� `F byJ p _- _ _ uC located at 3 Sv 0,-k- rM Pit �• was installed in conformance with the North Andover Board of Health approved plan, Svstem DesignPemnit r'r dated with an approved design flow of gallons per day. The materials used were in conformance with those specined on the approved plan; the system was installed in accordance with the provisions of 310 COIR 15,000, Title 5 aid 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. —mss Bed inspection date: .tive Final inspection Installer: Desi -an. F 3�M.�,representativ T: Date: 00 Date: AS -BUILT CHECKLIST TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 1 50' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE _ L'YDERVIOUS AREAS - DRIVEWAYS, ETC. i� NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER / V LOT LINES & LOCATION OF DWELLINGS I/ LOCATION & DEMENSIONS 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 TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 1 50' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE _ L'YDERVIOUS AREAS - DRIVEWAYS, ETC. i� NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUS PLAN AS -BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP &PARCEL NUMBER IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED LOT LINES & LOCATION OF DWELLINGS (/ LOCATIONS & DIMENSIONS OF SYSTEM, n V INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC _ TESTS DISTANCES FROM CORNERS OF HOUSE TO CENTER OF 1/ ELEVATIONS OF DISPOSAL SYSTEM IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED (/ TOP OF FDN ELEVATION LOCATIONS OF WELLS DRAINS WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS ELECTRIC LINES CABLE R, , _ DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED BOARD OF HEALTH 146 MAIN STREET NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: Olq)ff-- LOCATION OF SOIL TESTS: Assessor's ap X& parcel number: OWNER: /)4f ADDRESS: TEL. 688-9 540 177 a AUG TEL. NO.: b -al'0-35l W -MME ENGINEER: TEL. NO.: CERTIFIED SOIL EVALUATOR Inten0,9d use of land: residential subdivision, single family home, commercial ,-/-/� THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. Thi.- overs the two -dee oles and two percolation tests required for each lof ee of $75.00 per lot for 1/c., -OL repairs or upgrades. Gl�4:?141 GENERAL INFORMATION --VP a - 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. ,y, ," '+caew.:...:aslru.�rL.._ .t...�.�t_� 4.�✓f:_._ i [.. f f. 1 S r 1. } } ! r f � f 1 O O LOCATION, �- ENGINEE///// F;:---�'--- ,-- — - - - �9 BOH WITNESS. PERCOLATION TEST:'; _ BO i i OM DEP T'r' OF PERC TEST. e� TIME OF SOAK.: _ •� __ (� leesinu s Icrc) ` / TIME AT 1 %" TiN1E AT 1� Z) TIME AT E' / ;rt OVE;,NiGr T SOr.K TIME ST,=.F. T -D NE:,' -,'T , v S 71-! M E T TiME r"71 TIME AT5" j North lndover, Mass. Street No tA. Lo t No__4 7.oc/Subdi-v.---,-- PI and Owner Investigator Observer SOIL PROFILE DATES -1 ev 4.El-ev ev 2.Elev 3-h 0 0 0 Ben,chmark Elevation DATES 1 2 3 4 5 6 8 9 10 Datum PERC011ATION TESTS 1 2 3 4 5 6 7 8 9 10 Ties to Test Pi is Pit Number -Stlart Saturation 2 3 S C) a k - 1 271 U 3 -S Drop of 3"--Ti-me of 6-"--hirie Ml�ns-lst 3" drop T'in s. 2nd Percola--'k-.ion CD uj LL ;• rya-- �. to to 43 N . OC O y ei! • , w 10 1� it I Q V.J 9 u j to LCL41 • � n �lj C -j m N n c0 _ ,j N Nj m N N NNJ W0. d N M Q0 NN a ' o — N W• Iq � k oLIJro oQo�o o '`off j � LLij � �lj