HomeMy WebLinkAboutMiscellaneous - 29 BRADFORD STREET 4/30/2018North Andover Board of Ass6--rs Public Access Page I of I
Parcel ID: 210/061.0-0036-0000.0 Commu nity: North Andover
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PHOTO
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Avaft. 118 b I e
Location: 29 BRADFORD STREET
Owner Name: POIRIER, ELIZABETH A
Owner Address: 29 BRADFORD STREET
I City: NORTH ANDOVER State: MA ZIP: 01845'.
Neighborhood: 5 - 5 Land Area: 1.01 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 1215 sqft
ASSESSMENTS CURRENTYEAR PREVIOUS YEAR
Total Value: 304,600 291,300
Building Value: 136,000 130,500
Land Value: 168,600 160,800
Land Value: 168,600
Land Value:
LATESTSALE
Sale Price: 0 Sale Date: 12/31/1960
Anns Length Sale Code: N -NO -OTHER Grantor:
Cert Doc: Book: -00937 Page:0032
http://csc-ma.usNandoverPubAcc/jsp/flome.jsp?Page=3&Linkld=463899 6/21/2005
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C
PUBLIC HEALTH DEPARTMENT
Community Development Division
RT1q71CA(F-rE-.o(F com(PrT 0,YCE
As of
Septem6er 29, 2005
This iS to certfty that the
individualsubsurface disposalsystem was.-
Tuffy RepairedSystem
6Y. -
James Keffett
14 t.
29 Oradfordstreet
XorthAndover, 31A 01845
r1he Issuance of this certfi"cate shaff not fie construed as a guarantee that the system wiff
function satisfacto65.
Susan T Sauyer
, REj fSIR
(PU6(ic Yfeafth Director
1600 Osgood Street North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978f.688.8476 Web www.townofnorthandover.com
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owners Name
North Andover
Cityrrown
MA 01845
State Zip Code
1/20/2016
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. RECEDVED
Important:
A. General Information
When filling out
forms on the
computer, use
1 . Inspector:
only the tab key
to move your
Neil J. Bateson
cursor - do not
use the return
Name of Inspector
key.
-Bateson Enterprises Inc.
Company Name
VQ
111 Argilla Road
Company Address
Andover
Cityrrown
978-475-4786
Telephone Number
B. Certification
MA
State
S115
License Number
JAN 2 5 2016 A
TOWN OF NORTH ANDOVER
HEALTH DEPART7MENT
-01810
Zip Code
I 47-,j &
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 CIVIR 15.000). The system:
N Passes El Conditionally Passes El Fails
El NTeds Aurther Evaluation by the Local Approving Authority
1/20/201E
Inspe&—oAs sSnature Z/ 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 DER 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 I of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owners Name
North Andover MA 01845 1/20/2016
Cityfrown 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:
Z 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.
El Y El N 0 ND (Explain below):
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
C
Owner
information i's
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owner's Name
North Andover MA 01845 1/20/2016
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
F1 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):
El broken pipe(s) are replaced
El obstruction is removed
R Y F-1 N F1 ND (Explain below):
0 Y F-1 N [:] ND (Explain below):
0 distribution box is leveled or replaced F-1 Y R N [I ND (Explain below):
0 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 El Y F1 N El ND (Explain below):
obstruction is removed F-1 Y [I N El ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
0 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(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland �i or a salt marsh
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
MA 01845 1/20/2016
State Zip Code Date of Inspection
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:
El 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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El 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
E] Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2day flow
t5ins 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
El Z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El Z 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
1:1 El the system is within 400 feet of a surface drinking water supply
E] El the system is within 200 feet of a tributary to a surface drinking water supply
El El the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "Yes" to any question in Section E the system is considered a significant threat,
or iiinswered "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 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owner
Owner's Name
information is
required for
North Andover
MA 01845 1/20/2016
every page.
CityrFown
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:
El
Z 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.
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.
1:1
z 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 c . ertified
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.]
El Z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El Z 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
1:1 El the system is within 400 feet of a surface drinking water supply
E] El the system is within 200 feet of a tributary to a surface drinking water supply
El El the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "Yes" to any question in Section E the system is considered a significant threat,
or iiinswered "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 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owner Owners Name
information is
required for North Andover MA 01845 1/20/2016
every page. Cityrrown 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 No
M 0 Pumping information was provided by the owner, occupant, or Board of Health
E] M Were any of the system components pumped out in the previous two weeks?
0 El Has the system received normal flows in the previous two week period?
11 Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z El Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
E El Was the facility or dwelling inspected for signs of sewage back up?
E El Was the site inspected for signs of break out?
0 El
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?
Z El
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.
Z 1:1
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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330
t5ins - 3/13 Title 5 Offirial Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Owner
information is
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owners Name
North Andover MA 01845 1/20/2016
Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder?
0
Yes
E]
No
Is laundry on a separate sewage system? (Include laundry system inspection
El
Yes
Z
No
information in this report.)
No
Laundry system inspected?
El
Yes
D
No
Seasonaluse?
El
Yes
Z
No
Water meter readings, if available (last 2 years usage (gpd)):
Yes
Detail:
Sump pump?
Z
Yes
El
No
Last date of occupancy:
Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day (gpd)
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:
El
Yes
[I
No
El
Yes
F�
No
El
Yes
El
No
'ritle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 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
29 Bradford Street
Property Address
Elizabeth Poirier
Owners Name
North Andover MA 01845 1/20/2016
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?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Never pumped
1500
gallons
Measured tank.
Inspect tank & tees
Type of System:
Septic tank, distribution box, soil absorption system
Single cesspool
El Overflow cesspool
El Privy
0 Yes F� No
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 at 17
CommonWealth of Massachuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owner Owner's Name
information is
required for North Andover MA 01845
every page. City[Town State Zip Code
D. System Information (cont.)
1/20/2016
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
I I years old, 9/29/2005, as built plan
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
El cast iron El 40 PVC El other (explain):
El Yes Z No
3
feet
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Unable to see oiDina . finished cellar
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete El metal 0 fiberglass
2
feet
El polyethylene El other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate')
Dimensions: 10'x 5'x 4'
Sludge depth:
411
El Yes F-1 No
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Z�
'0
29 Bradford Street
Property Address
Elizabeth Poirier
Owner Owner's Name
information i's
required for North Andover MA 01845 1/20/2016
every page. City/Town 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 29"
Scum thickness V
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle 311
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid above outlet invert, found power for
pump off. Reset power & level returned to normal. All covers have riser on them 6" deep.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
El concrete F1 metal fiberglass
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:
t5ins - 3113
feet
El polyethylene [I other (explain):
Date
Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
-44 Commonwealth ot Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owner Owners Name
information is
required for North Andover MA 01845 1/20/2016
every page. Cityrrown 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 leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal El fiberglass El polyethylene El other (explain):
Dimensions:
Capacity:
Design Flow:
gallons
gallons per day
Alarm present: D Yes [--] No
Alarm level: Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and, float switches, etc.):
El Yes El No
Attach copy of current pumping contract (required). Is copy attached? El Yes F1 No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
1 L !- !-I giffi=
1-21
Owner
information i's
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form � Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
MA 01845
State Zip Code
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
a
1/20/2016
Date of Inspection
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -box level & distribution equal. No evidence of carryover. No evidence of leakage. Root
invasion from bush next to d -box. Remove roots from d -box & removed bush
Pump Chamber (locate on site plan):
Pumps in working order:
0 Yes E-1 No*
Alarms in working order: Z Yes El Nci*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
. Pump chamber flooded,found power off. Reset breakers & pump started, level back to normal.
Pump ok. Alarm ok. Alarm has both audible & visual. Riser cover over pump & floats. 3" deep.
* 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:
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Owner
information is
required for
every page.
t5ins - 3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owners Name
North Andover
Cityfrown
D. System Information (cont.)
Type:
11
leaching pits
z
leaching chambers
El
leaching galleries
E]
leaching trenches
El
leaching fields
MA 01845
State Zip Code
1/20/2016
Date of Inspection
number:
number:
number:
number, length:
number, dimensions:
16
E] overflow cesspool number:
El innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface. Sixteen infiltrators, two rows of eight
chambers Der row
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
El Yes El No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information is
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owner's Name
North Andover MA 01845 1/20/2016
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 soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information is
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System rorm - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Uwners Name
North Andover
MA 01845 1/20/2016
Cityrrown State Zip Code Date of Inspection
D. Syste'm 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:
Z hand -sketch in the area below
[I drawing attached separately
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 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
29 Bradford Street
Property Address
Elizabeth Poirier
Owners Name
North Andover MA 01845 1/20/2016
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Z
Check Slope
2
Surface water
Z
Check cellar
Z
Shallow wells
Estimated depth to high ground water:
5
feet
Please indicate all methods used to determine the high ground water elevation:
M0
1071
W
Obtained from system design plans on record
If checked, date of design plan reviewed:
5/17/2005
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
El Checked with local excavators, installers - (attach documentation)
j El. � Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan
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
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Bradford Street
Property Address
Elizabeth Poirier
Owners Name
North Andover MA 01845 1/20/2016
Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Z Inspection Summary: A, B, C, D, or E checked
Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System Information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated on 1/13/2016 2:27:17 PM by Karen Hanlon
Town of North Andover
Tax Map # 210-061.0-0036-0000.0
Parcel ld 11810
29 BRADFORD STREET
POIRIER, LEO
29 BRADFORD STREET
N. ANDOVER, MA
01845
Page 1
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.01 Acres
FY 2016
UB Mailina Index
Name/Address
Type
Loan Number
Active/Inact. From
Until
POIRIER, LEO
Payor
29 BRADFORD STREET
N. ANDOVER, MA
01845
UB AccountMaint.
Account No .
Cycle
Occupant Name
Active/Inactive
Bldg Id. 15290.0 - 29 BRADFORD STREET
Last Billing Date 12/15/2015
2120165
02 Cycle 02
Active
UB Services. Maint.
Account No. 2120165
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE 26.60
/1
UB Meter Maintenance
Account No. 2120165
Serial No Status
Location
Brand
Type Size
YTD Cons
34429267 a Active
ERT HH
b Badger
w Water 0.630.63
234
Date
Reading
Code
Consumption
Posted Date
Variance
11/9/2015
256
a Actual
7
12/30/2015
6%
8/14/2015
249
a Actual
7
9/14/2015
14%
5/14/2015
242
a Actual
6
6/22/2015
-6%
2/13/2015
236
a Actual
7
3/20/2015
-13%
11/6/2014
229
1 Actual
7
12/15/2014
-8%
8/12/2014
222
a Actual
8
9/11/2014
-11%
5/14/2014
214
a Actual
8
6/12/2014
12%
2/1412014
206
a Actual
8
3/17/2014
-15%
11/6/2013
198
a Actual
8
12/20/2013
7%
8/13/2013�
190
a Actual
8
9/18/2013
12%
5/14/2013,
182
a Actual
7
6/18/2013
-12%
2/1412013
175
a Actual
9
3/13/2013
4%
.11/5/2012
166
a Actual
7
12/13/2012
-21%
8/15/2012
159
a Actual
10
9/26/2012
41%
5/15/2012
149
a Actual
7
6/20/2012
-15%
2/14/2012,
142
a Actual
9
3/14/2012
0%
11/7/2011
a Actua 1
8
12/15/2011
-9%
8/11/2011
125
a Actual
9
9/14/2011
26%
5/13/2011
116
a Actual
7
6/13/2011
-13%
2/14/2011
109
a Actual
9
3/15/2011
-10%
11/8/2010
100
a Actual
9
12/13/2010
-33%
8/12/2010
91
a Actual
14
9/13/2010
75%
5/12/2010
77
a Actual
8
6/9/2010
14%
2/9/2010
69
a Actual
7
3/11/2010
-16%
11/9/2009
62
a Actual
8
12/11/2009
21%
.8/1 W2009
54
. a Actual
7
9/11/2009
14%
5/12/2009
47
a Actual
6
6/16/2009
-13%
2/10/2009
41
a Actual
7
3/16/2009
13%
11/10/2008
34
a Actual
6
12/10/2008
-7%
Commonwealth of Massachusetts
Cllt�/Town of
SOtem Pumping. Record
Form 4
DEP has provided this form'for use -by local Boards of Health. Other forms may be'used, but the
information, must be substantially the itame as that provided here. Before using.this form, check with your
local Board of Health to determine the forrh they use. The Systern Pumping Record must be submitted.to
the local Board of Health or other approving authority.
A. Facility. Information
earofhous eft right side of house, Left
1 . System Location: Left / Right front of house, Left /69���OL
Right side of building, Left Right front of building, Left / Right rear of building, Under deck
Address
Cltyfrown Si�te Zip Code
2. System Owner
Name'
Address rif different from location)
City/-rown State -
Telephone Number
.B. Pqmping Record
16�
1. Date of Pumping 2. Quantity Pumped: ts
Gallons
3. Type -of systeff. El Cesspool(s) 2-Seiptic Tank Tight Tank
Other (describe):
4. . Effluent Tee Filter present? C] Y" 01W0_____ If yes, was it cleaned?
11 Yes 0 No
5. Condition of Systern:
V
6; System Pumped By:
Nel[Bateibn F5821
Name Vehicle Ucense Number
Bateson Ehterr)rlses Ina
Company
7. Lo�a "nere contents -were disposed:
Date
t5form4.doc- 06/03
System Pumping Record - Page I Of 1
NEW ENGLAND ENGINEERING SERVICES
INC
September 30, 2005
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 018 10
Re: 29 Bradford Street, North Andover, MA
As -Built Septic System Design
Dear Ms. Sawyer
SEP 3 0 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
The following As -Built Plans for the above referenced property are being submitted for
approval.
1. Three (3) Copies of the As -Built Septic System Design Plans.
If you have any comments or questions please do not hesitate to contact this office.
Sincerely,
Tm1^bJerq1yrk4u_
Assistant to Benjamin C. Osgood Jr., P.E.
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845
978.688.9540 - Phone
Susan Y. Sawyer, REHS/RS
Public Healtfi Director 978.688.8476 - FAX
E-MAIL: healthdeptg_townofnorthandover.com
WEBSITE: hllp://www.townofnorthandover.com
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION
The undersignedhereby certify that the Sewage Disposal System constructed; (y) repaired;
(Print Name)
located at a!q rbzj> -Ie-, r 21 F"L�
(Installation Address)
was installed in conformance with the North Andover Board of Health approved plan, originally
dated
and last Revised on
, 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 3 10
CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the
approved plan. All work is accurately represented on the As -built which has been submitted to
the Board of Health.
Bed inspection date: dq)o
- -1
Final inspection date:_ 471 ?-!?/ 05-
A. c' ep!�l
Engineer Repres—enta9ve (Signature)
9e.2 �* &., e
And - Pfint Name
J5 of D !�
EnginWr Representati;e (Signature)
e- 4nS90jU*'C
And - Print Name
Installer: (Signature)
And - Print Name
Engineer: 6, (Signature)
13
On O.S 3)c
And - Print Name
Date:
Date: _90
t1a. -1 -
.4
0 0
TOWN OF NORTH ANDOVER
0
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET .. ....
NORTH ANDOVER, MASSACHUSETTS 0 1845 CHU
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.9542 — FAX
ADDRESS: 29 Bradford Street MAP: LOT:
INSTALLER: Kellett
DESIGNER: NEES
PLAN DATE: 6/2/2005, Rev 7/28/05
BOH APPROVAL DATE ON PLAN: 8/11/05
DATE OF BED BOTTOM INSPECTION: 9/7/05
DATE OF FINAL CONSTRUCTION INSPECTION: 9/15/05
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
21 Existing septic tank properly abandoned
0 Internal plumbing all to one building sewer
0 Topography not appreciably altered
Comments:
SEPTIC TANK
0 Bottom of tank hole has 6" stone base
0 Weep hole plugged
[H] 1500gallon tank has been installed
H-10 loading 2 piece construction
0 Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
El Inlet tee installed, centered under access port
IK Outlet tee (gas baffle) installed, centered under
access port
121 2-24" inch covers to within 6" of final grade installed
over one access port, must be over outlet of tank if
effluent filter is present
El Hydraulic cement around inlet & outlet
Comments:
Page 1 of 3
.00
N
TOWN OF NORTH ANDOVER
N
to
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845 C U
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.9542 — FAX
PUMP CHAMBER
0 Bottom of tank hole has 6" stone base
0 Weep hole plugged
121 1000 gallon Combo tank installed
H-1 0 loading - 2 piece construction)
[H] Inlet tee installed, centered under access port
El Pump(s) installed on stable base
1K Alarm float working
El Pump On/Off float working
®R Drain hole in pressure line
0 24" inch cover to within 6" of final grade installed over
pump access port
0 Water tightness of tank has been achieved
(Visual testing
121 Hydraulic cement around inlet & outlet
Comments:
Combo tank (see Septic notes)
D -BOX
121 Installed on stable stone base
121 Inlet tee (if pumped or >0.08'/foot)
®R Hydraulic cement around inlet & outlets
IZI Observed even distribution
Comments:
SOIL ABSORPTION SYSTEM
0
Bottom of SAS excavated down to soil layer, as
provided on plan
0
Size of SAS excavated as per plan
IKI
Title 5 sand installed, if specified on plan
121
laterals installed and ends connected to header (and
vented if impervious material above)
El
Gravelless disposal systems: type, number and
location as per plan
IF]
Elevations of laterals installed as on approved plan
El
40 Mil HDPE barrier installed
0
Final cover as per plan
Comments:
Page 2 of 3
'd 0
0 0
TOWN OF NORTH ANDOVER
a DIP
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845 CHU
Susan Y. Sawyer, REHS/RS 978.688.95 0 — Phone
Public Health Director 978.688.9542 — FAX
CONTROLPANEL
El Alarm & Pump are on separate circuits
El Alarm sounds when float is tripped
2 Location of control panel: Basement
0 Rated for exterior if placed outside
Comments:
Could not access Basement — Try to enter at final grade inspection
SETBACK DISTANCES
Tank SAS Sewer
(R] Property line 10 10
El Cellar wall 10 20
SYSTEM ELEVATIONS
Benchmark: 100.00
Rod at Benchmark: 0.75
Height of Instrument: 100.75
INVERT ON DESIGN PLAN INVERT ELEVATION
Building Sewer OUT
Septic Tank IN 94.27
94.46
Septic Tank OUT 94.02
94.19
Pump Chamber IN 94.00
94.17
Pump Chamber OUT 93.73
93.48
Distribution Box IN 96.21
96.30
Distribution Box OUT 96.04
96.15
Lateral 1 HIGH 96.40
96.45
Lateral 1 LOW 96.40
96.42
Lateral 2 HIGH 96.40
96.45
Lateral 2 LOW 96.4
96.45
Page 3 of 3
Q
0 TOWN OF NORTH ANDOVER 0
'90
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845
Susan Y. Sawyer, REHS/RS
Public Health Director
C
978.688.9540 — Phone
978.688.9542 — FAX
SEPTIC SYSTEM CONSTRUCTION NOTES
ADDRESS: MAP: LOT:
INSTALLER:
-�—f L&gw
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
DATE OF BED BOTTOM INSPECTILON-�:4 'r "tq 6 Jmelg
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION -
SELECT SYSTEM TYPE
GRAVITY DISTRIBUTION
PRESSURE DISTRIBUTION
PRESSURE DOSING
HOLDING TANK
ADVANCED TREATMENT
OTHER
COMPONENT SUMMARY FROM PLAN
GALLON TANK =
LOADING OF SEPTIC TANK
GALLON PUMP CHAMBER =
LOADING OF PUMP CHAMBER
TYPE OF SAS =
DIMENSIONS AND DETAILS OF SAS:
SITE CONDITIONS
Existing septic tank properly abandoned
Internal plumbing all to one building sewer
Comments: Topography not appreciably altered
Page I of 4
0 TOWN OF NORTH 0
ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER,
MASSACHUSETTS 01845
Susan Y. Sawyer, REHS/RS
Public Health Director
978.688.9540 — Phone
978.688.9542 — FAX
SEPTIC TANK
Bottom of tank hole has 6" stone base
Weep hole plugged.
gallon tank has been installed
(H-1 0 or H.-20) (monolithic or 2 piece)
El
Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
Inlet tee installed, under access port
Outlet tee (gas baffle or effluent filter) installed, under
access port
El
inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
Bottom of tank hole has 6" stone base
Weep hole plugged
gallon Pump Chamber installed
(H-10 or H-20) (monolithic,or 2 piece)
Inlet tee installed, under access port
Pump(s) installed on stable base
Alarm float working
Pump On/Off float working
Drain hole in pressure line
inch cover to within 6" of final grade installed over
one access port
Water tightness of tank has been achieved
Visual or Vacuum Test or Water held for 24 hrs
El
Hydraulic cement around inlet & outlet
Comments:
Page 2 of 4
0 TOWN OF NORTH ANDOVER 0 RTIf
0
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845
Susan Y. Sawyer. REHS/RS C HWU
Public Health Director 978.688.9540 — Phone
978.688.9542 — FAX
D -BOX
1 0
N
Comments:
SOIL ABSORPTION SYSTEM
0 0
Comments:
1 0
0
0
M
PRESSURE DISTRIBUTION
I
Comments:
Installed on stable stone base
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Bottom of SAS excavated down to soil layer, as
provided on plan
Size of SAS excavated as per plan
Title 5 sand installed, if specified on plan
3/4-1 Y2" double washed stone installed
1/8-1/2" (peastone) double washed stone installed
laterals installed and ends connected to head I er (and
vented if impervious material above)
Orifices @ 5 & 7 o'clock positions
Gravelless disposal systems: type, number and
location as per plan
Elevations of laterals installed as on approved plan
40 Mil HDPE barrier installed
Retaining wall (boulder / concrete / timber/ block)
Final cover as per plan
inch manifold
laterals installed with end sweeps
size:
material:
Squirt test ft in height
Equal distribution to all laterals
orifice size inch as per plan
Page 3 of 4
0 TOWN OF NORTH ANDOVER 0
Office of COMMUNITY DEVELOPMENT AND SERVICES Ilea,
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845
Susan Y. Sawyer, REHS/RS CHOU
Public Health Director 978.688.9540 — Phone
978.688.9542 — FAX
CONTROLPANEL
Alarm & Pump are on separate circuits
Alarm sounds when float is tripped
Location of control panel:
Comments: Rated for exterior if placed outside
SYSTEM ELEVATIONS
Benchmark:
Rod at Benchmark:
Height of Instrument:
Page 4 of 4
0 TOWN OF NORTH ANDOVER 0
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845
01
978.688.9540 — Phone
Susan Y. Sawyer, REHS/RS 978.688.9542 — FAX
Public Health Director healthdept@townofnorthandover.com - e-mail
www.townofnorthandover.com - website
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:- �? �_ � - 0 S -
LOCATION: I � 6 ra d -Fo rd S
HOMEOWNER NAME: 1 Z_ A6 e -+k C Cr�'
LICENSED INSTALLER NAME:
PLEASE PRINT
SIGNATURE:
CHECK ONE:
FULL SYSTEM REPAIR:
COMPONENT REPAIR (indicate what parts):
* NEW CONSTRUCTION:
TELEPHONE# 7 �-/ � s-3 '71 y1v
* If NEW CONSTRUCTION, please attach the Foundation As -Built Plan.
$250.00 or $1 25 Fee Attached? Yes -V No
Project Manager Obligation From Attached? Yes No
Foundation As -Built? Yes No
Floor Plans? Yes No
Approval of Health Agent
Date:
($250)
($125)
0 .0
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at 2- 6i 9 ra A -d 'Si —relative to the application
_�7v� / -2005-"'
ofJA"M--) dated CaMW for plans by /U cgu and
datedJ-U" 9-0 2-0'1'�_with revisions dated J-, 2,00y -
I understand the following obligations for management of this project:
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.
As the installer I must call for any and all inspections. If homeowner, contractor, project
manger, or any other person not associated with my company schedules an inspection and the
system is not ready theii item three shall be applicable.
As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a $50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection - Engineer must first do their inspection for elevations, ties, etc. As -built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade - Installer must re q*uest inspection when all grading is complete. Does not have to be
on site.
4. As the installer I understand that only I may perform the work (other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work by others unlicensed to install septic systems in
North Andover can constitute reasons for denial of the system, and/or revocation or
suspension of my license to operate in the Town of North Andover; significant fines to all
persons 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 o*f Health staff or consultant.
d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other
components. I .
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
Date:
rks Construction Permit #
Disp Sao
Leo Poirier
APPLICATION FOR SEWAGF, DISPOSAL IPSTALIATION gf Bradford St.
HEALTH DEPARTMENT - NORTH ANDOVFR, MSS.
I hereby make application for a peimit for a sewage disposal installation at
Bmdfnj:d Sts 6 1 will install this system in ac-'
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot Pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of ljo until 10 feet pre-
ceding the septic tanks where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of moo gal, in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-.
vide a minimum of 180 —lineal (sAggo) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe - The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4P (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet'will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be.less than 100 feet from any private water supply,
25 feet from any stream., 20 feet from any dwelling or 10 feet from any property line.
I further agree not to coveraLiy portion of this installation until approved bythe
inspection officer. as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE 5'�114.16 /
A0
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DA TE
Oignature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DA TO—
Percolation Tes t 2 min. Soil -sand
Garbage Grinder ____ 46
kA.
Signature of ��Pecting Officer
May 13, 1961
Miss Mary Sheridan R. N.
Health Agent
Board of Health
North Andover., Mass.
Dear Miss Sheridan:
An examination was made as requested in order to determine the
suitability of the soil for the subsurface disposal of sewage on the
proposed Bradford Street building site of Lao B. Poirier.
The land in general is high.
The subsoil in the area was of sand content and a 2 -minute
percolation test was conducted.
It is recommended that a 1,000 gallon concrete septic tank (per
,ownerts request) be installed together with 180 lineal feet of drain
�ipe*
Very truly yours,
William J. sco, I
WJD:hd
BOARD OF HEALTH
TOWN OF NORTH ANDOVER.. MASS.
13-0
k
oic Sf.;'rw-r4jjK.
1. NAM DATE
2, ADDRESS LOT NO. TEL*
3. NO, OF BEDROOhS DEN YES NO.
4*' GARBAGE GRINDER YES NO.
50 SHOW DIlvENSIONS OF HOUSE i��
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DhENSIONS OF LOT,,-"
8, SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEA4
10. SHGW LOCATION OF BROOKS, STREAWS., DITCHES., LEDGE OUTCRO
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
1#9-,Fflfi No)
-uu-&-f wit,
p, %� axxinr
WAWA(". I V ff4lo rwmomm
cok
----------- - ----- ....... .
lw-�OW Oil M-.
A IrO) U,*%j
vw
10 "AARD"of
"llolf a "I -amvg�l T LD).fity-ij
1110A
IWO
'A
TOWN OF NORTH ANDOVER Q-
Office of COMMUNITY DEVELOPMENT AND SERVICES
'�6 .6 a
HEALTH DEPARTMENT
0
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0 1845
Susan Y. Sawyer, REHS/RS
Public Health Director
July 29, 2005
Elizabeth Poirier
29 Bradford Street
North Andover, MA 0 1845
978.688.9540 — Phone
978.688.8476— FAX
RE: Septic System Design, 29 Bradford Street, North Andover, May 61, Lot 36
Dear Ms Poirier:
The North Andover Board of Health has completed the review of the septic system design plan
for the above referenced property, submitted on your behalf by New England Engineering
Services, Inc. dated June 2, 2005, last revision date of July 29, 20051
At the Board of Health meeting on July 28, 2005, the board members made a motion to approve
the local variance to allow a 3 -bedroom design; however, they did not approve the local upgrade
requested regarding reduction in setback to the dwelling from the leaching area. The members
noted that the property has substantial room to meet the codes and requested that the engineer
design a system that met the ftill compliance of the local and state regulations. A redesign has
been submitted in that regard.
The design has been approved for use in the construction of an upgrade onsite septic system.
This approval is generally valid for three years from the date of the approval and 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. The time
period for which this plan is valid is reduced to two years from the date of a septic system
inspection that did not meet the acceptable criteria in the state regulations. In the event an
imminent health problem such as sewage backup into the dwelling is occurring, the North
Andover Board of Health may reduce the time period for which this plan is valid
This approval is subject to the following conditions:
I 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.
2. 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 Boaromilding Inspector, Plumbing InspectorCuor Electrical Inspector.
The issuance of a Disposal System Construction Permit shall not construe or imply
compliance with any of the aforementioned requirement
3. The plan does not call for the installation of a septic tank effluent filter but one is
recommended. Please be advised that only certain brands of filters are permitted for use in
Massachusetts and each is required to follow certain approval criteria. Your designer or
installer should work with you to assure a licensed brand is selected for use if you choose to
install one.
4. A deed restriction shall be drafted which indicates the dwelling is limited to three bedrooms.
The document is to be created, signed and then recorded at the Registry of Deeds. A copy of
the recorded document must be presented prior to issuance of a Disposal Systems
Construction Permit.
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health Department may be reached at 978-688-9540 with any questions you
may have.
7%ne4erely
ZHSusan Y. Sawyer, RE S/R
Public Health Director
Encl: list of licensed septic system installers
Cc: New England Engineering Services, Inc.
File
011 '0
NEW ENGLAND ENGINEERING SERVICES
INC
July 29, 2005
Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 0 1845
Re: 29 Bradford Street, North Andover, MA
Septic System Design Plan Re -Submittal
Dear Ms. Sawyer,
R E E
JUL 2 9 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
The following plans and enclosures for the above referenced property are being re -submitted for
approval.
1. (3 )) Copies of the Septic System Design Plans.
Changes to this revised plan,.include moving the proposed leach field away from the existing
dwelling to comply with Title 5 setback requirement ofa minimum distance from a leach bed to
a foundation wall.
Please contact this office with any questions or concerns.
Sincerely,
Thomas Hector
Project Engineer
.60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
ORT#hf
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET '14
NORTH ANDOVER, MASSACHUSETTS 0 1845 8 C
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public.Health Director 978.688.9542 — FAX
July 5, 2005
Elizabeth Poirier
29 Bradford Street
North Andover, MA 0 1845
RE: Septic System Design, 29 Bradford Street, North Andover, Mai) 61, Lot 36
Dear Ms Poirier:
The North Andover Board of Health has completed review of the septic system design plan for the above referenced
property submitted on your behalf by New England Engineering Services, Inc. dated Ju I ne 2, 2005 and received by
this office on June 10, 2005.
Accompanying the plan is the following requests to the Board of Health;
1) A Local Upgrade Approval to reduce the setback from the soil absorption system to the cellar wall from the
required 20' to 10'
2) A variance request to reduce the design criteria from the required 4 bedrooms to 3 bedrooms was be
reviewed at the Board of Health meeting of July 28, 2005.
The nex . t Board of Health meeting is scheduled for July 28, 2005. At that meeting, your engineer will address the
Board Members with his requests. If these requests are granted as listed above, your design will be stamped
approved on the next business day and a subsequent approval letter will be sent to you. Due to local regulations
regarding system sizing, please be aware of the following.
1. A deed restriction shall be drafted which. indicates the dwelling is limited to three bedrooms. The document is
to be created, signed and then recorded at the Registry of Deeds. A copy of the recorded document must be
presented prior to issuance of a Disposal Systems Construction Permit.
Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health
Department may be reached at 978-688-9540 with any questions you may have.
Sincerel
san Y. Sawyer, REHS/RS
Public Health Director
Cc: New England Engineering Services, Inc.
file
NEW ENGLAND ENGINEERING SERVICES
INC,
June 8, 2005
Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 0 1845
Re: 29 Bradford Street, North Andover, MA
Local Upgrade Approval Request &
Local Bylaw Variance Request
Dear Ms. Sawyer,
RECEIVIED
JUN 1 0 2005
TOWN OF NOR Y H ANDOVER
HEALTH DEPARTMENT
The purpose of this letter is to request that the above referenced property be included in the
upcoming Board of Health meeting agenda to discuss the following local upgrade approvals and
Title 5 variance requests:
Local Upgrade Approval Required
1. Allow reduction in offset distance between the leach bed and a foundation wall from 20
feet required by Title 5, section 15.211 (1) to 10 feet.
Local Bylaw Variance Required
Allow a design based on 3 bedrooms in lieu of a 4 bedroom minimum required by the
North Andover Health Bylaw. Approval of this plan requires that a deed restriction
limiting the dwelling to 3 bedrooms be recorded at the registry of deeds.
If you have any questions or comments, please do not hesitate to contact this office.
Sincerely,
"'le Zli-
Steven E. Pouliot
Project Manager
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 688-1768 - (888) 359-7645 - FAX (978) 685-1099
NEW ENGLAND ENGINEERING SERVICES
INC
June 8, 2005
Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 0 1845
Re: 29 Bradford Street, North Andover, MA
Septic System Design Plan Submittal
Dear Ms. Sawyer,
MINE
JUN 10 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
The following plans and enclosures for the above referenced property are being submitted for
approval.
I . (3)) Copies of the Septic System Design Plans.
2. (2) Copies of the Form 11 Soil Evaluator Sheets.
3. (2) Copies of the Local Upgrade and Variance Request Letter.
4. (2) Copies of the Form 9A -Request for Local Upgrade Approval.
5. (2) Copies of the Form 913 -Local Upgrade Approval.
6. (2) Copies of the Infiltrator Approval Form.
7. Check for the Town approval fees.
Please contact this office with any questions or concerns.
Sincerely,
Steven E. Pouliot
Project Manager
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
Tdw-n�bf Nofth' Andover
HEALTH DEPARTMENT
27 Charles Street
North Andover, MA, 01845
978.688.9540
health!ImKOmvnofnorthandaver.com
PTIC PLAN SUBMITTAM-9
JUN 1 0 2005
DATE OF SUBM[1SS1ON:__.._.r0
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SITELOCATION:
ENGMER.- 4)?w eFk 4 eo- rl A
NEW PLANS: YES X $225.00/Plan Check#:
(Includes 14WFNW—and one Re-ReWew Only)
REVISED PLANS: YES S 75.00/Plan Check 4:
SITE EVALUATION FORMS INCLUDED: NO
LOCAL UPGRADE FORM INCLUDED: NO -
Telephone #: q 7:9
Faxff:
Fmail:-
HOMEOWNER NAME: f/;7_4�-efLi P�,f-%ar
OFFICE USE ONLY
ff%en the submission is complete (including check):
-D* stamp plans and letter
[etc and attach Receipt
3. Vy File; Forward to Consultant
"I P-1
4. Enter on Log Sheet and Database
NEW ENGLAND ENGINEERING SERVICES
ING
June 8, 2005
Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
Re: 29 Bradford Street, North Andover, MA
Local Upgrade Approval Request &
Local Bylaw Variance Request
Dear Ms. Sawyer,
RECEIVED
JUN 1 0 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
The purpose of this letter is to request that the above referenced property be included in the
upcoming Board of Health meeting agenda to discuss the following local. upgrade approvals and
Title 5 variance requests:
Local Upgrade Approval Required
1. Allow reduction in offset distance between the leach bed and a foundation wall from 20
feet required by Title 5, section 15.211 (1) to 10 feet.
Local Bylaw Variance Required
Allow a design based on 3 bedrooms in lieu of a 4 bedroom minimum required by the
North Andover Health Bylaw. Approval of this plan requires that a deed restriction
limiting the dwelling to 3 bedrooms be recorded at the registry of deeds.
If you have any questions or comments, please do not hesitate to contact this office.
Sincerely,
Je IV Ii -
Steven E. Pouliot
Project Manager
60 BEECHWOob DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-`1099
No. TP -rp-2
14 TPQ
JUN 1 0 2005
TOV'N OF NO TH ANDOVER
HEALTH DE:�PARTMaNT
I
Date.: —qk
Commonwealth of Massachusetts
A��-4\ AvJ�e_r Massachusetts
Soit Suitability Assessment for On-site Sewapw DiVIRSal
Performed By: .._Thpmas� K -He-a-01 .......................................... Date: 11 05
Y/ ..........
Witnessed By: .-Ay-t-as w ......
.... Alit ...... Klycr ............... .4w.1 YI
Location . Addmssor aLq BrOJIF04 Isif-e;17
Loto �dor+�i Ay\d over) /MA
�ew Construction El Repair
Owner's Nam, E112-aLeA�
Address. and 9,9 &-j-Ford S+r-o-et-
Telephone I
A)�(411 AvJover-,AA
(q78) 0866
Published Soil Survey Available: No E! Yes
Year Published ...... Publication Scale
Drainage, Class Soil Limitations
.Surficial Geologic Report Available: No x Yes
Year Published Publication Scale
Geologic Material (Map Unit) ..............................
Landform.
Flood Insurance Rate Map:
Above 500 year flood boundary No E]Yes
Within 500 year flood boundary No E]Yes
W . ithin 100 year flood boundary No OYes F1
Wetland Area: . .
National Wetland Inventory Map (map unit)
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS): Month
Range :Above Normal ONormal xMQBe1cwNormal
Other References Reviewed:
aDEP APPROVED FORM - 12107195
Soil Map Unit
ve�:y ....
............................ - ........ ...... —,
........ /V/,A . .. .... . ....... : ...... .
............ MA .........................................
d 0015-
Locatio n Address or Lot i4o. Rq 81-qjpo(-� stj)jor-��-,AV�JCVQr
On-site Review
beep Hole Number TPI_ Date:..4.!,7_10'-5' Time: -1-0., - .
Location (identify on site plan) �eAfr L�-Pt Weather
Land Use Slope Surface Stones
Vegetation .,C -f- ........... . . .
Landform oqfw
Position'on landscape (sketch on the back)
Distances from:
y k..JPPP,' feet 1goo
Open Water Bod Drainage way'..--- feet
PossibleMet Area.aQ.16...", f -ty Li nie
eet Proper feet
trinking Water Well )j5-9_ f eet Other
DEEP OBSERVATION HOLE LOG
Depth from
Surfacelinches).
Soil Horizon
Soil Texture
USDA)
Soil Color -Soil
(Munsell) Other
Mottling (Structure, Stones. Boulders, Consistency, 0/9
Gravel)
/A
S. L
i oYK
BW
asy (14
/A4
Ili 1111, 11.11F 11011''t,
Parent Material (geologic)
1:11JR,
J USED DISPOSAC AREA
kl_ DePthtoSedrock:
Depth to Groundwater: Standing Water in the Hole:
j .
Estimated Seasonal High Grio�und Water.,
it ti
Weeping from Pit Face:
DEF APPROVED FORNI - 12/07/9S
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Locatio n Address or Lot i4o. r� q grx 0
On-site Review
.beep Hole Number Date:.'�-Jt�! Wea ther
Location (identify on site plan)
Land Use
Slope Surface Stones —7 . ...... ... . . .......... ..
Vegetation
Landform
Position*on landscape (sketch on the back)
Distances from:
Open Water Body J.0.0.0— feet Drainage way. -00-0.... feet
Pos�sible'.We� Area...J-77 ... feet Property Line feet
.15 . rinking Water Well feet Ot'6r
DEEP OBSERVATION HOLE LOG*
Depth from
Surface jInches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency, %
Gravel)
3/ia
YR
Lj
-L- 5
5/8
MINIMUM
OF 2 HOLES
REQ1J= AT
DFA
Parent Material (geologic) DepthtoBedrock:
.Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:
Estimated Seasonal High Grio'und Water:
DEP APPROVED FORNI 12/07/95
TOIW 11 SOIL UkUUAT
OR FORM
Page 2 of 3
Location Address or Lot i4o.
On-site Review
beep Hole Number T Date:,,.510pr Fa't r 5 �0
Weather
Location (identify on �ite plan) I.S)��
Land Use Rm SlopeM Surface Stones
Vegetation.
Landform -0.9i"ak
Position on landscape (sketch on the back)
...... . . .. ... . .. . .... .
Distances from:
Open Water Body
feet
Drainage way,.)49- feet
Po�sible'.We�'Area...JV,. 6.— fee- Property Lin*e....9-0.-.
t feet -
'6rin.king Water Well _�:,U2b_._ feet 'Other . . ...
DEEP OBSERVATION HOLE LOG
Depth from' Soil Horizon Soil Texture Soil Color 'Soil Other
surface (Inches) (USDA) ' o
(Munsell) Mottling (Structure, Stones, Boulders, Consistency, 0/9
Gravel)
2.1a
S' L
lov
0jq-
5-7
a4- 11 16- 7/a
01 .5-Y
5- YR
. ....... .. ..... .
ZZI
MiNIMUM OF 2 1�1 !`1"RrWM1 AT EVERY P DISPOSAL AREA --
Parent Material (geologic)
DepthtoBedrock-
Depth to Groundwater: 'Standing Water in the Hole -
3" Weeping from Pit Face:
Estimated Seasonal High Ground Water:
DEP APPROVED FORNI 12107/95
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. &Jr- r -J
Determination for Seasonal H h Water Table
ig
Method Used:
El Depth observed standing in observation hole ................. �. inches
Depth weeping from side of observation hole ........ ... ..... inches
k - - -rp
M-Dep.th to soil mottles -777P�.- inches (7d-' - ifi) (6 8%k alk -7. TIP -3)
El Ground water adjustment ................... feet
Index Well Number .................. Reading Date .................... Index well level ..........
Adjustment factor ................... Adjusted ground water level ....................................... A ..........
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist irl p1l areas
observed throughout the area proposed for the soil absorption system? ye -5
If not, what is the depth of naturally occurring pervious material? —
Certification
I certify that on 16S (date) I have passed the soil evaluator examination
approved by the De�attment 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 Date
1� '. _1%
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
0
Commonwealth of Massachusetts
City/Town of
Form 9A - Application for Local
IV
ro a I
rp 9 IP
TOWN Or j�.t�TH Ar-400VER
DEP has provided this form for use by local Boards of Hea t[j � I
Ith. 0 __a, _dg L�W bu the
information must be substantially the same as that provided here. Before usin L66—i
g this form, check with your
local Board of Health to determine the form they use.
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CIVIR
5.404(l), is not feasible.
310 CIVIR 15.403(4) requires the system owner to provide a copy of the local upgrade approval to the
appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource
Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before
commencement of construction.
System upgrades that cannot be performed in accordance with 310 CIVIR 15.404 and 15.405, or in full
compliance with the requirements of 310 CIVIR 15.000, require a variance pursuant to 310 CIVIR 15.410
through 15.417.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved
capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CIVIR 15.000.
A. Facility Information
1. Facility Name and Address:
Elizabeth Poirier
Name
29 Bradford Street
oireet Aaaress
North Andover
City[To tvn
2. Owner Name and Address (if different from above):
same
Name
City/Town
Zip C �d_e
3. Type of Facility (check all that apply):
E Residential El Institutional
4. Describe Facility:
Sinqle familv dwelli
5. Type of Existing System:
0 Privy El Cesspool(s)
MA
State
Street Address
State
Telephone Number
El Commercial
0 Conventional
01845
Zip Code
El School
El Other (describe below):
Form 9A Application for Local Upgrade Approval -29 Bradford Street,
North Andover - rev. 5/02 Application for Local Upgrade Approval* Page 1 of 4
0
Commonwealth of Massachusetts
City/Town of
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
A. Facility Information (continued)
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
leach trenches
7. Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility:
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
MCI
gpd
330
gpd
330
gpd
El Voluntary 0 Required by order, letter, etc. (attach copy)
0 Required following inspection pursuant to 310 CMR 15.301:
2. Describethe proposed upgrade to the system:
Installation of a new subsurface sewage disposal system.
3. Local Upgrade Approval is requested for (check all that apply):
4-8-05
date of inspection
E Reduction in setback(s) — describe reductions:
Reduction in offset distance between a foundation wall and a leach bed from 20 feet required by Title
5, Section 15.211 (1) to 10 feet.
El Reduction in SAS area of up to 25%: SAS size, sq. ft. % red i-ction
El Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate
min./inch
Depth to groundwater ft.
Form 9A Application for Local Upgrade Approval -29 Bradford Street,
North Andover - rev. 5/02 Application for Local Upgrade Approval* Page 2 of 4
Commonwealth of Massachusetts
City/Town of
Application for Local Upgrade Approval
Form 9A
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
B. Proposed Upgrade of System (continued)
El Relocation of water supply well (explain):
n/a
El Other requirements of 310 CMR 15.000 that cannot be met — describe and specify sections of the
Code:
n/a
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 15.405(l)(i)(1). The soil evaluator must be a member
or agent of the local approving authority.
High groundwater evaluation determined by:
Evaluator's Name (type or print)
C. Explanation
Signature
Date of evaluation
Explain why full compliance, as defined in 310 CMR 15.404(l), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CIVIR 15.000 is not feasible:
Site conditions allow limited area for location of upgraded system.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
Alternative systems are cost vrohibitive.
Form 9A Application for Local Upgrade Approval -29 Bradford Street, Application for Local Upgrade Approval* Page 3 of 4
North Andover - rev. 5/02
0
Commonwealth of Massachusetts
City/Town of
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
C. Explanation (continued)
3. A shared system is not feasible:
NO
4. Connection to a public sewer is not feasible:
NO
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
0 Application for Disposal System Construction Permit
Z Complete plans and specifications
E Site evaluation forms
0 A list of abutters affected by reduced setbacks to. private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
El Other (List):
D. Certification
"l, the facility owner, certify under penalty of law that this document and all attachments, to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for submitting false information, including, but not limited to, penalties or fine and/or
imprisonment for deliberate violations."
Facility Owner's Signature
Benjamin C. Osgood, Jr., P.E. (Agent)
Print Name
New England Engineering Services, Inc.
Name of Preparer
60 Beechwood Drive
Preparer's address
MA, 01845
State/ZIP Code
Form 9A Application for Local Upgrade Approval -29 Bradford Street,
North Andover - rev. 5/02
6/8/05
Date
6/8/05
Date
North Andover
City[Town
978-686-1768
Telephone
Application for Local Upgrade Approval* Page 4 of 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
I &11-�
vt�=A
0
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 913
0
RECENED
JUN 1 0 2005
DEP has provided this form for use by local Boards of HeLL&"=*�
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner. The system owner shall provide a copy of the Local Upgrade Approval to the
appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource
Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before
commencement of construction.
A. Facility Information
1 . Facility Name and Address
Elizabeth Poirier
Name
29 Bradford Street
Street Address
North Andover
City/Town
2. Owner Name and Address (if different from above):
Same
Name
Cityrrown
Zip Code
3. Type of Facility (check all that apply):
LM
01845
State Zip Code
Street Address
State
Telephone Number
E Residential El Institutional El Commercial M School
4. Design flow per 310 CIVIR 15.203:
5. System Designer:
60 Beechwood Drive
330
gpd
Benjamin C. Osgood, Jr., P.E.
Name
North Andover MA
Address Cityrrown
B. Approval
1. Local Upgrade Approval is granted for:
State, ZIP
41� �M�
[E Reduction in setback(s) — specify:
Reduction in offset distance between a foundation wall and a leach bed form 20 feet required by Title
5, Section 15.2110) to 10 feet.
D Reduction in SAS area of up to 25%:
SAS size, sq. ft.
% reduction
Form 913 Local Upgrade Approval - 29 Bradford Street, North Andover
- rev. 5/02 Local Upgrade Approval* Page 1 of 2
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 913
B. Approval (continued)
0 Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate
Depth to groundwater
El Relocation of water supply well (explain):
ft.
min./inch
ft.
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
Allow a design based on 3 bedrooms in lieu of 4 bedrooms required by the North Andover Health
Bylaw. Approval of this plan requires that a deed restriction limiting the dwelling to 3 bedrooms be
recorded at the reqistry of deeds.
List variances granted requiring DEP approval:
Approving Authority
Print or Type Name and Title Signature Date
Form 9B Local Upgrade Approval - 29 Bradford Street, North Andover
- rev. 5/02 Local Upgrade Approval* Page 2 of 2
. I
MITTROMNEY
Governor
IKERRY BEALEY
Lieutenant Governor
0 0
COMMONWEALTH OF MASSACHUSETTS
ExEcunvE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292-5500
JUN 10 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
MODIFIED CERTIFICATION FOR GENERAL USE
Pursuant to Tide 5, 3 10 CMR 15.000
Name and Address of Applicant:
Infiltrator Systems, Inc.
P.O. Box 768
6 Business Park Road
Old Saybrook, CT 06475
ELLEN ROY IIERZFELDER
Secretary
EDWARD P. KUNCE
Acting Commissioner
Trade name of technology and model: High Capacity Chamber, Standard Chamber, Infiltrator 3050
(Storm Tech SC -740) and Equalizer 24 and 36 (hereinafter the "System").
Transmittal Nurnber: W023699
Date of Issuance: February 21, 2003
Date of Expiration: February 21, 2008
Authority for Issuance
Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000, the Department of
Environmental Protection hereby issues this Certification to: Infiltrator Systems, Inc., P.O. Box 768,
6 Business Park Road, Old Saybrook, CT 06475 (hereinafter "the Company"), for General Use of the
System described herein. Sale and use of the System are conditioned on and subject to compliance by
the Company and the System owner with the terms and conditions set forth below, Any
noncompliance with the terms or conditions of this Certification constitutes a violation of 3 10 CMR
15.000.
Glenn Haas, Director
Division of Watershed Management
Department of Environmental Protection
Date
This Wortextion b available in atternalle fortast, Call AMI McCabe, AI)A cWrAnator at 1-617-556-1171. TDD SerAce - I-SM298-2207.
0EP on the World Wide Web: httpJMww.massgov/dep
() Prinled on Recycled Paper
X
Infiltrator Modified Certification for General Use
Page 2 of 8
1. Purpose
N
The purpose of this Certification is to allow use of the System in Massachusetts,
on a General Use basis.
2. With the necessary permits and approvals required by 310 CMR 15.000, this
Certification authorizes the use of the System in Massachusetts.
3. The System may be installed on all facilities where a system in compliance with
3 10 CMR 15.000 exists on site or could be built and for which a site evaluation in
compliance with 310 CMR 15.000 has been approved by the local approving
authority, or by DEP if DEP approval is required by 3 10 CMR 15. 000.
Ii. Desip Standards
I . The models listed below are covered under this Certification.
2. The System is an open -bottom leaching unit molded from polyolefin resin. It can
be installed without aggregate or distribution pipe as an absorption trench in
accordance with the requirements in 310 CMR 15.251.
3. the use of aggregate as specified in 310 CMR 15.247 is not necessary with the
System when installed as a trench, bed or field.
4. The mininium separation between any two trenches shall be as specified in 310
CMR 15.25 1.
5. For new construction, the applicant can size the System in a trench configuration
without aggregate, using the effective leaching areas presented in the following
table. No System shall be designed and constructed with a soil absorption system
area of less than 400 square feet.
Dimensions
Invert
Model
WxLxH
Height
Inches
Inches
Equalizer 24
15 x 100 x 11
6
Equalizer 36
22 x 100 x 13.5
6
Standard Chamber
34 x 75 x 12
6.5
Infiltrator 3050 or
51 x 85.4 x 30
24
StormTech SC -740
I
I
High Capacity Chamber
]_ 34 x 75 x 16
1
2. The System is an open -bottom leaching unit molded from polyolefin resin. It can
be installed without aggregate or distribution pipe as an absorption trench in
accordance with the requirements in 310 CMR 15.251.
3. the use of aggregate as specified in 310 CMR 15.247 is not necessary with the
System when installed as a trench, bed or field.
4. The mininium separation between any two trenches shall be as specified in 310
CMR 15.25 1.
5. For new construction, the applicant can size the System in a trench configuration
without aggregate, using the effective leaching areas presented in the following
table. No System shall be designed and constructed with a soil absorption system
area of less than 400 square feet.
X
Infiltrator Modified Certification for General Use
Page 3 of 8
X
1. Effective leaching area is equal to 1.67 times the bottom width plus two x invert.
2. Effective leaching area is equal to 1.0 times the bottom width plus two x invert.
6. Systems shall be sized in accordance with the following table for new
construction in DEP designated nitrogen limited areas as defined in 310 CMR
15.214 and 15.215, The effective leaching area, as shown in the following table,
shall be used for any System installed in a Department designated Nitrogen
Sensitive Area or for any System that is installed for new construction where a
private drinking water supply well is proposed to serve the facility, . as defined in
3 10 CMR 15,214 (2) and for which a variance to the minimum setback distance
of 100 feet has been granted.
Effective
Effective
Model
Leaching'
Leachinfl
Area
Area
2.3
SF/LF
SF/LF
Equalizer 24
3.75
NA
Equalizer 36
4.73
NA
Standard Chamber
6.53
NA
Infiltrator 3050 or
NA
8.2
StormTech SC -740
Fhgh Capacity Chamber
7.79
NA
1. Effective leaching area is equal to 1.67 times the bottom width plus two x invert.
2. Effective leaching area is equal to 1.0 times the bottom width plus two x invert.
6. Systems shall be sized in accordance with the following table for new
construction in DEP designated nitrogen limited areas as defined in 310 CMR
15.214 and 15.215, The effective leaching area, as shown in the following table,
shall be used for any System installed in a Department designated Nitrogen
Sensitive Area or for any System that is installed for new construction where a
private drinking water supply well is proposed to serve the facility, . as defined in
3 10 CMR 15,214 (2) and for which a variance to the minimum setback distance
of 100 feet has been granted.
I. Effective leaching area is equal to 1.0 times the bottom width plus two x invert.
Systems installed on remedial sites shall be allowed to utilize the effective
leaching areas presented in item 5 above or additional reductions in soil
absorption leaching area approved by the approving authority in accordance with
310 CMR 15.284. In no instance shall the reduction in the soil absorption system
required in 310 -CMR 15.242 exceed the maximum reduction allowed for
alternative systems approved in accordance with 3 10 CMR 15,284. The effective
leaching areas presented in item 6 above shall be used for remedial sites located
in Department designated Zone II or IWPA when the facility is to be brought into
full compliance in accordance with 3 10 CMR 15.404.
Effective
Model
Leachingi
Area
SF/LF
Equalizer 24
2.3
Equalizer 36
2.8
Standard Chamber
4.0
i trator 3050 and
8.2
Storm Tech SC -740
ffigh Capacity Chamber
1 4.5
I. Effective leaching area is equal to 1.0 times the bottom width plus two x invert.
Systems installed on remedial sites shall be allowed to utilize the effective
leaching areas presented in item 5 above or additional reductions in soil
absorption leaching area approved by the approving authority in accordance with
310 CMR 15.284. In no instance shall the reduction in the soil absorption system
required in 310 -CMR 15.242 exceed the maximum reduction allowed for
alternative systems approved in accordance with 3 10 CMR 15,284. The effective
leaching areas presented in item 6 above shall be used for remedial sites located
in Department designated Zone II or IWPA when the facility is to be brought into
full compliance in accordance with 3 10 CMR 15.404.
14"A
infiftrator Modified Certification for General Use
Page 4 of 8
8. In accordance with 310 CMR 15,240 (6) absorption trenches should be used
whenever possible. When the System is installed for new construction without
aggregate in a bed or field configuration, as defined in 310 CMR 15.252, the
System shall be designed using the effective leaching area for the bottom width
presented in the following table. Chambers shall be spaced a mininium of six
inches apart (edge -to -edge) when used in a bed configuration. No system shall be
designed and constructed with a leaching area of less than 400 square feet. The
effective leaching area shall only be equal to the bottom width for any System
installed in a Department designated Nitrogen Sensitive Area or for any System
that is installed for new construction where a private drinking water supply well is
proposed to serve the facility, as defined in 310 CMR 15.214 (2) and for which a
variance to the minimum setback distance of 100 feet has been granted.
1. Effective Leaching area is equal to 1.67 times bottom width only.
2. Effective leaching area for Infiltrator 3050 or StormTech SC -740 is equal to 1.0
times the bottom width
9. The System, when installed in a bed or field configuration without aggregate on
remedial sites, shall utilize the effective leaching areas presented in item 8 above
or additional reductions in soil absorption system area approved by the approving
authority in accordance with 3 10 CMR 15.284. In no instance shall the reduction
in the soil absorption system area required in 310 CMR 15.242 exceed the
maximum reduction allowed for alternative systems approved in accordance with
310 CMR 15.284.
10. The System, when installed as specified in 310 CMR 15.253: Pits, Galleries, or
Chambers, shall have an aggregate base and/or be surrounded by aggregate and
shall be sized as specified in 310 CMR 15.253 (1) (a) and (b). Effective depth
can be increased up to two feet with the corresponding addition of up to 14 inches
of base aggregate. Bottom width can be increased by two to eight SF/LF with the
corresponding addition of one to four feet of aggregate per side.
Effective
Model
Leaching
Area
SF/LF
Equalizer 24
2.08
Equalizer 36
3.05
Standard Chamber
4.72
Infiltrator 3050 or
4.25 2
StormTech SC -740
I High Cap2SLCharnber
1.72
1. Effective Leaching area is equal to 1.67 times bottom width only.
2. Effective leaching area for Infiltrator 3050 or StormTech SC -740 is equal to 1.0
times the bottom width
9. The System, when installed in a bed or field configuration without aggregate on
remedial sites, shall utilize the effective leaching areas presented in item 8 above
or additional reductions in soil absorption system area approved by the approving
authority in accordance with 3 10 CMR 15.284. In no instance shall the reduction
in the soil absorption system area required in 310 CMR 15.242 exceed the
maximum reduction allowed for alternative systems approved in accordance with
310 CMR 15.284.
10. The System, when installed as specified in 310 CMR 15.253: Pits, Galleries, or
Chambers, shall have an aggregate base and/or be surrounded by aggregate and
shall be sized as specified in 310 CMR 15.253 (1) (a) and (b). Effective depth
can be increased up to two feet with the corresponding addition of up to 14 inches
of base aggregate. Bottom width can be increased by two to eight SF/LF with the
corresponding addition of one to four feet of aggregate per side.
101
Infiltrator Modifled Certification for General Use
Page 5 of 8
11. The requirement that Chambers installed in trench configuration as specified in
310 CMR 15.253(6) be provided with inlets at intervals not to exceed 20 feet is
not applicable to the System
Ill. General Conditions
I The provisions of 310 CMR 15.000 are applicable to the use of the System,
except those that specifically have been varied by the terms of this Certification.
2. The facility served by the System, and the System itself, shall be open to
inspection and sampling by the Department and the local approving authority at
all reasonable times.
3. In accordance with applicable law, the Department and the local approving
authority may require the owner of the System to cease use of the System and/or
to take any other action as it deems necessary to protect public health, safety,
welfare or the environment.
4. The Department has not determined that the performance of the System will
provide a level of protection to the environment that is at least equivalent to that
of a sewer. Accordingly, no new System shall be constructed, and no System shall
be upgraded or expanded, if it is feasible to connect the facility to a sanitary
sewer, unless allowed pursuant to 3 10 CMR 15.004.
5. Design, installation and use of the System shall be in strict conformance with the
Company's DEP approved plans and specifications and 310 CMR 15.000, subject
to this Certification.
IV. Conditions Applicable to the System Owner
1. The System is approved for the treatment and disposal of sanitary sewage only.
Any wastes that are non -sanitary sewage generated or used at the facility served
by the System shall not be introduced into the on-site sewage disposal system and
shall be lawfully disposed of
2. For new construction, the owner initially shall size a soil absorption system *in
accordance with 310 CMR 15.242 to demonstrate that a conventional Title 5 soil
adsorption system using aggregate, including a reserve area, can be installed on
the site. The owner may than size the soil absorption system for the System The
total area required for the aggregate system, which may include the area
designated for the System and a reserve area shall be preserved and the owner
shall ensure that no permanent structures or other structures are constructed on
that area and that the area is not disturbed in any manner that will render it
unusable for future installation of a conventional Title 5 soil absorption system.
3. The owner of the System shall at all times properly operate and maintain the on.
site sewage disposal system.
Infiltrator Modified Certification for General Use
Page 6 of 8
4. The owner shall ftirmsh the Department any information that the Department
requests regarding the operation and performance of the System, within 21 days
of the date of receipt of that request.
N o owner shall authorize or allow the installation of the System other than by a
person trained by the Company to install the System
V. Conditions Applicable to the Company
By January 31st of each year, the Company shall submit to the Department a
report, signed by a corporate officer, general partner, or Company owner that
contains information on the System for the previous calendar year. The report
shall state known failures, malftinctions, and corrective actions taken for the
System as well as the date and address of each event.
2. The Company shall notify the Department's Director of Watershed Permitting at
least 30 days in advance of any proposed transfer of ownership of the technology
for which this Certification is issued. Said notification shall include the name and
address of the proposed new owner and a written agreement between the existing
and proposed new owner containing a specific date for transfer of ownership,
responsibility, coverage and liability between them All provisions of this
Certification applicable to the Company shall be applicable to successors and
assigns of the Company, unless the Department determines otherwise.
3. The Company shall furnish the Department any information that the Department
requests regarding the System, within 21 days of the date of receipt of that
request.
4. Prior to any sale of the System, the Company shall provide the purchaser with a
copy of this Certification. In any contract for distribution or sale of the System
theCompany shall require the distributor or seller to provide the purchaser of the
System, prior to any sale of the System, with a copy of this Certification.
5. If the Company wishes to continue this Certification after its expiration date, the
Company shall apply for and obtain a renewal of this Certification. The Company
shall submit a renewal application at least 180 days before the expiration date of
this Certification, unless written permission for a later date has been granted by
the Department.
6. The Company shall prepare an installation manual specifically detailing
procedures for installation of its System The Company shall institute and
maintain a training program in the proper installation of its System in accordance
with the manual and provide a training course at least annually for prospective
installers. The Company shall cer* that installers have passed the Company's
training qualifications, maintain a list of certified installers, submit a copy to the
0
Infiltrator Modified Certification for General Use
Page 7 of 8
Department, and update the list annually. Updated lists shall be forwarded to the
Department.
7. The Company shall not sell the System to installers unless they are trained to
install these Systems by the Company.
VI. Conditions Applicable to Installers of the System
Each Installer shall install the System in accordance with Company training on
the installation of the System and the conditions of this Certification.
2. No Installer shall install the System unless the Installer has been trained by the
Company on installation of the System.
VII. Reporting
1. All submittals of notices and documents to the Department required by this
Certification shall be submitted to:
Director
Watershed Permitting Program
Department of Environmental Protection
One Winter Street - 6th floor
Boston, Massachusetts 02108
VIII. Rights of the Department
The Department may suspend, modify or revoke this Certification for cause,
including, but not limited to, non-compliance with the terms of this Certification,
non-payment of an annual compliance assurance fee, for obtaining the
Certification by misrepresentation or failure to disclose fidly all relevant facts or
any change in or discovery of conditions that would constitute grounds for
discontinuance of the Certification, or as necessary for the protection of public
health, safety, welfare or the environment, and as authorized by applicable law.
The Department reserves its rights to take any enforcement action authorized by
law with respect to this Certification, the System, the owner, or operator of the
System and the Company,
IX Expiration Date
Notwithstanding the expiration date of this Certification, any System installed
prior to the expiration date of this Certification, and approved, installed and
maintained in compliance with this Certification (as it may be modified) and 310
CMR 15.000, may remain in use unless the Department, the local approving
authority, or a court requires the System to be modified or removed, or requires
discharges to the System to cease.
Infiltrator Modified Certification for General Use
Page 8 of 8
W 023699 LTI Reduced Size -Jan. 2DO3SHC
11
BOARD OF HEALTH
NORTH ANDOVER) S9.01 45
978-688-9540
APPLICATION FOR SOIL TESTS
DATE: MAP & PARCEL:
LOCATION OF SOIL TESTS: 29 &AA-D-fii)99
t,AA? (pl t- 0, -C 3 (0
0WNER-�---EL-'ZAi1,,r---1-;14 P5-11/�'I---i�� — TEL. NO.:
ADDRESS- 2-9 /3,P- P
/66 -
ENGINEER: MiW 10411-1-14m) EIVLIA16�XIAI.( TEL. NO.: 11 96
CER=D SOIL EVALUATOR: 460*IN 6�M)Q';4J 47010�1
Intended use of land: Residential Subdivision (ji�n�&FamilyHom�e--, Commercial V.
Is This:
Repair testing X Undeveloped lot testing Upgrade for addition
In the Lake Cochichewick Watershed? Yes No
THE FOLLOWING MUST BE INCLUDED WrM THIS FORM:
1 . Proof of land ownership Crax bill, deed, or letter from owner permitting tests)
2. Plot plan
3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes.and two percolation tests
required for each disposal area. Fee of $360.00 per lot for mpairs or pperades.
GENERAL INFORMATION
Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
3. At least two deep holes and two percolation tests are required for each septic system disposal arm
4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative
5. Fa 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 I"-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.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval:'.
Date Received: Check Amount: Check Date:
S�7
RECEIVED
MAY - 3 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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