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HomeMy WebLinkAboutMiscellaneous - 25 WELLINGTON WAY 4/30/2018y ;I G�j oRTNq� CANE `SSA C H US�� North Andover Health Department fommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 25 Wellington Way MAP: 105.0 LOT: 0090 INSTALLER: Dave Maynard DESIGNER: Christiansen and Sergi PLAN DATE: dated July 25, 2016, final revision August 17, 2017, received on August 18, 2017 BOH APPROVAL DATE ON PLAN: 8/23/2017 INSPECTIONS TANK INSPECTION: 10/19/2017 DATE OF BED BOTTOM INSPECTION: 10/23/2017 DATE OF FINAL CONSTRUCTION INSPECTION: 11/7/17 DATE OF FINAL GRADE INSPECTION: 11/14/2017 SITE CONDITIONS N/A Contractor reports any changes to design plan N/A Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: ... SEPTIC TANK ® 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 Comments: SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan N/A 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan N/A Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: 65' L x 25'W 24 at other end Inlet tee installed, centered under access port Outlet tee installed, centered under access port (gas baffle) ® 24" inch cover to within 6" of finish grade installed over inlet and outlet access ports ® Neoprene boots around inlet & outlet Comments: A change in placement was made on the position of the septic tank. I have received confirmation of approval from engineer. DISTRIBUTION -BOX ® Installed on stable stone base ® H-20 D -Box N/A Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution N/A Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan N/A 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan N/A Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: 65' L x 25'W 24 at other end FINAL GRADE ® Loamed ® Seeded ® Cover per plan • 17,1iT�ii0 DOCUMENTS NEEDED ® Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ® As -Built Plan BM = 126.32 HR = 6.17 Hl = 132.49 SYSTEM ELEVATIONS ROD ELEVATION AS -BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN 2.12 130.02 130.00 Septic Tank OUT 2.44 129.70 129.75 Distribution Box IN 7.16 124.98 124.96 Distribution Box OUT 7.34 124.80 124.79 Lateral 1 TOP 7.38/7.56 Lateral 1 INVERT 124.76 / 125.58 124.75 / 125.50 Lateral 2 TOP 7.38/7.56 Lateral 2 INVERT 124.76 / 125.58 124.75 / 125.50 Bottom of Bed/Chamber 9.85 122.64 122.50 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws • S� f�L'ED76g6 . co TED AQ��v PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: November 21, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Construction of an On -Site Sewage Disposal System By: Dave Maynard At: 25 Wellington Way Lot 7 Map lOS.0 Lot 90 North Andover, MA 01845 They ce of this ifi e shal of be construed as a guarantee that the system will function satisfactorily. BIV an J. L/Grasse, CEHT`� Director of Public Health 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov b. ...uwsa. PUBLIC HEALTH DEPARTMENT community & Economic Development TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; ( ) repaired; By: Dave Maynard (Print Name) Located at: 25 Wellington Way (Lot 7 Wellington Woods) (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated 7/25/2016 and last revised on 8/17/2017 , with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: Z T Engineer Representative (Signature) Pfil Christiansen, P.E. And — Print Name Final Construction Inspection Date:_U Zdl't7 Phil Christiansen. P.E. And — Print Name Installery��/j'i{ �gnature) Dater And — Print Name Date: Phil Christiansen, P.E. And — Print Name 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov 0�� WA, (t V Town of North Andover — Septic System - AS -BUILT CH KLIST 1) V All changes to the design plan have been reflected and noted on the as -built plan 2) " As -built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans) 3) Street Address, Assessor's Map and Lot Number 4) _7Lot Lines and Location of welli s served by the system G 5) Locations, Elevations nd imensions o As -built system components, including reserve (if applicable) 6) y Ties to all tank openings, d -box, and leach area from dwelling or Permanent Structure Setback distances are shown on the as -built plan from system components to: ASubsurface, interceptor & founMion drains AV Catch basins — 6VV4, 1PJ�— l Property lines �t-Dwellings or other structures Private water supply or irrigation wells Watercourses or wetlands 8) `� Locations of Wells, Drains, Wetland Resource Areas within 150 feet of system 4 A i 9 Location of water, gas, electric lines, cable, control panel (if applicable) c 719, 10) `I Location of Structures within 6 Inches of Finished Grade L/ 11) V Original Stam re d holder of an easements which could impact the s ra v (/ ► 12) Lo ation an y p Y 13 —Impervious Areas Driveways, etc V �L� Y , 14) J North Arrow v J/ )b 1� Location & Elevation of Benchmark used 16) STATEMENT ON PLAN (NA 5.3) a. "I certify the locations, elevations, ties, cover material; exposed component covers etc., shown on this as -built substantially agree with the approved plan and have determined that the break out elevations, if applicable, have been met. " Signature of Designer Date b. "If a STUCTURAL WALL IS PRESENT W 4.9) a Letter or statement on the as -built indicating the wall - waste or was notconstructed in accordance with the intended design and any manufacturer's specifications. " Signature of Designer Date As of: Tuesday, March 17, 2015 1���- +mss L } i Commonwealth of Massachusetts Map -Block -Lot of • 4�-4j�v , 108.00139 ----------------------- BOARD -- ---------------- BOARD OF HEA Permit No North Andove F LE COPY BEE -2017-0512 P.I. --- �p $275.00 F.I. DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted--------------------------------------------------------- ---------------------------- ---------------------- to (Construct) an Individual Sewage Disposal System. at No 2 -5 - Wellington Way ------------------------------- ----------- ---------------------------- as shown on the application for Disposal Works Construction Permit No. BHI' -2017 -Dated my _ ---------- Issued On: Ju1-25-2017 BOARD OF HEALTH SCANNED • a,6��a Application for Septic Disposal System Construction Permit — TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $ -Full Repair $17755..00 00 -Component Important: ApplicatioD4 hereby made for a permit to: RECEIVED When filling out Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* OCT t 6 2017 only the tab key to move your El Repair or replace an existing system component —What? cursor - do not TOWN OF NORTH ANDOVER use the return A. Facility Information % iiEALTH DEPARTMENT key. As— Address ot # 7 ' rah � 9 J City/Town 2.- *TYPE OF SEP IC SYSTEM*: ➢ ❑ Pump ffrGravity (choose one) ***If pumps stem, attach copy of electrical permit to application— ➢ conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ,.__�_,,..�__.�._�_ _:�_�__,�—➢= u_Pressare:Dosed-(D=Box-Present}-S:A=:S�_�__�.-,_.._�__,�__ _ ➢ [:]Does the system require an effluent filter? Yes �No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information Names Address (if different from ab e) e:j57'ecl � e1��-a� City/Town State Zip Code p'7,F - 6 3 Email address Telephone Number 3. Installer Information %'7 , /�/�-yam �. � . �-z, C'a Name Name arCompany -2 2 Add xt_ City/Town State Zip Code 2Z2,F Telephone Number (Cell Phone # if possible please) 4. Desianer Information Name Name of Company Address City/Town State Zip Code 9�� Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 y»' •,°nam Application for Septic Disposal System__ Construction Permit -TOWN OF TODAY'S DATE $350.00 -Full Repair NORTH ANDOVER, MA 01845 $175.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: efResidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed syste, ' not approved. 00/ '7_ Name Date A lidation pproved B and o .ealth Representative) me Date Tt Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Ye111 No 2. Project Manager Obligation Form Attached. 3. Pump S sy tem? If so, Attach copy ofElectrical Permit Applicant received copy of "Electrical Inspection Notes for Septic Systems" Handout? 4. Reviewed approvalletter, all paperwork received. 5. Foundation As -Built? (new construction only): (Same scale as approved plan) Yes No �/ Yes_ No ` Yes No Yes No Yes No G. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 r� SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: a (Address of septic sys em) For plans by (-21[75 (Engineer) Cle Relative to the application of (Installer's nand And dated E —.2,3;::/0 (Ungmaal date) Dated i0 /�� 2�/ % CEIV`, E® (IoT's ate) With revisions dated (Last revised date) OCT 16 2017 I understand the following obligations for management of this project: TOORTH ANDOVER WN OF DEPARTME NT 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations mgtresult in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@nortaandoverma.gov) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete theinstallation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to allpersons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) /0116 0 (Name — Print(Name —Signed) (i. •• . 8048 I f µORiH q OL Town of North Andover HEALTH DEPARTMENT SSACNUSf CHECK #: I DATE: /o LOCATION: A56,&&60Z43/) Zdda-41 I'E NAME:111 ��ct.✓ cr 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 00, $ $ Septic Disposal Works Construction (DWC) $ Sa " /❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ ealth A ent Initials White - Applicant Yellow - Health Pink - Treasurer North Andover Health Department (ommunity and Economic Development Division August 24, 2017 Messina Development Corp 277 Washington Street Groveland, MA 01834 Re: Subsurface Sewage Disposal System Plan for 25 Wellington Way Lot 7 (Map 105C, Lot 90) To Whom It May Concern:. The proposed wastewater system design plan for the above site dated July 25, 2016 with a final revision date of August 17, 2017 and received on August 18, 2017 has been approved. The design has been approved for use in the construction of a new on-site septic system for a 4 - bedroom (max 9 -room) home utilizing gravity leaching trenches. This design plan approval is valid until August 24, 2020. During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. This approval is also subject to the following conditions: 1. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit a foundation as -built at the same scale as the approved plan 2. Prior to the issuance of the Disposal Works Construction Permit, the applicant must submit the floor plans of the proposed dwelling showing no greater than 4 bedrooms or a total of 9 rooms. Page 1 of 2 North Andover Health Department Town Hall, 120 Main Street North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688. 9542 25 Wellington Way August 24, 2017 3. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit (3 10 CMR 15.020(1)). Ot `4.M,It�is the responsibility of the applicant and/or the applicant's septic system designer, '�. septic system installer or other representative to ensure that all other state and ,:'municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to, contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Si" Brian J. aGrasse, CEHT Director of Public Health Encl. Installers list cc: Philip Christiansen, P.E. File Page 2 of 2 North Andover Health Department Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688. 9542 -- CHRISTIANSEN & SERGI, INC. ' PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET, HAVERHILL, MA 01830 tel: 978-373-0310 www.csi-engr.com fax 978-372-3960 August 17, 2017 Mr. Brian LaGrasse Director of Public Health North Andover Health Dept. 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Re: Septic System Design Plan for Lot 7 Wellington Woods (Map 105C Lot 90, Subdivision Lot 7) Dear Mr. LaGrasse: F11� CG�v S� We have received your August 11, 2017 comments on the above referenced plan, and we offer the following response. 1. The foundation drain location and invert elevation have been added to the plan. 2. The grading around the septic tank has been revised to represent the grading depicted in the profile view. 3. The test pits and perc tests have been labeled. trust that these responses fully address all of your comments. Please contact me if you have any questions. Very truly yours, Christiansen & Sergi, Inc. Philip G. Christiansen North Andover Health Department Community and Economic Development Division August 11, 2017 Philip Christiansen, P.E. Christiansen and Sergi, Inc. 160 Summer Street Haverhill, MA 01830 Re: 25 Wellington Way (Map 105C, Lot 90, Subdivision Lot 7) Dear Mr. Christiansen, S 0�vl� coo� cee' % G ZC ill The proposed wastewater system design plan for the above site dated July 25, 2016, with a final revision date of July 25, 2017 and received on July 25; 2017 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item where applicable. 1. The foundation drain location and the elevation are not shown on the design plan (NA 3.2). 2. On sheet 1 of 2, the site plan view does not depict the same finish grading in the location of the septic tank as shown on the profile view. 3. On sheet 1 of 2, the test pits are not labeled. Please feel free to contact the office or Mill River Consulting at 978-282-0014 with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Page 1 of 2 North Andover Health Department, Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688. 9542 Sincer y, rian J. L Grasse, CEHT Director of Public Health ,'cc Messina Development Company �Fil47 /� y North Andover Health Department, Town Hall, 120 Main Street, North Andover, MA 01845 Phone: 978.688.9540 Page 2 of 2 Fax: 978.688. 9542 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH T® d OF Nol"M ANL)0() 2 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Nd Repair( ) Upgrade ( ) Abandon ( ) -`;Complete System [-]Individual Components 25 i EU/A)G Q4) WAY Locate Map/Parcel # Lot # rq"&d InstalleV Name Address Telephone # Al e5S�t/AIA. O 0EWM&AJ-r0,n,C ame N7 6k, Cho^ 11 X77 L? 1g° p.�/ Ad ss/ Z:) o Tele hone # t! >A,e/S77AAl �,E0 � c�-,/ /1l) L Addr 1? -7 373 -D3 / Telephone # Type of Building: 1/I/Xl) FI Lot Size,6 &Sq. feet Dwelling — No. of Bedrooms Garbage Grinder ( Other — Type of Building No. of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow ( in. equired) gpd Calculated design flow gpd Plan: Date 7Syd Number of sheets Revision Title 5ePriG 5 yS M /SFS/6A/ 102r W&LL( 07-7-/1 Design flow provided ' 1tJ gpd Description of Soil(s) ;Me- S Soil Evaluator Form No.YES Name of Soil Evaluator P &91577AVSEIIJ Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS r/1 ghA1, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Inspections Date FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer Designer: Inspector Date The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Date FORM 2 - DSCP FORM 1255 (REV 5/96) Board of Health DEP APPROVED FORM 5/96 H&W HOBBs& WARREN TM PUBLISHERS - BOSTON k. t p { TOWN OF NORTH ANDOVER^ Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENTok 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 — Phone 978.688.8476= FAX E-MAIL: hea(thdept@northandoverma.gov WEBSITE: http://wNvw.northandoverma.gov SEPTIC PLAN SUBMITTAL FORM RECEIVED Date of Submission: / JUL 2 5 20117 �..�- We 11 Iyc - vc I iUQ TOWN OF NORTH ANDOVER Site Location:' HEgLTHDEPARTMENT Engineer: %�lST1 u JE tk1 S !� 6 New Plans? Yes x$275/Plan Check # (includes 1St submission and one re- review only) Revised Plans?Yes $125/Plan Check # Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes No N Telephone #:q7,? -3 '© 3/D Fax #: E-mail: �� 1 L CSC, — en 0m Homeowner Name: ,/ pcc OFFICE USE ONLY 6 When the submission is complete (including check): ➢ _Date stamp plans and letter ➢ Complete and attach Receipt ➢„ V Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database 4 R t Commonwealth of Massachusetts City/Town of North Andover W Percolation Test Form 12 M RECEIVED JUL 2 5 2017 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. Important: When A. Site Information filling out forms on the computer, use only the tab Gordon Family Trust key to move your Owner Name `,, r cursor - do not 602 Boxford Street LOT 9 (2,5 Vy e { (f ►L� 1 O L rl w use the return Street Address or Lot # key. North Andover MA 01845 L City/Town State Zip Code Philip Christiansen 978.373.0310 Contact Person (if different from Owner) Telephone Number B. Test Results t5form12.doc• 06/03 '60 (� j C> .51L Perc Test • Page 1 of 1 1/13/2015 3:18 1/13/2015 3:20 Date Time Date Time 9-A 9-13 Observation Hole # Depth of Perc 10 + 17 = 27 10 + 18 = 28 Start Pre -Soak 3:18 3:20 End Pre -Soak 3:32 3:35 COULD NOT COULD NOT Time at 12" MAINTAIN MAINTAIN Time at 9" PRESOAK PRESOAD Time at 6" 25 GAL 25 GAL Time (9"-6") <2 MIN/INCH < 2 MIN/INCH Rate (Min./Inch) Test Passed: ® Test Passed: Test Failed: ❑ Test Failed: ❑ Philip Christiansen Test Performed By: Isaac Rowe Witnessed By: Comments: t5form12.doc• 06/03 '60 (� j C> .51L Perc Test • Page 1 of 1 O D V/ 1 0 L N N Q d � N t � tom/) > � Q tV.0 �+ O cn d Z 1 3 0 r C E 0 E L- 0 :L- o:L- O U U LL rn N 0 � U JLOU CoU-) J ca C. co �22o O U a N O cu 0) CL O z:) Z ❑ ❑ Z N E E ❑ ❑ @ C } Z O h U O Z O Z O _o O m c ❑ ❑ ❑ Z O N Z E o, Z cv U c U) O om 0 O 0 Z L Z N O 0 a _ — O E :E o c '0 L c J Co�-0 CD vNi O _� LL m a C z Q U m m O co U. 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U C � � C (6 O N 0 C m C � O y z� co 4 M M d 0 CL • 7960 p` NORTh 1h Town of North Andover HEALTH DEPARTMENT ,ss�cHus�s CHECK #: DATE: LOCATION: 073 4- Q H/O NAME: CONTRACTOR NAME: (_..✓)/'�.37`i Q -n %i'1 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 S Ica) $ Septic -Design Approval P ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5Inspector $ . ❑ Title 5 Report $ ❑ Other. (Indicate) $ h Agent Initials White - Applicant Yellow - Health Pink - Treasurer