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HomeMy WebLinkAboutMiscellaneous - 247 FARNUM STREET 4/30/2018 (5)I ❑ � -. `' '�' L� �� � C ,� „ORT16824 0. Town of North Andover HEALTH DEPARTMENT SACH CHECK #: DATE LOCATION: _ P? y n IN H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector Title 5 Report $ $ L04 VU ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer M OF PHONE SOC AREA COD � ER(`^ _EXTENSION n MESSAGE � (r'(/� turaii GALL , SIGNED TOPS q" FORM 4003 J TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page T - LOCA TION� Pint J _ PROPERTY OWNER Print 100 Year Old structure MAP NO: _ PARCE_L __. __ ZONING DISTRICT: ''HistoriclDistrict Machine Shop Village yes yes TYPE OF IMPROVEMENT. PROPOSED USE Residential Non= Residential ❑ New .Building YOne family ❑ Addition ❑ Two or more family ❑ Industrial Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic D 1Nell ❑ Flo.odpla_in Wetlands ❑ Watersl ed.19.istricf ❑ -Water/Sewer ; DESCRIPTION OF WORK TO BE PERFORMED' , _ r� f 2 e -cap L-� �T� �' /U t�1 k . Q%.' Fled(7s, R 4 r4- P�'al�S-���C�14-5 A�� Iden 'fication P}}ease Type or Print Clearly) ` OWNER: Name: RRNCy gq;ET ,� j��q' i_ 7g1 ?z. Phone: 60'46"4012 Address: 1,51 e-RlC [�11— F144 A4 NO-41Vc(011,9C i1'1V CONTRACTOR Name:_ S'R_�!!_ , Phone:._- Supervisor's Construction'L.icense: Home; Improvement License: __ __ ._. _ Exp Q:ate: ARCHITECT/ENGINEER Phone: Addre Reg. No FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ -7 S-- 9 --'->, 00 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered ontractors do not have access to the guaranty fund Si nature ofeAgent/®wner='!�= - Sig ature,ofrcontractors._ Plans Submitted 1] Plans Waived ❑ Certified Plot Plan 11 Stamped' Plans 11 Plans Submi-tted ❑ Plans ..Certified Plot Plan ❑ Stamped Plans ❑ THE. FOLLOWING SECTIONS FOR -OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT- COMMENTS EVELOPMENT COMMENTS -::.-DATE REJECTED: DATE:APPROVED El CONSERVATION Reviewed on Si�hafure COMMENTS HEALTH COMMENTS Reviewed on�L it a i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/Signature & Rate Driveway Permit .DPW Tow;2 Engineer: Signature: Located 384 Osgood Street FIRE DP,gRT11�11=:1T :-~Temp Dumpste"r on site yes...... no Located at;124,Mairi'street Fire-bd0 m' erit signatu'r"e/date "' COMM NTS 12/23/13 2476 Farnum Street Question from realtor. S. Sawyer response. Q: what is the maximum # of rooms allowed in this house without having to upgrade the septic system. A: The system is sized for a 3 -bedroom (330 gallon), maximum 7 -room home. It also was granted a reduction to the water table from the bottom of the septic system. For both these reasons; there shall be no increase in the design flow. When counting rooms this includes rooms such as living room, study, kitchen (eat in area included), bedrooms etc. This does not include bathrooms, non -living areas such as storage areas, unfinished attic, unfinished and/or non- occupied basement. Theoretical building addition question; To receive Health Department sign off on an application for a building permit that does not increase the home footprint; the applicant must provide a floor plan showing a maximum 7 —room home. When combining small rooms, please show any walls that are to be removed and rooms reconfigured to make 7 rooms. If there is also an expansion of the footprint; a passing title V must be submitted. z O �X OL z LL 0O C I o � IL - m d' — ~ o CD \ I IN HI � x LL II 3 I ell II v o0 0 II � em.z Z Q } II 7- LI� O 11 II 11 OSA � aid g <L i u zp�1,1 !L a CJ) 04 Z r4 p OL of— 11 I N -----il--- ----- @_- } FF---- 8 11Ali �d 11 s IT9 Hi ly FS�1py OF,c�im.. 2 . . ,�• 61LB-7LEC8L6) 6£810 'b11 '9 '3/.V LhLi9321 85 SMN17d1�1 VFIL?�VL! 'A9 W(fv2b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 247B Famum Street Property Address Randy Hart Owner Owner's Name information is North Andover MA 01845 5/28/2014 required for every page. Cityfrown 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. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. General Information 1. Inspector: James Wright Name of Inspector Asoen Environmental LLC Comoanv Name RECEIVE® JUN 16 2014 OF NORTH ANDOVER 270 Lawrence Street Company Address Methuen MA 01844 City/Town State Zip Code 978-881-5023 S12035 Telephone Number License Number B. Certification I certify that 1 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. l am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes El conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ns ors Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board, of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""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 • 3M3 Title 5 Official Inspection Form; Subsurface Sewage Disposal System • Page 1 of 17 Owner Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 247B Farnum Street Property Address Randy Hart Owner's Name North Andover MA 01845 5/28/2014 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 1 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 replacedoftli a complying septic tank as approved by the Board of Health. ` * A metal septic tank will p inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating t the tank is less than 20 years old is available. F1 ❑ ❑ ND (Explain below): t5ins . 3113 Title 6 official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 247B Famum Street Property Address Randy Hart Owner Owner's Name Information is required for every North Andover MA 01845 5/28/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 uneve ribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or r laced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system requ' ed pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pas inspection if (with approval of the Board of Health): ❑ broke 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 Heal etermines In accordance with 310 CMR 15.303(1)(b) that the system is. not fu oning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy ismi in 50 feet of a surface water ❑ Cesspool or privy)d within 50 feet of a bordering vegetated wetland or a salt marsh t51ns • 3/13 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 247B Famum Street Property Address Randy Hart Owner Owner's Name Information is required for every North Andover MA 01845 5/28/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall 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 ismithin a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS d the SAS is less than 100 feet but 50 feet or more from a private water supply w Method used to determine dista ** This system passes if th ell. water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indic7roblvided absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm . that no other failure criteria are triggered. A copy of the analysis must be attached to this fdrm. 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 ElBackup of sewage into facility or system component due to overloaded or �elged SAS or cesspool �?Discharge or ponding of effluent to the surface of the ground or surface waters to an., overloaded or clogged SAS or cesspool ❑ �Slaiquid level in the distribution box above outlet invert due to an overloaded ed SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than' day flow t51ns • 3113 1108 5 Oftidel Inspection Form: Subsurface Sewage Olsposal System - Page 4 of 17 • C_N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i" r 247B Farnum Street Property Address Randy Hart Owner Owner's Name information is required for every North Andover MA 01845 5/28/2014 page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: � ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ tributary to a surface water supply. L� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy Is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes If the well water analysis, performed at a DEP certified laboratory, for 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.] ❑ �he system is a cesspool serving a facility with a design flow of 2000gpd- / 10,000gpd. ❑ ,r_,1,/ The system fails. l 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 w` In 400 feet of a surface drinking water supply ❑ ❑ the syst is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the stem is located in a nitrogen sensitive area (Interim Wellhead Protection ea — IW ora 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. - t5ins - 3113 Title 5 Offidal Inspection Foran; Subsurtaos Sewage Disposal System - Page 5 of 17 Owner information is required for every page. t5ins • 3H3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 247B Famum Street Property Address Randy Hart Owner's Name North Andover MA 01845 5/28/2014 Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes o umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? 011�❑ as 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 NIA) Was the facility or dwelling inspected for signs of sewage back up? D. System Information Residential Flow Conditions: Number of bedrooms (design): — D Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Title 5 official Inspection Form. Subsurface Sewage Disposal System • Page 6 of 17 Was the site inspected for signs of breakout? 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): — D Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Title 5 official Inspection Form. Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 247B Famum Street Property Address Randy Hart Owner Owner's Name information is required for every North Andover MA 01845 5/28/2014 page. Cityrrown state Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes 2 ----No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes 2, No information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: CommerciaUlndustriai Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., i Grease trap present? Industrial waste holding tank p/ent? Non -sanitary waste dischpt�ed to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes 2r"'No ❑ Yes No sr_= 16 rz /�Ij ❑ Yes ['No 14" y - e- =e>/t., Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3M3 'ntle 6 official Inspection Form: Subsurface Sewage Disposal system - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2476 Farnum Street Property Address Randy Hart Owner Owners Name information is required for every North Andover MA 01845 5/28/2014 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes E3,1ro If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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): thins • 3113 Title 6 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2478 Farnum Street Property Address Randy Hart Owner Owner's Name information is required for every North Andover MA 01845 5/28/2014 page. City/town state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if know and source of information: Were sewage odors detected when arriving at the site?. ❑ Yes P -1q0-- Building Sewer (locate on site pian): Depth below grade: feei� Material f construction: cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material o construction: concrete E3metal [3 fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: /01le x 16 3 r/ Sludge depth: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r- 247B Farnum Street Property Address Randy Hart Owner Owner's Name information is required for every North Andover MA 01845 5/28/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet.tee or baffle s/ 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 z / ' How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1 yY<— d /�" /" f Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins • 3113 Title 5 Official Inspection Forth; Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 247B Farnum Street Property Address Randy Hart Owner Owner's Name information is required for every North Andover MA 01845 5/28/2014 page, Cityr town State Zip Code 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 198'kage, 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of [] polyethylene ❑ other (explain): gallons alleWp& day ❑ Yes ❑ No Alarm in working order. ❑ Yes ❑ No Date and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3113 We 5 official Inspecfion Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 247B Famum Street Property Address Randy Hart Owner Owner's Name information is required for every North Andover MA 01845 5/28/2014 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): i Depth of liquid level above outlet invert ! 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.): Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: Comments (note condition of pump ch ep�l/0 -Jr Yes ❑ No* Yes ❑ No* ar, condition of pumps and appurtenances, etc.): J * 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: t5lns • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System r Page 12 of 17 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 constructio Indication of groundwater inflow t5ins • 3113 ❑ Yes ❑ No Title 5 Of5dal Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °f 247B Farnum Street Property Address Randy Hart Owner Owner's Name Information is required for every North Andover MA 01845 5/28/2014 page. cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ 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.): 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 constructio Indication of groundwater inflow t5ins • 3113 ❑ Yes ❑ No Title 5 Of5dal Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 2476 Famum Street Property Address Randy Hart Owner Owner's Name information is required for every North Andover MA 01845 5/28/2014 page. Cityrrown 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 s 1, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 14 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 247B Famum Street Property Address Randy Hart Owner Owner's Name information is required for every North Andover MA 01845 5/28/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provides 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: Vd -sketch in the area below wing attached separately t5ins - 3/13 %tie 5 Official inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "f 247B Famum Street Property Address Randy Hart Owner Owner's Name information is every North Andover required for eve MA 01845 5/28/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: heck Slope ❑ Surface water ff/Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: (tom Obtained from system design plans on record If checked, date of design plan reviewed:]/��� ❑ Observed site (abuttingproperty/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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3113 We 5 Of idol inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 a Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 247B Farnum Street Property Address Randy Hart Owner Owner's Name information Is required for every North Andover MA 01845 5/28/2014 page. Cftyrrown 7 State Zip Code Date of inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked �; Ins ection Summary D (System Failure Criteria Applicable to All Systems) completed S stem 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 Farm: Subsurface Sewage Disposal System •Page 17 of 17 �S Bulcr TIES BLP6. Co R . A B C T M, H, (cTQ) I3,0' 26, S' M -H . 18,0' ZI -o' -- D - Box ECJ) TIZ - SS. �{ ' 3 3.3' (e cA P) I S2w SEPn� TA►.rX. 1000 6W, fl�r�� eNAr�aE2 g m N� A -S bu i LT Vo s,D•Q. zG PV.c. 1mv,, lug'_ -Box-Z�S;11 14 "� �eH. uo P•V,C. i�v, ou?" e p-&aX = 'ZHq 9q ( jut'�T" T2#) -.` ZyL1, SZ 11J'OT" ` V03 = ZW q , e % y qs SAN. LID Over) ,l -'v. e- -Euz T20 = 2�1472 TRN2 - 2411.'77 � , rR*3 =-2 -wq 7 * (9- To 8f- AOTus-r D L -6-F E> 61 1 962 S,F, 2,x'1 0 O L vF J AS BUILT PLA14 OF SUBSURFACE DISry AL SYSTEM LOCATED IN I JORT-H AKJDOvER, P --IA. AS PREPARED FOR RR)AN LAWLoR. DATE: MAY !6, 1 qI( SCALE: 1'"40' ! 2y7 FAQWUt--,l SZ" MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS. 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 0 1,A. (Cas) 175-3555, 373-5721 r!1 rG'Z4o `� —_ }FOP ► soo GAL SEMI C TA Uj:::� reg, Iit=14o ).OTB �Nh., IX 0 `Y +� VO �Y A) ti N �1T N N N N 0o U ooX�U aj c J ca f0 Q) N m 0 N 6 2 w d U Cl L) U (1) N m N N 0) C CL N " � C. C O S2wUs O M N F -a2 LL c (D.2 CL- W -MUf=211 03 N 1 3 U) ��F`-�U Z N T N LL t0 ti ti O O CV U U) o Cl U mdU O � Q J o¢ Q W JW O tD J O O) 00 Z O Q MM aE M LO d a) ai f4 U +. 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W a W.. cd a� w m'�e0� I (m ZLL WE ¢ c m mem o•o � Li c LL C SIL -a "a O } tT W o� c o amix@ 000 LM U � ¢�H w�0C)0- mo Z R 00 m GLr) C14 oF-:F- to Q in W X d (6 � N Uw G uj fnw (o Lo. O1 d lfl N Cm''C7,� -0 6 m a O °mmm N N m !!= azYe ca 'a m� = o .. ,ti HmLi2WCOY W LbmQ L64T m in N �♦ I♦ 0 0 L U x0 Z' 2m C.0 F- F- @? M rY t F- uJ(nwwLL MLL*LL Ui aw (n PITS MIN 660 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x ##) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x ##) (2 x (L+W)xD x ##) (G/ft2) FIELDS MIN 660 GPD 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4" PEA STONE? DIST LINE SLOPE .005? >31COVER-VENT SCH 40 MIN 12" COVER RATE LDG X 660 = X = TOTAL G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = 90'9D PUMP CAPACITY G4 gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE c% ALARM SEP. CIRC. GW—L (Min. 1' below inlet) HWL a37, LWL a3j �" CHECK VALVE BLEEDER HOLE L,'� MANUAL OP. SWITCH Copyright © 1995 by S.L. Starr Alp* FORM 11 - SOIL EVALUATOR FORM Page 1 No ................... Date_ 11�!�`h/,16 _ . Commonwealth of Massachusetts Massachusetts Location Address or T /% 11 _Fj�V/ eA�O -,r /t owner's Name, P/V A 9��� Lot p Address, and Telephone # New construction ❑ Repair V�_­ Office Review Published Soil Survey Available: No ❑ - Yes Year Published JqN Publication Scale ..... Drainage Class ......... Soil Limitations Surficial Geologic Report Available: No. ❑ Yes ❑ Year Published Publication Scale ............. Geologic Material (Map Unit) ._ __................................._............................. Landform ... ..... _ _. Soil Map Unit, ...._......... ............................................................. Flood Insurance Rate Map: ............_.._......... ................. . Above 500 year flood boundary No ❑ Yes ❑ Within 500 year flood boundary No ❑ Yes ❑ Within 100 year flood boundary No ❑ Yes ❑ Wetland Area: National Wetland Inventory Map (map unit)........................................................................................... Wetlands Conservancy Program Map (map unit)._...................................................................... Current Water Resource Conditions (USGS): Month ........ . Range : Above Normal ❑ Normal ❑ Below Normal ❑ Other References Reviewed: FORM 11 - SOIL EVALUATOR FORM Page 2 On-site Review Deep Hole Number ...... /....... Date: ./Z!..Time:.a'OQ.f'M Location (identify on site plan)...................................................................................................... Depth from Surface (Inches) Land Use`�1�C—SI,D iV.l"/AG__.... Slope M 1&.7..Z5- Surface Stones _.. Vegetation .... ..AGc��u.............................. ........ .......................... .... ....... ....:........................................ . Landform......... ........... ............. ................... ....... .............. ............................ Position on landscape (sketch on the back)......................................................................... Distances from: Open Water Body ................... feet Drainage way................... feet Possible Wet Area ................. feet Property Line .........:........ feet Drinking Water Well ................... feet Other ..... ..................... ._...... ... Weather '�'1 T4.y..0 PY.. 3b s ......................................................................... .......... ................. ............I.......................... . ........................................................ DEEP OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders; Consistency, % Gravel) d - 8 �� /9p V, G.e/ABGE /rl/SZ5 S �� / / - �[.J / I /� S • .C.. /D Y�''"¢� �.e/BGE G�u> �/,UE .C'T •� MASS, MQ 55. N 7�1101 Parent Material (geologic) ............. Depth to Bedrock: Depth to Groundwater: Standing Water in the Hole: ..... ...&..... Weeping from Pit Face:........ Estimated Seasonal High Ground Water:.. . r Y FORM 11 - SOIL EVALUATOR FORM Page 2 Y On-site Review � � Deep Hole Number ............. Date:..Z..�.�... 9� Time:�.' ¢..... Location(identify on site plan).......................................................................................................... Land Use ...................................................... Slope (%} .................. Surface Stones .......... Vegetation............... ........................ .......... ............................................... ...... ........ ............................................. Landform . ................... .............. ............................... ................... ........ ...........................:................................... . Position on landscape (sketch on the back) ...................................... .. ................ Distances from: Open Water Body ................... feet Drainage way................. feet Possible Wet Area ................. feet Property Line ... .4�P.*f feet Drinking Water Well .................. feet Other ..... __.................. .......... Weather —5RT61... 4,D.y_...J6 ....................................................................... DEEP OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders; Consistency, % Gravel) Z `� � 7,f -/ Parent Material (geologic) ................�p...^L�G. ..0 ..T .�. Depth to Bedrock: ........................... Depth to Groundwater: Standing Waier in the Hole: ....... ............ Weeping from Pit Face:.`.... Estimated Seasonal High Ground Water: /r c FORM 11 - SOIL EVALUATOR FORM Page 3 Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole ............... finches E❑ Depth weeping from side of observation hole ................. inches D— epth.to soil mottles ...0... inches ❑ Ground water adjustment ............. feet Index Well Number ................. Reading Date ................... Index well level ... Adjustment factor .................. Adjusted ground water level.....................I............:... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed foF the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on (date) I have passed the 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 31.0 CMR 15.017. Signature Date Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the individual subsurface disposal system 'lD , constructed ( ) or repaired (X) by 64 i ,q• /Yj Ufa G() y,�51C installer at has been installed in accordance with the provisions of TITLE 5 of the State Sanitary Code and with Board of Health regulations as described in the Design Approval Permit # �?-4% dated J-/,3 ,/ .THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. 2-'d2zellzw ��J a Board of Health Inspector I BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 0 MERRIMACK ENGINEERING SERVICES INC. Engineers • Surveyors • Planners 66 Park Street � ANDOVER, MASSACHUSETTS 0180' (508) 475-3555 Fax (508) 475-1448 TO �lq pn OF t� WE ARE SENDING YOU ❑ Shop drawings ❑ Copy of letter ❑ Attached ❑ Under separate cover via d Prints ❑ Change order ❑ Plans 4 VVIgn W UMGJMOVULad D ATE 1 T^ J JOB NO. ATTENTIO I ASTA2fZ 2 y9 iZ�v�-�1 S i L LJL.o (L affR9i u of 9-fl_s. ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION affR9i u of 9-fl_s. THESE ARE TRANSMITTED as checked below: Cs�For approval ❑ Approved as submitted ❑ Resubmit ❑ For your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE REMARKS Sit J46. -% , COPY TO ❑ Approved as noted ❑ Returned for corrections IN] 19 ❑ Submit ❑ Return copies for approval copies for distribution corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US PLr,AS � l rv5r-- "tel- 3 ` A 13o V6_: 2.14. La,r -. L"A i ulr-" . 1'-S r 6ZC—a-ta,Co F0(L JT41S QC-9)4kf. eA L(— Ir VOL.) !4-Avur_- SIGNED: If enclosures are not as noted, kindly notify us at once. n PLAN REVIEW CHECKLIST ADDRESS O 47 1111ti ENGINEER GENERAL /�� / 3 COPIES STAMP v LOCUS NORTH ARROW SCALE CONTOURS PROFILE SECTION BENCHMARKi---- SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS\ WATERSHED?_Q DRIVEWAY // (Elev) WATER LINE FDN DRAIN SCH40 ✓ TESTS CURRENT? VAL SEPTIC TANK MIN 1500G .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR�v MANHOLE v ELEV GW ## COMPS. D -BOX SIZE ## LINES FIRST 2' LEVEL STATEMENT INLET,�-Y- cq 7 - OUTLET 70 = 1 ( 2" OR .17 FT) TEE REQ' D?v2z5 LEACHING , / MI60 GGD?0IL v RESERVE AREA 4' FROM PRIMARY?-' � 2% SLOPE 100' TO WETLANDS 100' TO WELLS 4' TO S.H.GW �(5'>2M/IN) 35' TO FND & INTRCPTR DRAINS 01L 325' TO SURFACE H2O SUPP e--� 4' PERM. SOIL BELOW FACILITY ✓ MIN 12" COVER � FILL?--� (25' if above natural elev; 10'if below) BREAKOUT MET? TRENCHES 9cyn Lt MIN--4&0- SLOPE (min .005 or 611/100')SIDEWALL DIST. 3X EFF. W OR D (MIN 61) y RESERVE BETWEEN TRENCHES?y IN FILL? MUST BE 10' MIN. 4" PEA STONE?O/& VENT? (>3' COVER; LINES >50') BOT J3 3� + SIDE ZZ Z- X LDNG 'C/bO = TOT � 3 (L x W x ##) (DxLx2x##) (G/ft2) /. 6,16 8 Copyright 0 1995 by S.L. Starr Z-1 C//� r D %�/N E�%S IQA,�% rOWN'"xr N P DA Ub SYSTEIM u I SYSTEM OWN-Eit-i ;177, DATE OF PUMPING: RECEIVED ECE E ... ......... ,TH ANDOVEROCT5 2 4 "INQ RECORI) 000 5 2004 0 T 0 00 0 0, VER RT TOWN OF N H ANDOVER LT�i ORTH A. [T TOWN A DF p R M LOCATION Leif -- �/i s%fie ��' ��us-� . �;j: _QUANTITY PUMPED: CESSPOOL: NO YES_..:.._._.,.. SOPtic Tank: NO YES V/1' NAT'I)RE OF SERVICE: OBSERVA'rIONS; GOOD CONDITION /FULL'ro COVER HEAVY OREASE BAFFLES IN PLACE ROOTS LW, KFIELD RUNBACK BXCESSIVE SOLIDS FLOODED SOLID CARRYOVER,- OTHER EXPLAIN System Pumped by COMMENTS: CUNTENTS rKANSFERKED TO I 1 d1 Ql CL A LL 4-- 0 _v z FjT I II{ I' c 'B C 10 + O � � C d.J � t 0 O � m H L E C. R 7 C c L e o+ r o 0 - L 4 r m 0 i_ O E c O 3 }_0 !C O QI V Q I= 4- C6 m N F c 0 n` _ } V Q O t E m U O C m Z E o` LL r H- t w a� 0 � a Z � U O �= U � J � N ce �w o LLc Z OU O Q � N t � Y o Z m 3 o J c o Q p F- a u j5 C �J O Q L O Q = 0 a N w 2 O � o � o U a 3 � m o c o �Ln b > a. o N � a o Q c U D L � t c � 0 U 0 0 c -v s N c b b0 E � T N 0 �\ v� O u 0 3 \ � LL. V NORTs, O � p M � °mob -Ir x ;,s`TACHUSEt� Town of North Andover, Massachusetts BOARD OF HEALTH a IQ DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Form No. 2 Applicant --X �- � �Test No. Site Location' Reference Plans and Specs.- ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CORM ARD OF HEALTH Fee 0 Site System Permit No. 'r-4/ SEPTIC SYSTEM INSTALLATION YES LICENSED? NO IS THE INSTALLER 7cTI0N : NEW REPA R .' 1 TYPE OF CONSTR cERTIFIED _YES NO STR�CT1Crr. CONDZTIONsPOFTAP RP OVAL REVIEW YES NO NEW CON (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT PAID? YES' NO DWC PERMIT NO. INSTALLER: BEGIN INSPECTION YE No: EXCAVATION INSPECTION: NEEDED: PASSED L-r� BY CONSTRUCTION INSPECTION: NEEDED: FINAL CONSTRUCTION APPROVAL: DATE:�z/ BY AS BUILT PLAN SATISFACTORY: YES) APPROVAL TO BACKFILL: DATE://7��1� BY �iI l / BY FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: DATE:�z/ BY