HomeMy WebLinkAboutMiscellaneous - 30 PENNI LANE 4/30/2018 (2)- . I ft
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SEPTIC SYSTEM INSTALLATION
Is the installer licensed?
Type of Construction'.
New Construction: Certified Plot Plan Review
Floor Plan Review
Conditions of Approval from Form U
Issuance of DWC permit:
DWC Permit Paid?
DWC Permit # 1633 Installer:
Begin Inspection:
Excavation Inspection:
Needed:
Passed- By -.-
Construction Inspection:
Needed:
As Built Plan Satisfactory:
YES:
Approval of Backfill- Date: 6i By:
Final Grading Approval: Date: Vz?lqg By:
. d,
�YES
2i::)
NEW
YES
NO
YES
NO
YES
NO
A�
NO
NO
jotf tj 1) 1
Final Construction Approval: Date- By.
16lq2Certificate of Compliance: Approval: Date:
NO
Commonwealth ofMassachusetts
North Andover, Massachusetts
System Pumping Record
System Owner & Address:
Lynn Smith
30 Penni Lane
North Andover, MA 0 1845
Location of system: Rear yard
Date of Pumping: July 25, 2013
Type of system: Septic Tank
Gallons Pumped: 1500 gallons
System Pumped by:
Service Pumping & Drain Co., Inc.
5 Hallberg Park
North Reading, Ma
License #: BHP -2013-0098,0100,0765,0096,0097,0099,0101
Contents transferred to: Greater Lawrence Sanitary District
RECEIVED
A; I 'n '15 2013
�_)j
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Date:, jLi1y_'25,-2013,
Rumping Technician: JN'
This is PROPRIETARY and CONFIDENTIAL information that may
be used only by the Board of Health for regulatory purposes
Commonwealth ofMassachusetts
North Andover, Massachusetts
System Pumping Record
System Owner & Address:
Lynn Smith
30 Penny Lane
North Andover, Ma 0 1845
Location of system: Front
DateofPumping: August4,2011
Type of system: Septic
Gallons Pumped: 1500 gallons
System pumped by:
Service Pumping & Drain Co., Inc.
5 Hallberg Park
North Reading, Ma
License #: BHP -2011-0413,0412,0411,0410,0409,0408
I FA I i
IJO 10 2011
TOWN OF NORTH ANDOV6R
—E961TH DEPARTAAMP"
Contents transferred to: Greater Lawrence Sanitary District
I Date: August 4, 2011 Pumping Technician: CH
This is PROPRIETARY and CONFIDENTIAL information that may
be used only by the Board of Health for regulatory purposes
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TO" OF NORTH A'ND-O-V.E.R--.-�� -
11Y OF N',ORI'H ANDOVER/7
SYSTEM PUMPINCU't FqJf-,� OPHEAL—RA
-7
DEC - 5 202
I'S I'E.-M OWNER& ADDRESS
/k,
§YSTEM �LOCATION
(�.VamPlt: M( rroni urhou�t)
dp c" o
I OF PUM?INC:—//-5-e"2 QUANTITY PUMPID/
1'0 0 L: N 0 YES SCIPTICTANK: NO Y E S
"I URE OF SERVICE: ROUTINE
EMERGENCY
m�rRv,:\TIONS:
COOD CONDITION FU L L TO CO V
HF,\VY CREASE BAFFLLS IN
ROOTS LEACHFIELD RUNUACK.,
CXCESSIYE SOLIDS L",�FLOODED
SOLIDS CARRYOVER O�HFR (EXPLAIN)
llM P U M 1) C 0 0 Y: :71
-, J �) M F N TS:
I U '� 1 1 ''N 1'� TI Z A N S F C I Z I � LD TO:
Commonwealth ot
North Andover, �
System Owner & address:
Lynn Smith
30 Penni Lane
North Andover, MA
Location of system: Rear
Date of Pumping: June 20, 2006
Type of system: Septic tank
Gallons Pumped: 1500 Gallons
System Pumpin2 Record
System pumped by: Service Pumping & Drain Co., hic.
License#: BHP -2005-0649
Contents transferred to: Greater Lawrence Sanitary District
1, Date: June 20, 2006 Pumping Technician: JM I
This is PROPRIETARY and CONFIDENTIAL information that may be used only
by the Board of Health for regulatory purposes
SJ -
ST�MT IS SEPTIC TANK SERVICE
47 RAILpOAD SrREET,
BRADFORD,r MA 01835
978-372-7471
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ADDRESS
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ST�MT IS SEPTIC TANK SERVICE
47 RAILpOAD SrREET,
BRADFORD,r MA 01835
978-372-7471
/Vo Aiomver,
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104'
30 PENNI LANE
MAP 107D LOT 3 PARCEL 59
1.13 ACRES
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PETTIS ENGINEERING
29TENADELAVENUE
HAVERHILL,MA 01830
(978) 374-3186
TO 8"
PENNI LANE MAIN
��1111_01111mir'41
JOHN
H.
PETTIS,III
CIVIL
No.38528
I s r
DE
MIN. DISTANCES FROM PROP. LINE:
SEPTIC TANK = 38'
D -BOX = 39'
SAS = 38'
MIN. DISTANCES FROM DWELLING:
SEPTIC TANK = 13'
D -BOX = 35'
SAS = 26'
MIN. DISTANCES FROM CATCH BASIN:
SEPTIC TANK = 161'
D -BOX = 182'
SAS = 173'
INVERT TABLE
TANK IN
103.6'
TANK OUT
103.35'
D -BOX IN
102.75'
D -BOX OUT
102.58'
BED PIPE IN
102.55'
BED PIPE END
102.20'
I LEGEND
CONTOUR LINE
DEEP HOLE D4
PERCOLATION TEST PT+
TEMP. BENCHMARK TBM -
AS -BUILT
SCALE: V=40'
SANITARY SUBSURFACE
DISPOSAL SYSTEM
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TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
This is to certify that
the individual subsurface disposal system
constructed or repaired ( x
by North Andover Licensed Installer
John L. DiVincenzo
at
30 Penni Lane, North Andover, MA 01845
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations as described in the Design
Approval Site System Permit # 990 dated November 4, 1997.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System constructed; repaired;
by
located at
was installed in conformance with the North Andover Board of Health approved plan, System
Design Permit # , dated ' with an approved 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.
Installei
Design
Ljt A0
j Al A Lic. Date:
/7
Er&eer: Date:
y
LOCUSPLAN
AS-BUILr _"WLIST
LOT NUMBEF
ASSESSORS*
LOT LINES & LOCATIOiN iGS
LOCATION & DEMENSIONS OF SYSTEM`
INCLUDING RESERVE
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
W/IN 150'OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
STAMP & SIGNATURE
IMPERVIOUS AREAS -'DRIVEWAYS, ETC.
NORTH ARROW
FINAL CONTOURS
LOCATION & ELEVATION OF BENCHMARK USED
LOCUSPLAN
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
6htt
DATE: CURRENT INSTALLER'S LICENSE#
LOCATION: (i Z�,,
LICENS EDINSTALLER:
SIGNATURE:� TELEPHONE#
CHECK ONE:
REPAIR: L"_�
NEW CONSTRUCTION:
IEF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$75.00 Fee Attached?
Foundation As -Built?
Administrative Use Only
Yes L'�� No
Yes No
Floor Plans? Yes No
D
Approval at e,
Town of North Andover, Massachusetts Form No.2
vkolt'rh BOARD OF HEALTH
to
�"10 '.
o
J� tv - .4
0
DESIGN APPROVAL FOR
CHU SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant- Jo 7-1-�7-zj-5 Test No
Site Location 3 6 —T�wv/ &
Reference Plans and Specs. JOHL) _T�F'27-/0-
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
40 --
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 99�
I � ��- . . 4
Pettis Engineering
Professional Civil Engineering, Certified Soil Evaluator
29 Tenadel Avenue, Haverhill, Massachusetts 01830
(508)374-3186
October 31, 1997
Health Department
Town of North Andover
146 Main Street
North Andover, Massachusetts 0 1845
Re: 30 Penni Lane
�13 1997
Subsurface Disposal System Repair
Attached are three copies of the Plans for the repair of the septic system at 30 Penni Lane. Also
attached are the Deep Observation Hole Logs and the Percolation Test Form for this project, and
a copy of my certification as a Soil Evaluator.
Please contact me at (617)973-8831 (daytime) or (508)374-3186 with any questions. I thank you
for your time and effort.
attach.
Sincerely,
/ 4 /� J;r
John H. Pettis 111, P.E.
1997
�,FO
RM 11 - SOIL EVALUATOR FORM
Location Address or Lot No. �0 ppw �j / 4A Y6 N
On-sile Review
Deep Hole Number Date: Time: Weather A�keorls�q
Locaton do ti on site plan)
Land Use SlopeM Surface Stones IVAME
V*getsmon
Landform
Position on landscape (sketch on the back)
Distances from:
Open Water Body >.�00
f eat
Drainage way
->.300 feet
Possible Wet Area >100
feet
Property Une
13' feet
Drinking Water Well —
feet
Other
DEEP OBSERVATION HOLE LOG
Depth from
Swfew gin-chos)
Sad Horizon
SoN Texture
!USDA)
SON Color
JMunsell)
Sail
mowing
Other
IStructurs. Stones. Bouklers. C;onsistency, %
Grevell
�0
A Y11,312-
31 -3�
IOYA511
-5�A(-(- 741AXIt,
�4
MAYS
1AUM
Up a MUL" M&UUIKtU
A I CVLKT
rKUMSW
MrWbAL ARFA
r7LACMt 0117-IAW�
Dsolh to GriNMjhNil= SUndft Water in go Hole: Vfte" ftm Pit Few:
Eftneted Susand High Groisid Wow
OW AFMLOVM POW UWM -
m
V/00969
76*t Lw r-
FORM 11 - SOIL EVALUATOR FORM
Location Addmss or Lot No. �5p Lh , Y
I t A1VP,0VV
On-site Review
Deep Hole Number Date: /P It
1117 Time: Weather AVCMrl
Location lidentif on site Ion)
W7
t P . �(19W SlopeM Surface Stones �10,Alt,
Land Use .. - — I. .'-- -
Vegetation . .. .....
Landform
Position on landscape (sketch on the back)
Distances from:
Open Water Body ;,J'9p feet Drainage way '300 feet
Possible Wet Area �3&410 feet Property Line 30 feet
Drinking Water Well — f set Other
DEEP OBSERVATION HOCE LOG
DoM from Sod Horizon Soil Texture Sam color Soil Otheir
Surface lindws) JUSDA) Munimill Mottling (Structure, Storms. Boulders, Consistency, %
Gravel)
2, lisM P/A
�o4 413 10YR 0 mfa q, r e
�-37`
So J7
OF a MUMS LU114111:0 AT tVtRY MWVbW IMUMOALM"
Forwa M to AMOW 6LACIPL 4fWfild 141111111 Me d 7/
peommangnWwmn Sftn*qWsMinftMoM: Moo ftm Fft Face:
bftmd Seworml M10 OWN! WOW 3 7
00 ANSOM F0111M UWM
_i!
FORM 12 - PERCOLATION TEST
Location Address or Lot No. J6 pcw�// LAIVI� ___(VP6PPC)
COMMONWEALTH OF MASSACHUSETTS
�orA AnA,DVw , Massachusetts
Percolation Test*
Date: Time: 11;d 6
Observation Hole #
Depth of Perc
Start Pre-soak
End Pre-soak
Time at 12"
Tim e at 9"
Time at 6"
Time W-61
30 1h 14,
Rate Min./Inch
minimum of 1 percolation test I must be performed in both the primary area AND
reserve area.
Site Passed 11� Site Failed
...............................................................................................................................................................
Performed By: PC 77 15. EF
Witnessed By: ROPI-0
OY Al 4 6��
A
�cf
47
VIA
18 3
Massachusetts
Department of Environmental Protection
and
University of Massachusetts Amherst
Division of Continuing Education
certify that
John Pettis
has satisfactorily completed the soil examination, which meets the
requirements of 310 CMR 15.000 Title 5 of the State Environmental Code,
and is hereby recognized by the Department of Environmental Protection as
an approved Soil Evaluator.
Program Coordinator, Divisi
University of Massachusetts
of Continuing Education
Fall 1996
Pettis Engineering
Professional Civil Engineering, Certified Soil Evaluator
29 TenadelAvenue, Haverhill, Massachusetts 01830 (978)374-3186
May 12,1998
Sandra Starr
Health Administrator
Town of North Andover
30 School Street
North Andover, Massachusetts 0 1845
Re: 30 Penni Lane
Submittal of Revised Plans
Dear Sandra:
At this time I am submitting the second revision for the plan of the upgraded septic system at 30
Penni Lane (three copies are enclosed). Also attached are copies of the logs for the additional
Deep Hole and Percolation Test which were recently performed. I am hereby requesting to be
scheduled to go before the Board of Health at the May 28th meeting, if required, regarding the
latest percolation test rate being more than 30 minutes per inch (34 minutes per inch).
Please contact me at (617)973-8831 (daytime) or (978)374-3186 with any questions. I thank you
for your time and effort.
Sincerely,
John H. Pettis 111, P.E.
MAY 12 ;'0' 0 1
FORM 11 - SOIL EVALUATOR FORM
Location Address or tot No. VCR
KIETY7,
Data: Time: Weather
Deep Hole Purnber Y
Location ficientify on site plan)
L
Slope Surface Stones
LAind Use
Vegeuition
Landform
Position on landscape (sketch on the back)
013tances from:
Cpan Water Body 7yap feet Drainage way feet
Possible Wet Area )160 fast Property Une feet
Drinking Water Well — --fast ---- Other
DEEP OBSERVATION HOLE LOG*
t;j, 6 V
DmM from Sod Horizon SON T*xturs SON cow SON Other
Surface 41neheel JUSDAI Imunsem) Ma" fStructurs. Stones. BoukWs. Consistencv, %
ars"i)
313
�Rx /0YX
OS711 ` it vAorc ox
4A. / la
L#
Madmum up a MOL" UAI
Desch 0 onm"mm sur&vq Wow in go Mob:
9 71
Eglh Smsonsi High Ground Wsftr___
M AFrROVW POW UWM MY
� "k
FORM 12 - PERCOLATION TEST
Location Address or Lot No. moo y 'U'
COMMONWEALTH OF MA.SSACHUSETTS
, Massachusetts
Percolation Test*
Date: �17_31� F rime:
Observation Hole #
�12,
Depth of Perc
A
Start Pre-soak
End Pre-soak
3 `2-6
P3/
Time at 12"
r.3/
rime at 9"
rime at 6"
'rime W-61
Rate Min./Inch
1 14 e_
Minimum of 1 percolation test must be performed in both the primary area AND
reserve -area.
Site Passed 0 Site Failed 130 PIA1111b #/M 121,
A ..........................................
.............................................................................................................
Performed By: hthl
Witnessed BY: tko 7-0 L,
Pettis Engineering
Professional Civil Enzineerin2. CeWled Soil Evaluator
29 Tenadel Avenue, ffaverhill, Massachusetts 01830 (978)374-3186
October 6, 1998
Sandra Starr
Health Administrator
Town of North Andover
384 Osgood Street
North Andover, Massachusetts 0 1845
Re: 30 Penni Lane
Septic System As -Built
Dear Sandra:
Attached are the Installation Certificate and the As -Built plan for the septic system installed at 30
Penni Lane. Please note that the elevations shown on this plan were determined using a Rotating
Laser & Detector. This device determined the actual ground surface elevations of the testing
locations to be slightly different than the values shown on the design plans (for which I had used
a Hand Level). The estimated high groundwater table is at elevation 97.17', based on the top of
ground at a6e�.hole #2 being 100,25'. The bottom of system was installed more than 4 feet
above the estimated high groundwater.
Please contact me at (978)374-3186 if you have any questions or require more information from
me. Thank you for your time and effort.
Sincerely,
4)4 /�4�
John H. Pettis III, P.E.
Town of North Andover
OMCE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLLAM J. SCOTT
Director
June 4, 1998
Mr. John Pettis 111, P.E.
Pettis Engineering
29 Tenadel Avenue
Haverhill, MA 01830
Re- 30 Penni Lane
N. Andover, NIA 0 1845
Dear Mr. Pettis*.
30 School Street
North Andover, Massachusetts 0 1845
This is to inform you that the proposed plans for the site referenced above have been approved.
If you have any questions, please do not hesitate to call the Board of Health Office at the number
below.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/gb
cc- Joseph Titus
Eil�e
0
0 ,
BOARD OF APPEALS 688-954; BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Town of North Andover
OITICE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLIAM J. SCO77
Director
March 16, 1998
Mr. John Pettis
Pettis Engineering
29 Tenadel Ave.
Haverhill, MA 01830
Re: 30 Penni Lane
N. Andover, NLk 01845
Dear Mr. Pettis'.
30 School Street
North Andover, Massachusetts 0 1845
This is to inform you that the proposed plans for the site referenced above have been
disapproved for the following reasons:
1. There is insufficient soil testing within the system area - 98% of the leach area is
untested. Additional testing must be performed. Also in reserve if specified as such
(3 1 0CMR 15.102(2) and 15.104(4)).
2. Your system profile shows trench- .75' deep. Your section states something entirely
different. Please understand that calcs are done using the minimum depth of the
trench: i.e. the depth from the botton of the end pipe invert to the bottom of the
trench. In addition, the bottom of the trench is to be level (3 10 CMR 15.246(l)).
'90
". L0
�io*
3 Leach lines in excess of 50'in length shall be connected and vented accoriding to 310
CMR 15.241 (3 1 OCMR 15.25 1 (11)).
4. Please explain note 1. Is the house location on your plan the actual location of the
house on the lot?
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Page 2
30 Penni Lane
N. Andover, MA 01845
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
Sandra Starr, R.S.
Health Administrator
S S/rel
cc: Joseph Titus
File
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
30 School Street
WILLIAM J. SCOTT North Andover, Massachusetts 01845
Director
December 31, 1997
John Pettis
Pettis Engineering
29 Tenadel Avenue
Haverhill, NIA 01830
Re: 30 Perini Lane
Dear Mr. Pettis:
'10
0
'It L;�"-00
0-
0 0 ..
This is to inform you that the proposed plans for the site referenced above have been disapproved
for the following reasons:
I . All distances missing from site plan (N.A. 8.03).
2. No water line shown (3 10 CN4R 15.220 (4) (m)
3. No driveway shown (3 10 CNIR 15.220 (4) (d)
4. IvEssing gas baffle in tank (3 10 CNIR 15.224).
5. Please show trench length on profile.
6. No final grading shown on site plan (N.A. 8.02 v
7. No area of excavation shown on site plan (N.A. 8.02 z).
8. Note concerning reserve area would result in setback violation of dwelling to leach area,
please correct.
9. There is no soil testing within system area (3 ) 10 CNIR 15.102 (2) & 15.104 (4)
10. What is trench depth? Clarify on section.
11. Note required: First 2 feet of pipe from D -box to be laid level (310 CNIR 15.232 (c)
12. Please show breakout elevation on profile.
13. Gas baffle missing from tank (3 10 CNIR 15.224).
14. Elevation of perc; test missing (N.A. 8.02 n).
15. Elevations of deep holes missing (3 10 CIVIR 15.220 (4) (h)
16. No vent shown (3 10 CNIR 15.2 5 1).
If you have any further questions, please do not hesitate to call the Board of Health Office at the
number listed below.
Sincerely,
'j T12j--1b
Sandra Starr, R.S.
Health Administrator
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNINO 688-9535
cc: Joseph Titus
William J. Scott, Director, MCD
File
Pettis Engineering
Professional Civil Engineering, Certified Soil Evaluator
29 Tenadel Avenue, Haverhill, Massachusetts 01830 (978)374-3186
February 12, 1998
Sandra Starr
Health Administrator
Town of North Andover
30 School Street
North Andover, Massachusetts 0 1845
Re: 30 Penni Lane
Submittal of Revised Plans
Dear Sandra:
At this time I am submitting the revised plan for the upgraded septic system at 30 Penni Lane.
Below are the responses to the reasons the originally submitted plan was not approved:
1. Previously missing distances are now shown on or next to the site plan.
2. Water line is now shown.
3. Driveway is now shown.
4 It is now noted on section view of septic tank that outlet tee is to be equipped with gas
baffle.
5. Trench length is now shown on profile.
6. Final grading is now shown on site plan (new contours for elevations 102' and 104').
7. The area of excavation is now shown on the plan.
8. 1 had incorrectly stated on the original plans that the trenches would be located to the east
of the primary trenches. The reserve trenches are to be located to the west of the primary
trenches. The note has been changed on the plan accordingly.
9. 'The location of the soil absorption system has been moved. Deep hole #2 and the
percolation test are now within the proposed system area.
10. The trench depth at the inlet, and at the north and south ends of the trenches is shown on
the trench sections.
11. Note 5 on the plans includes the statement that the first two feet of the outlet lines from
the D -box shall be level.
12. The breakout elevations (for the north and south ends of the trenches) is shown on the
trench sections.
13. It is, now noted on section view of septic tank that outlet tee is to be equipped with gas
baffle.
14. The elevation of the percolation test has been added.
!;p
15. The elevations of the deep holes has been added.
16. The trench design has been changed. None of the distribution lines is now in excess of
5 0' in length.
Also, please note that the estimated high groundwater table elevation determined at deep hole #2
is higher than was shown on the system profile of the originally submitted plans. That drawing
had been made by amending a system profile drawing for the plans at another site, and I had
mistakenly not changed the value of the estimated high groundwater table elevation. For this
submittal, all existing elevations were rechecked, and the system profile was redrawn.
Please contact me at (617)973-8831 (daytime) or (978)374-3186 with any questions. I thank you
for your time and effort.
Sincerely,
I k W 4-1 r -
John H. Pettis 111, P.E.
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
DATE 3//3 Igg
FEE: PERMIT # DATE RECEIVED AI)7199
APPLICANT l0f2 4�-
,P// 7-17-0-5 MAP 16 -7b PARCEL
ADDRESS aO ZA LOT # STREET #
ENG. 10#k) --T�Zrl,5 STREET'
ENGINEER'S ADD -A 9 1414,7 - ljllq
PLAN DATE REV. DATE
CONDITIONS OF APPROVAL
APPROVED DISAPPROVED
REASONS FOR DISAPPROVAL:
16 IA-)
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142,�,50 IA -1 E95
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PLAN REVIEW CHECKLIST
ADDRESS 14-91V,6 ENGINEER Jo
GENERAL
3 COPIES STAMPC-`� LOCUS NORTH ARROW`� SCALE
CONTOURS PROFILE L--' (Sc) SECTION BENCHMARK SOIL &
PERCS lkl ELEVATIONS,�C WETS.- DISCLAIMER L,"'X WELLS & WETS
Alo WATER LINEZ FDN DRAIN— M&P
WATERSHED? DRIVEW�Y_��_/
SCH40 TESTS CURRENT? SOIL EVAL IJA-)
—7—
SEPTIC. TANK--— -
MIN, 1510OG .17 INVEi- DROP GARB. GRINbERAL2 +200)
10 TO . __FDN MANHOLE'.::�:"""" ELEV_ GW #,.COMPS. GB_X
D-BOX—
SIZZ # LINES_4�1_ FIRST 2' LEVEL STATEMENT -Z
INLET- 165e.93 - OUTLET/Z)3- e��' 17 (2" OR .17 FT) TEE REQ'D?-A&
LEACHING
-.----MIN '440 � GPD? RESERVE AREAX 4' FROM PRIMARY?Y 206 SLOPE
100' TO. -WETLANDS L,-' 100' TO WELLS 4 ' TO S.H.GW — (51>2M/IN)
2-0.' TO FND & INTRCP TR DRAINS
400' TO SURFACE H20 SUPP
4' PERM. SOIL BELOW FACILITY MIN 12 " COVER &--""FILL? 15'
BREAKOUT MET? 6
k)6 & gef.4 L), 51iO4t)A)
TRENCHES
MIN 440 gpd_ SLOPE (min .005 or 6"/100' SIDEWALL DIST. 3X EFF.
W OR D (MIN 61 RESERVE BETWEEN TRENCHES?— IN FILL? / MUST
BE 10' MIN.� A" PEA STONE? L-"' VENT? (>31 COVER; LINES >SO')
B 0 T + SIDE x LDNG TOT
.(L x W x #) (DxLx2x#) (G/ft2)
I
Copyright @ 1996 by S.L. Starr
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
DATE
FEZ:. PERMIT # DATE RECEIVED,,�V�,f 1�qq
APPLICANT 0 5,L,01V 7-1 r&1,5 MAP 107D PARCEL
ADDRESS LOT # STREET
ENG.
STREET_ :5W -WI
EN�i-NEER'S ADD 7—&,UAb,,-2Z klE.
PLAN ---DATE- REV. DATE
CONDI-TIONS OF. APPROVAL
AP PROVED- DISAPPROVED
--R.EA8ONS FORDISAPPROVAL: .0
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cm
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REVIEW CONTINUED
SHEET 0�. OF
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Applicant
Site Location
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 1
b a, I -� 19 q-_
- N- F
APPLICATION FOR SITE TESTING/INSPECTION
-Fi
Engineer
6)NAME ADDRESS TELEPHONE
Test/inspection Date and Time IIOAZ,�F 7 9,f,00
-If> �5 6b CHAIRMAN, BOARD OF HEALTH
Fee Test No.—Mv
S.S. Permit No.—D.W.C. No. C.C. Date—Plbg. Permit No.
Town of North Andover, Massachusetts Form No.1
IAORTiq BOARD OF HEALTH
�6 0 19-
Z.
0
0
APPLICATION FOR SITE TESTING/INSPECTION
ED 19 1.) -
HU
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer NAME ADDRESS TELEPHONE
Test/I nspection Date and Time
CHAIRMAN, BOARD OF HEALTH
Fee Test No.
S.S. Permit No.-D.W.C. No._C.C. Date-Plbg. Permit No
pS� Ck— 1*- 13-3
BOARD OF HEALTH
146 MAIN STREET TEL. 688-9 540
NORTH ANIDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
DATE: 7,-/ 7- � -7
LOCATION OF SOIL TESTS:
Assessces map & parcel number:
OWNER- VI -0 TEL. NO.: 3—'o
.ADDRESS: 3
/'V
ENGINEER: TEL. NO.:- 3 7 4/ 3
CERTIFIED SOIL EVALUATOR:
Intended use of land: residential subdivision, single family home, commercial
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
1. Proof of land ownership (Tax b ill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of $175.00 per lot for new construction. This covers the two deep holes
and two percolation tests required for each lot. Fee of $75.00 per lot for
repairs or upgrades.
GENERAL INFORMATION
1.. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design
septic plans.
3. At least two deep holes and two percolation tests are required for each septic
system.
4. Repairs require at least two deep holes and at least one percolation test, at
the discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of
testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-'100') shall be
submitted to the Board of Health showing the location of all tests (including
aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
DATE: / (�' -I b - T7
LOCATION�P
ENGINEER
BOH WITNESS:
LA Al L
PERCOLATION TEST#
BOTTOM DEPTH OF PERC TEST:
TIME OF SOAK: (At least 15 minutes long)
TIME AT 12"
TIME AT 9"
TIME AT 6"
OVERNIGHT SOAK
TIME STARTED
NEXT DAY SOAK:
TIME AT 12"
TIME AT 9"
TIME AT 6"
(At least 1.5 minutes)
DATE. -
LOCATION:
ENGINEER,
si
BOH WITNESS'
PERCOLATION TEST #
BOTTOM DEPTH OF PERC TEST.
TIME OF SOAK. (At least 15 minutes long)
TIME AT 12"
TIME AT 9"
TIME AT 6"
OVERNIGHT SOAK
TIME STARTED
NEXT DAY SOAK.- (Ali- least 15 minutes)
TIME AT 12"
TIME AT 9"
TIME AT 6"
MINIMUM
GROWERS I
1111111IM11111
MINIBOOM
1111111101111
all ISBN lill
VVIIIIAm F. Weld
Govemor
Tlud
S.r. I Coxe
t.,Y, EOEA
David B. Struhs
Commissioner
Commonwealth of Massachusetts
Executive Off ice of Environmental Affairs
Dep
,jrtment of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address- $41 Address of 6wner:
Date of Inspection: po (if different) L
Name of Inspector: U-) Zir V_A�AW
Company Name, Address and Telephone N --m e
./7//
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and.that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper functiort and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Sighature: Date:
/610 The S 'em- nspector sr01�1,ubmit �acopy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection If the symern i� a shared systern or has a design f1m% of 10,000 gpd or greater, the inspector and the system owner shall submii
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent tc tho sys1enn 0\,,,ner and copies sent to the buyer, if applicable and the approving dutllolit�.
INSPECTION SUMMARY:
Check A, B, C, or D
A] SYSTEM PASSES: 4'
I have not fo An any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
BI SYSTEM CONDITIONALLY PASSES: �—t, d
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined IV, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
I
One VVInter Street 0 Boston, Massachusefts 02108 0 FAX (617) W61-1049 Telephone (617) 292-SSOO
0 Printed on Recyded Paper
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
T
5., �/' 2 -7
III SYSTEM CONDITIONALLY PASSES (continued) r H �
Sewage backup.or breakout or high static wa er level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box, is levelled or repla*ced
�k
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EV ALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH r(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
.:t 7
The system w a S6pjiEr f,ank—anid -soil absibrl5iion' S�str e and is within a Zone I of a public Water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
EM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an 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.
I I (revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued),
Property Address:
Owner:
Date of Inspection: T T -(j
D) SYSTEM I'AILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number tirfiesvumpeo,��.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyz . ed to be acceptable, attach copy of well water analysis for
coliforrn bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
Zone 11 of a
n�Xre-a 6VPA) or a mapj)�d
—7 tCe systern is located"in itrogen sensi ive area ClnW�jm'NV�Ili;��d rotectio
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
4 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 36
Owner:
Date of Inspection:
Check if the following have been done:
p4po 6 U-A�
V_�F mpinj informat" ni was�equesie&Vf the Board'of Heali�.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined, Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
7
The system does not receive non -sanitary or industrial waste flow
7'
The site was inspected for signs of breakout.
7
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of'baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/he size and. location of the Soil Absorption System on the site has been determined based on existing information or
a p
proximated by non-intrusiv e methods.
—The facilit� o-,% ner (and occupants, if different f rom owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
Zt
(revised 8/15/95) 4
Property Address: 1 30 PC, I,1 V� it �'"A/. A"oo u-eL.,)
Owner:
Date of Inspection: 'T/-rkj%
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current resi ents:
Garbage grinder (yes or no):_a.
Laundry connected to system (ye or no)V--
Seasonal Ne (yes or no):
Water meter reading-, avai able:A
Last date of occupancy: V1 '_ J
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non-sapitary waste discharged to the Title 5 system: (yes or no)—
Water meter readings, if available:
Last date of occupancy
OTHER: (Describe) —
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
�ystem pyrnped as part. of inspec$ion: (yes or,Ro)-si�'s, #
-f s, v6lbf�e"'�"6r46# ?_�511*6'kn', "" %F `4P
Re7ason for pumping: Ch ea,__ 8),441e,�z __L te-,11 T
TYPE/OFTEM
YS
Septi c tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all c omponents, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) _�4 V
(revised 6/15/95) 5
Alt*
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C,
SYSTEM INFORMATION
X
Property Address: 1 30 PC, I,1 V� it �'"A/. A"oo u-eL.,)
Owner:
Date of Inspection: 'T/-rkj%
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current resi ents:
Garbage grinder (yes or no):_a.
Laundry connected to system (ye or no)V--
Seasonal Ne (yes or no):
Water meter reading-, avai able:A
Last date of occupancy: V1 '_ J
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non-sapitary waste discharged to the Title 5 system: (yes or no)—
Water meter readings, if available:
Last date of occupancy
OTHER: (Describe) —
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
�ystem pyrnped as part. of inspec$ion: (yes or,Ro)-si�'s, #
-f s, v6lbf�e"'�"6r46# ?_�511*6'kn', "" %F `4P
Re7ason for pumping: Ch ea,__ 8),441e,�z __L te-,11 T
TYPE/OFTEM
YS
Septi c tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all c omponents, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) _�4 V
(revised 6/15/95) 5
4
SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM
PART C
SVSTEM INFORMATION (continued)
Property Address: C) POO M 1 A4 A,�Jn6vfi,"
Owner:
Date of Inspection: -1-o
SEPTIC TANK:Y?S
(locate on site plan)
Depth below grade:)-'
Material of construction: ---C/Oncrete metal FRP other(explain)
'A F
1A
DirnensioAsji A -Ter, 4
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: /1,1,
Distance from top of scum to top of outlet tee or baffle: 4
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) r- " A, ja jQ 0,0*, ig �be .2,11 P r. A,, 1,, 1 1- 5A4 "V
AJA -1714 4� 1-19151 -A Evet (A 114 46
A&EAZ -AS 12,16 4 A :4
GREASE TRAP:
(locate on site �lan)
Depth below grade:
Material of construction: —concrete —metal _FRP —other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom oi crurn in bottom of outlet tee or battle:
Comments: A
OU Iff il T� el
commendation fo 63i in'lePaWd" ou
ire' " ^ � pli p in g, �c on' d i t i*'o n u et tees or ba r�s,*depitl� of liq'ui ev in fela�ion'6 4t invert, strLictura
Mdence of leakage, etc.)
integrity, evi
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
1) QVCi4,11 /1/V 0 0-11,
Property Address:
Owner: I/
Date of Inspection:
TIGHT OR HOLDING TANK: —90
(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal —FRP —other(explain)
'A
Dimensions:
Capacity: _gallons
Design flow:_________gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth o f liquid level above outlet invert: j I/ tol
Comments:
(note if leve! and distribul'ccr equa!, evidence of sohd� carryover, evidence of leakage into or out of box, etc.)
4, �o iv f�. f'w 4; P, r f. 0 f e qu 4, 1 P A4
PUMP CHAMBER:
(locate on iite,plan)
umps in working order:(yes or no)
P A
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
mpg
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):—
(locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
if not determined to be present, explain:
Type:
leachin pitst number:
g I
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Comments: (note condition of soil, signs of hydraulic failure, level of pondin condit on of vegetation,etc.)
a 70 o,'
U 12
CESSPOOLS:
(locate on site plan) /r
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 (cesspool.must be pumped as part of inspection)
A.
Comments1note 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.)
(revised 8/15/95) a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Ad . dress: 3& IV e
Owner: 1-/1-0
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
e
!� I)- & /—
P7. - I -A x I A,
4
I
1 ap
39),
4
DEPTH TO GROUNDWATER
Depth to groundwater: J� feet
method of determ,ination or approximation: 14 j0F4,A2,,)-1 &0 14 #_7--eX jj&�p�q-eZ
MN t,A-r-e-V 4115 V, V-tl J 14 43 Aa 4d 1 --&Ii=
(revised 8/15/95) 9
TO:
FROM:
NORTH ANDOVER, MASS Ct 19
BOARD OF HEALTH
DESIGN ENGINEER
Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
Zo lRe'Yly /, 'Z 14 /V/7-- North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
—19—
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