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Miscellaneous - 300 DALE STREET 4/30/2018
r 300 DALE STREET - - -- 210/064.0-0025-0000.0 r i r I Lot & Street ;6p ���- �� Map/Parcel q CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: Approved by: Designer: 1'� Plan Date: Conditions: Water Supply: own Well Well Permi . Driller: Well Tests: Chemical Date Approved Bacteria I Da ved Bacteria II Date Approve Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: - All Permits Paid? YES NO Well Construction Approval? Y S NO Septic System Construction Approval? YES NO Certification? E NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD O H LTH APPROVAL: DATE: lD 69J APPROVED BY: � � � � r pA l'' SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? C�ycngPAIR ES� NO Type of Construction: NEW New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U QE NO Issuance of DWC permit: NO DWC Permit Paid? r, , NO DWC Permit L71 Installer: Qh 0l�C�LD j Begin Inspection: C YES NO Excavation Inspection: Needed: Passed: z-, By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: By: LOS,Final Grading Approval: Date: By: Final Construction Approval: Date: ' By: Certificate of Compliance: Approval: Date: LOZ71,OA- i J � TOWN OF NORTM ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received " Permit NO- Date Issued: IMPORTANT:Applicant must com lete all items on this age LOCATION PROPERTY OWNER Print. MAP NO ( - ric;District yes no pARCEL:�ua ZONING DISTRICT: M shine hop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Two or more family ❑ Industrial [i Addition No.of units: [I Commercial "Iteration ❑ Others: Q Repair, replacement ❑Assessory Bldg ❑ Other ll - Demolition _ s - = -t {fir ® WatershedIIDistrict ,�' - Zmm�' ' ' odplam ❑W�tlands ,=a �,;� z3: z iL ®fSeptic IT 1�Flo Nell ^C � rt ' PS {9* #` • f - '- - ---- r yus�- v. .vt_5..: �4•._ __ �'--__-�3!tit ®Water/ DESCRIPTION OF WORK TO BE PERFORMED: `ntirc Ple Ne Typ�rl� int CIearly) l ' Phone: l OWNER: Name: �'' G Address: Phone:--NT - Address: — i ?` Ex Date: Supervisor's Construction License: p• 71 Home Improvement License: Date: ARCHITECT/ENGINEER _ - Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$925,00 PER S.F. Total Project Cost:. $ T �� <L FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund r F ug- - - - ;Sinatu�e�ofcontra ___ ent/O_,wne Si natiite�:of�AgL-_.._ 9_-- ��---- ---- <-- Plans Submitted ❑- Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ FE F SEWERAGE DISPOSAL wer ❑ Tauning/MassageBody Art ❑ Swkw1ingPools ❑ ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ eptic tank,etc. ❑ PermanentDumpster on.Site ❑ - I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNI DEV LOPMENT ❑ ❑ CO E TS v CONSERVATION Reviewed on c7— Si nature i x r COMMENTS U0 HE �- a ALTH Reviewed on x � �� Signature COMMENTS ,,.,. ZoningBoard of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water&Sewer Connection/Signature&Dafe Driveway Permit DPW Towim Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main.Street Fixe Department signature/date C0A4VP.7\rc Dimension Number of Stories:_Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, inast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL.Chapter 166 section 21A—F and G min.$10041000 fine ; NOTES and DATA-- For department use Ll Notified for pickup -- Date Doc:.Building Permit Revised 2008 # 9 Gf 10R7:,� 4 9 f \J G _ 9 Town of North Andover ` '•,,,,,.: HEALTH DEPARTMENT ,S31CHUS /J CHECK#: y,�D/ E: LOCATION: H/O NAME: r CONTRACT NAME: � G /7 Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ N ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ { ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ r ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ `r ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ I, ❑ Septic Disposal Works Construction(DWC) $ i ❑ Septic Disposal Works Installers(DWI) $ ❑ Ti 5 Inspector $ 8 Title 5 Report $ y ❑ Other:(Indicate) $ n E t g Health Agent Initials ' White-Applicant Yellow-Health Pink-Treasurer i a � t < Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 300 Dale Street Property Address . Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information on the computer, �p{ y - only the tab key to move your 1. Inspector: R , F V key I. cursor-do not F. Paul Cardone use the return key. Name of Inspector Septic Compliance, Inc. Company Name TOW 447 Boston Street HEALTH DEPARTMENT Company Address Topsfield Ma. 01983 City/Town State Zip Code 978-681-0726 978-407-1808 3294 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further v io by ocal Approving Authority is Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform e orm in the future under Y p the same or different conditions of use. 300 dale st no.andover 7-17-2010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town 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: ® 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: According to neighbor house has been vacant for 3 weeks prior to inspection. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 300 dale st no.andover 7-17-2010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 300 Dale Street M Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. CityFrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 300 dale st no.andover 7-17-2010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 300 dale st no.andover 7-17-2010-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area— IWPA) or a mapped Zone 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 answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 300 dale st no.andover 7-17-2010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is North Andover Ma. 01845 7-17-2010 required for every - page. City/Town 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 ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 300 dale st no.andover 7-17-2010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 300 Dale Street M Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection l D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d enclosed 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: end of june2010 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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 300 dale st no.andover 7-17-2010•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 300 Dale Street Property Address P Y Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Last pump record on file2-1-2002 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Pump truck tube Reason for pumping: overdue for routine pump,check interior of tank. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Constuction permit#1270 Dated 8-9-2002 assigned to John Shaw Were sewage odors detected when arriving at the site? ❑ Yes ® No 300 dale st no.andover 7-17-2010•08/06 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 13"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): All in good shape Septic Tank (locate on site plan): 4.. Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10'6"x5'8"x4' Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 3" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Septic Dip-Stick and Tape 300 dale st no.andover 7-17-2010•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 �1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): We recommend tank be pumped on a yearly basis,Tee's in good condition,Structural integrity appeared to be good,level good,no evidence of leakage in or out of tank. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 300 dale st no.andover 7-17-2010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: N/A Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Good and even 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.): Box was level,3 outlet pipes with levelers going to trenches distribution was equal, ran water through box for 25minutes started 6:05 PM through 6:30 PM all lines took flow with no problem, no apparent leakage in or out of box, no solids carryover. Reason for running so much water through housevacant Pump Chamber(locate on site plan).- Pumps lan):Pumps in working order: ❑ Yes ® No Alarms in working order: ❑ Yes ❑ No 300 dale st no.andover 7-17-2010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Dale Street M Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 3 trenches each ® leaching trenches number, length: 56'long168'total ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): good none none no grassy back yard area. 300 dale st no.andover 7-17-2010•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 300 dale st no.andover 7-17-2010•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts o Title 5 Official Inspection Form =' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p.M Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. 13c Z tt, 4 P Y y t5insp(2)•08/06 - .moi t )isposal SystemPage 14 of i i y� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 300 Dale Street M Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. 300 dale st no.andover 7-17-2010.08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 300 Dale Street Property Address Lenders Processing Services-1 West Bank Owner Owner's Name information is required for every North Andover Ma. 01845 7-17-2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ®. Check cellar ❑ Shallow wells Estimated depth to ground water: 27 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5-1-2002 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Current soil logs on file,basement was dry,no sump,system is relatively new.Seperation variance from 4'to 3' to water table, mounded up system. 300 dale st no.andover 7-17-2010•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 SEPTIC &DRAIN BORACZEKSERVICE • THE PROFESSIONAL EXPERTS IN THE SEPT11,'f` & DRAIN INDUSTRY • PLEASE PAY FROM THIS BILL- Customer Name: 7 CHISHOLM ROAD Service Location: KINGSTON, NH 03848 (603)329-6005- (978)374-8803 Phone: (978)921-5353-(978)465-2121 -(603)772-2759 www.boraczekseptic.com Contact: 4__ RESIDENTIAL / COMMERCIAL Billing Address: ? x IV. SERVICING THE ENTIRE NORTH SHOF City: Zip: • CERTIFIED TITLE V INSPECTORS SAME DAY EMERGENCY SERVICE Date of Service: Nature of Service Special Instructions 0 Completed /0 Reg. Maint. 0 Incomplete Reason: 0 Reg. 0 Emergency Per: 0 Schedule: 0 N/C -Day ONight AMS)PM Services Rendered 0 Car Wash Vacuum Pumping 0 Dump Charges Observations Drain Cleaning ErSeptic Tank minimum 5 tons of sand 0 Drywell $ /ton+9%fuel mood Condition 0 Main Line 0 Leach Pit/Overflow surcharge.Any amount over 0 Leach field Runback 0 Toilet Bowl 0 D-Box 5 tons will be billed. 0 Riding High 0 Kitchen Sink 0 Pump Chamber (liquid level) 0 Bathtub/Shower 0 Grease Trap 0 Yearly Profile Fee$i_ 0 Full to Cover 0 Vanity 0 Catch Basin 0 Excessive Solids 0 Floor Drain 0 Portable Toilet0 Boraczek Charges Top/Bottom 0 Yard Drain 0 Other ❑ 4 hour minimum 0 Use No Powdered Soap 0 Vent Qty: 1 hour travel 0 Heavy Grease 0 Water Jetting Size: 0 Roots 0 Other 0 Suggest Electric Rootering 0 Footage: 0 Under 1000 gallons E11000gallons 01500gallons 0 Van Called 02000gallons 113000gallons 04000gallons 0 Other 05000gallons 06000gallons Oother Miscellaneous 0 Digging Charge 0 Backhoe 0 Inspection 0 Location ft./in. 0 Kubota hrs. El Title V Inspection 0 Service Call 0 Consultation Reason: 0 Labor 0 Estimate 0 Pump Repair 0 Waiting Time 0 System Installation 0 Repair 0 Portable Toilet Rental 0 System Treatment -Digging Charge Is Per Driver's Discretion 0 Baffle El Rejuvenation Description of Work J Recommendations Terms of Payment: C.O.D. PARTS Vacuum Pumping Drain Cleaning Payment- KF 3e.aired Upon Service 15-cash TAX -Yr. Month Yr. Month 0 Check0 Credit Terms & Conditions DISCOUNT 1.Not responsible for damage beyond the curb,khe 3.1.5%per month will be charged to accounts past due. 2.All complaints shall be reported within 48..hburs..,' 4.The purchaser agrees to pay all cost of collection. TOTAL-, I the undersigned agree to all term and copelffions6/ Customer Signatu\re ,, Serviceman Jul 14 `10 02: 28p DPW 9786889573 p. 1 • Summary Record Card generated on 71142010 12.01:03 PM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-064.0-0025-0000.0 Parcel Id 12430 300 DALE STREET US BANK NATIONAL ASSOCIATION TRUSTEE FOR THE LXS 2005-9N 888 EAST WALNUT STREET PASADENA, CA 91101 Class 101 Single Family Property Type 1 Residential Size Total 4,6 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until US BANK NATIONAL ASSOCIATION Owner TRUSTEE FOR THE LXS 2005-9N 888 EAST WALNUT STREET PASADENA,CA 91101 COLON,ELVIN R&MARIA Previous Customer Inactive 5/612010 300 DALE STREET NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18346.0-300 DALE STREET Last Billing Date 7/712010 3180427 03 Cycle 03 Active UB Services Maint. Account No.3180427 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 131.50 /1 UB Meter Maintenance Account No.3180427 Serial No Status Location Brand Type Size YTD Cons 16336942 a Active 00 METE METE w Water 0.63 0.63 251 Date Reading Code Consumption Posted Date Variance 6/11/2010 831 a Actual 30 7115/2010 0% 3117/2010 801 a Actual 32 4/14/2010 13% 12115/2009 769 a Actual 28 1112/2010 -3% 9/15/2009 741 a Actual 30 10/15/2009 3% 6112/2009 711 a Actual 26 7/20/2009 6% 3/19/2009 685 a Actual 27 4/29/2009 1% 12/15/2008 658 a Actual 26 1/20/2009 2% 9115/2008 632 a Actual 27 10/10/2008 0% 6/11/2008 605 a Actual 25 7/16/2008 -9% 3/1412008 580 a Actual 27 4/11/2008 6% 12/18/2007 553 a Actual 27 1/22/2008 -20% 9/17/2007 526 a Actual 32 10112/2007 20% 6/22/2007 494 a Actual 29 7/20/2007 -4% 3/19/2007 465 m Manual estimate 30 4/16/2007 -9% 12/15/2006 435 a Actual 30 1/1912007 21% 9/20/2006 405 a Actual 26 10/20/2006 10% 6/22/2006 379 a Actual 24 7/10/2006 4% 3/23/2006 355 a Actual 20 4/17/2006 0% 1/3/2006 335 a Actual 25 1117/2006 -5% 9/26/2005 310 a Actual 27 10/14/2005 3% 6/16/2005 283 a Actual 20 7/1512005 5% I Location: owner's Name: F26 trj �!✓'r`� ��►" ;� ` Map/Parcel:-- "1'1�1��� _�j,7iS Address: 151ew t2A l-'E � A ���� Installer: Tel*i New(stse)• Repair t' Date: S'• 'dZ► Wetlands 7 ,one II Soil Symbol S611 RitaieSoil Class„ Deep Observation Hole Logs Elevation Depth Soil Horizon Soil Terre Soll.bolor Soil Mottling. % Gravel,Stones,etc: , -7- 9YWee V, i' V Parent Matelot 1^ Depth to Bedrock:' Standing Water in the Hole: ~"' Weeping front Pit Face 1 7 ESHG%V. Z��t �.. I O tz�3 tel_• iz•�,.,u c� t V f� grlV" 4FJ 1(,f�JLI 7, Y}y_�// ~w �.✓ �V L • Parent Matertat 'f I L11- Depth to Bedrock=Standtnt Nater 1n the Hair. %Veeptnp from Pit Face LSHGIY: ?7'! Date , percolation Tests Observation Hole# - Depth of Perc Start Pre-soak 11 leg Time at 12" !W Time at 9" ; Time at 6" { Time(90'-611) -Rate bun/Inch 1 Performed lgy: 921 [2i(!J (S —Witnessed Br: � � r . s . Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH eto pORTH pt S .• p DISPOSAL WORKS CONSTRUCTION PERMIT Bg�cNW TELEPHONE Applicant ADDRESS NAME Site Location Q Permission Soil is hereby granted to Construct ( } or Repair (G� / ' Sewage Disposal System as shown on the Design Approval S.S. No. � AIR AN,BO RD OF HEALT r D.W.C. No. Fee Town of North Andover NORTH Office of the Health Department Community Development and Services Division 27 Charles Street *� # North Andover, Massachusetts 01845 4ss"`HU Sandra Starr Telephone(978)688-9540 Fax(978)688-9542 Health Director TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 10/17/2002 This is to certify that the individual components 0, entire(X) subsurface disposal system constructed O, repaired (X), or upgraded() by John Shaw at 300 Dale Street has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5), North Andover Board of Health septic system regulations, and the design plan approval #1191 dated July 25, 2002. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 AS-BUILT CHECKLIST - ' GOY 1 6 2002 / LOT NUMBER, STREET NAME ASSESSORS MAP& PARCEL NUMBER I LOT LINES& LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM, TIES TO LOT LINES&DWELLING, VIA- a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES& PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION A)4 LOCATIONS OF WELLS,,DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER,GAS,ELECTRIC LINES,CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF j TANK&D-BOX ORIGINAL STAMP& SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW `� LOCATION&ELEVATIONS OF BENCHMARK USED TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The u dersigned hereby certify that the Sewage Disposal System ( ) constructed; ( repaired: I by located at 1200 („E was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # , dated with an approved design flow of444t*2 gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted tt d to the Board of Health. Bed inspection date: Engineer Represetative Final inspection date: Engineer Represents ive Installer: Lic.#: Date: za/ o02 Design Engineer: Date: . /p pZi ' I L 1CAi I0fel: NJWI r --- O- .r Ul 3 T IINiE E N- \- liv icA V I .'l.'P`, Y� �`� m �� � ��f /� �� �. �� i i, ` /i �/ ~ i INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO Initial A. Bottom of Bed 1. Excavation to proper depth f 2. With trenches,sides of excavation are beneath B horizon �36/� 3. Edge of excavation specified distance from foundation,etc. _V", Comments: i B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed j 3. Wall minimum 10'to leaching facility Al / 4. Wall meets specifications of plan IV Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints _ 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8"per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade �"- 9. Manholes at any 90°change 10. 10'minimum offset to water line Comments: D. Septic Tank 1. Level 2. 1 500al minimum g i/ 3. Gas baffle present on outlet �- 4. Manhole to grade S. Manholes over center and each tee 6. 3-20"manholes 7. Inlgt tee minimum 12"under invert -� 8. Outlet tee minimum 14"under invert 9. Outlet line cemented 10. Air space 3"above tees 11. 2"-3"drop from inlet to outlet 12. Pipe set �- 13. Compact base with 6"of 3/e"crushed stone under tank 14. Tank is watertight Comments: I i Yes NO E. Pump Chamber 1. If separate from tank,compact base with 6"of/d'stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole 4. Tank level / 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box . 1. D-box level 2. Minimum 0.1 T'(2")drop from inlet to outlet 3. Minimum 6"sump _L_ 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe _ Comments: G. Soil Absorption system 1. All stone double-washed-%"- 1 ''/z" -pea stone Bucket test done? off& 2. Minimum 2"of pea stone above distribution lines 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not,then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan-Minimum 2';maximum-4'. 4. Vent present if<50 feet or specified 5. Distance between trenches minimum 4' and maximum of 6' 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6"per 100' 8. Depth of trenches below outlet invert minimum of 6". V/ Yes NO 9. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' 3. Separation between pipe 6'maximum 4. Pipes connected at end 5. Separation between adjacent fields 10'minimum 6. Pipes set on stable base 7. Maximum 4'separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: I Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"wide 4. Access manholes on each pit r 5. Pipes cemented with hydraulic cement Comments: ' K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All Y system components covered b at least 9 soil Y r 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 7 � Doi CURRENT INSTALLER'S LICENSE# LOCATION: 300 LICENSED INSTALLER:_. � SIGNATURE. TELEPHONE# 9 7 0 S/5 7 W CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 160.00 Fee Attached? Yes No Project Manager Ob. Yes��- No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: �;7 Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH 2 NORTH 1 OL L s _� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACNUSE'( Applicant ��^ DDR ESS TELtrrtONE pp NAME ' Site Location or air an Individual Soil Absorption Re Permission is hereby granted to Construct ( ) p ( / Sewage,Disposal System as shown on the Design Approval S.S. No. HAIR AN,BO RD OF HEALT r D.W.C. No. /a 7(D Fee Town of North Andover, Massachusetts F°""N • f NORrh BOARD OF HEALTH o w ._.�. . DESIGN APPROVAL FOR bZ— • 'SS4CHU ` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant Test No. pp ' Site Location eference Plans anpecs. "� R d SENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed • in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. UY-1 i MERR MACK ENGINEERING (SERV CES INC. L�� lJ 4CG OO Cry' ° GJ�G��44C°�C� Engineers • Surveyors • Planners 66 Park Street ANDOVER, MASSACHUSETTS 01810 DATE r 1 jos No. —off (978) 475-3555 ATTENTION Fax (978) 475-1448 �` TO RE: �C2 o WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via the following items: ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION y ' BOARD I, I CP LUU4S THESE ARE TRANSMITTED as checked below: drapproval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ O FORBIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS 4� 00 with A 211 OeTl ift ► sWIRR W,212" �o MAS 1!�2_ (7r 'fH CV_6F0r� ot- �2' - �2 VTC COPY TO j SIGNED: 0—a-CID �v If enclosures are not as noted,kindly notify us at once. SEPTIC PLAN SUBMITTAL FORM LOCATION: NEW PLANS: YES $160.00/Plan REVISED PLANS: ('YES/ $ 60.00/Plan'o SITE EVALUATION FORMS INCLUDED: YESVi �`i' �►'�� DATE: DESIGN ENGINEER: F� lJI'Lkl F-f �1J�o If•S�` lG!(2'-0 DATE TO CONSULTANT: When the submission is all in place, route to the Health Secretary. 27 Charles Street North Andover,MA 01845 Telephone#(978)688-9540 North • • _ Fw*(978)688-9542 Board of To: �J�,`7// / � t From: Fax: TI/- Pages: Phone: Date: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle • Comments: 1 1 Town of North Andover, Massachusetts -` Form No•.a Monne BOARD O.F,;HEALTH. v :O'� •o o .�.0 tP. z t• t " c • _ , •b, e;,..�a` .DESIGN APPROVAL FOR. ass"�""5`t� SOIL ABSORPTION SEWAGE•DISPOSAL SYSTEM Applicant- ` '/ �1•;Y } USj Test No 1 Site Location ��' .9L % 4. t. r �{• 4 ,}'• Reference Plans and Specs L /gro N i ENGINEER E'r;' �,� pAT Permission Is rantetl;for an indrndual soil`,absor"tion Sewa a dls osal s stem to:be Installed' g p g. p... Y.. In accordance with regulatl6n§v6. Board of Health wa F CHAIRMAN BOARD OF HEALTH' � �. 9 Ff Fee µ r SI'te SYstem.Permlt No ', r s Town of North Andover NORTH O t��ao ie 1ti Office of the Health Department Community Development and Services Division 27 Charles Street North Andover,Massachusetts 01845 CHU Sandra Starr Telephone(978)688-9540 Public Health Director Fax(978)688-9542 Bill Dufresne July 16, 2002 Merrimack Engineering i P e 66 ark Street Andover, MA 01810 Dear Mr. Dufresne: Please be advised that the proposed plan dated 6/5/2002 for the repair of the septic sstem at 300 Dale Street has technical deficiencies that must be addressed before the plan can be approved. They are as follows: There appears to be no basis for allowing a reduction in the separation distance to ground water. There exists sufficient elevation change to comply with the four foot offset to the estimated seasonal high groundwater. In addition the LUA does not support the need for a variance. Test pit #1 should be revised to reflect 27"to the water table. Identify wetlands within 150' of the system. (NA 8.02) Missing identification of the water line as either pressure or suction. • Missing requirement stating that tees in the septic tank can be no further than 12"from the centerline wall. • Missing buoyancy calculations for the septic tank. • Minimum 10' separation between trenches in fill is not met. The minimum design flow in North Andover is 440 gpd. Anything less requires a variance and a deed restriction. If a variance is sought and granted, this should be noted on the plan with the statement that a deed restriction will be required prior to issuance of the Certificate of Compliance. • Adjust bottom of trench to highest grade for water table offset on line 1. • All variance requests must be listed on the plan. Please remember that all re-submittals require a$60 fee. Feel free to call if you have questions about the content of this letter. Sincerely, ��L1J1/L� Sandra Starr, Health Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNINTG 688-9535 JUL-17-2002 WED 09:40 AM FAX NO. P. 01 12 New England ExewUve Park Sutlingm,MA 01803 DOT] FAA New ANE•14,(781)238-7259 England Region To: Sandra Starr From: Patti J.Torrisi Fax: 976-688-9542 P890= 1 Phone: 978-688-9540 Date: 7/17/02 Re: 300 Dale Street CC: Dear Mrs. Starr, Thank you For taking the time to return my call last week. l am the person you left a message with regarding the 300 Dale Street property. I am sorry to burden you with yet another message, but I'm hoping for some guidance as it relates to the process. This is actually my mother's home and we have moved her into an apartment. We also have a buyer for the house who is scheduled to close on.July 3e, pending approvals of the new septic system. The buyer has been very understanding and l want to be as fair as I can with them. If we have an unrealistic time frame for approval, I would like to let my realtor know so that we can explore an extension with the buyer and their bank. I realize that these are my details to contend with, but I would value any input that you may have. Thank you for your time and patience. Patti Torrisi } SEPTIC PLAN SUBMITTAL FORM LOCA ION: 12" ��ritefn- -'NEW PLANS: S 0.• /Plan eel, REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: NO DATE: c--4o --0-7, DESIGN ENGINEER: i-1 �INI p� r1C�I hPC� � jGt ��C DATE TO CONSULTANT: When the submission is all in place, route to the Health Secretary. i t i Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non-conforming system with a design flow of<10,000 gpd,where full compliance, as defined in 310•CMR 15.404(1),is not feasible. To be submitted to DEP: For the upgrade of a failed or non-conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: ri, vt 4th"i --rKLIS-r Flo P.Aq--r'e �&,ft4z+ssi. Address: ALvtouev-- al s$5 Phone#: � Address of facility: VK-td 9?V. 2) Applicant (if different from above) Name: Address: Phone#: 3) Type of Facility: Residential Commercial School Institutional (Specify) AN Page 2 of 5 4) Type of Existing System: _privy cesspool(s) ✓ conventional system other(describe) Type of soil absorption system(trenches,chambers, pits, etc.) AI�gW=4ZI'I-O 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system U Q 15�Q• gpd Approved: _yes Approval date: �j�. no Why: b) Design flow of proposed upgraded system Ik gpd Why ��rFiA7j- c) Design flow of facility_j3g?_gpd 6) Proposed}rpgrade of existing system is: a) Voluntary required by order, letter,etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b Describe theproposed upgrade to the system:m: C®trNcU r�Cl, 5Y5T�� K&O 6A-t,- 0/4vr r-fes FZa;e,.1 �o c) Which of the following are applicable to the proposed upgrade? ffA Reduction of setback(s)(list setbacks to be reduced with proposed setback distances) A,A _Percolation rate of 30-60 minutes per inch(state actual perc rate) iQ Up to 25% reduction in subsurface disposal area design requirements (state required&proposed size) Relocation of water supply well(identify well,describe relocation) Reduction of required separation between bottom of SAS & high` groundwater(specify proposed reduction& perc rate) 4' 40 V ( l7 alb,( I) Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404& 15.405,or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) 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 ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: a Distance from soil absorption system to high groundwater 17 feet As determined by: Evaluator's name: �-74A)fes- .�qWn-P-- Evaluator's Signature: Date of evaluation: 57 I --oz. 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date,time and place where the upgrade approval will be discussed. If the department is the approving authority,then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: MA. b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. c) A shared system is not feasible. d) Connection to a sewer is not feasible. 10)An application for a disposal system construction permit, including all required attachments (e.g. plans& specifications,site evaluation forms), must accompany this application. Is the DSCP application attached? yes no Page 5 of 5 11)Certification "I, 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 t , nalties or fine an or imprisonment for knowing violations." Facility Owne s ignature Date Tu r---I d P-r Tr o ss Print Name L L� r-- C�Ff6l Name of Preparer Date Telephone No. &Address of Preparer NOTE: Title 5,310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. Town of North Andover NORTI� Office of the Health Department 0 �p Community Development and Services Division 27 Charles Street North Andover,Massachusetts 01845 Sandra Starr Telephone(978)688-9540 Public Health Director Fax(978)688-9542 Bill Dufresne July 16, 2002 Merrimack Engineering 66 Park Street Andover,MA 01810 �p� Dear Mr. Dufresne: Please be advised that the proposed plan dated 6/5/2002 for the repair of the septic system at 300 Dale Street has technical deficiencies that must be addressed before the plan can be approved. They are as follows: • There appears to be no basis for allowing a reduction in,the separation distance to ground water. There exists sufficient elevation change to comply with the four foot offset to the estimated seasonal high groundwater. In addition the LUA does not support the need for a variance. • Test pit#1 should be revised to reflect 27"to the water table. • Identify wetlands within 150' of the system. (NA 8.02) • Missing identification of the water line as either pressure or suction. • Missing requirement stating that tees in the septic tank can be no further than 12" from the centerline wall. • Missing buoyancy calculations for the septic tank. • Minimum 10' separation between trenches in fill is not met. • The minimum design flow in North Andover is 440 gpd. Anything less requires a variance and a deed restriction. If a variance is sought and granted, this should be noted on the plan with the statement that a deed restriction will be required prior to issuance of the Certificate of Compliance. • Adjust bottom of trench to highest grade for water table offset on line 1. • All variance requests must be listed on the plan. Please remember that all re-submittals require a$60 fee. Feel free to call if you have questions about the content of this letter. Sincerely Sandra Starr, Health Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 t �"`, !'o.�� NOONAN & Mc DOWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice (978) 667-9736 Fax (978) 671-9565 Email: nnigconversent.net l I June 26,2002 XL._ ., Town of North Andover Office of the Health Department ' Community Development and Services Division 27 Charles Street ! North Andover,MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770/070A 300 Dale Street Assessors Map 64, Lot 25 Dear Members of the Board, Please be advised that Noonan&McDowell,Inc. has reviewed the plan dated: May 28,2002, by :Merrimack Engineering Services. It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health`By-Laws" if the following is addressed: 1) There appears to be no basis for allowing a reduction to water table offset. There exists sufficient elevation change to comply with the four foot offset to estimated seasonal high water table. 2) Revise test pit T-1 to reflect 27 inches to water table. 3) Identify water line as either pressure or suction. 4) Identify wetlands within 150-ft. NA 8.02 5) Identify septic tank tees to be no farther than 12-in from centerline wall. 6) Provide buoyancy calculations for septic tank. 221(8) 7) Adjust bottom of trench to highest grade for water table offset on line 1. 8) Trenches in fill require a 10-ft separation. NA 14.01 9) Minimum design flow 440 gallons without deed restriction. NA 13.01 Respectfully, John L.Noonan,P.L.S.-P.E. F lOffice/boh/1770070A.do c Land Surveyors Civil Engineers Environmental Planners NOONAN &MC- DOWELL, INC. 25 Bridge Street, Suite 6, Billerica; AIA 01821-1023 Voice (978) 667-9736 Fax (978) 671-9565 j Email: nm@netway.com Date dd A) l Town of North Andover { Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770/ d'7041 30 1-7 Qli - J-- Assessors Map 'f ,Lot Z j Dear Members of the Board, Please be advised that Noonan &McDowell, Inc. has reviewed the plan dated /�,5P 2 Z ? Z It is our opinion that the proposed design will meet the requirements of Title 5 and the North dover Board of Health `By-Laws" if the following is addressed: i �� ®�- S ✓c:7rP�ti S` T� < �Ly�-;�«�� •�lG eT T� T' - J= i Q ��� � — 7-4;;' z - 7-r -t-,'-z7-Z> Respectfully, John L. Noonan, P.L.S.-P.E. G:office/forms/tonarev �Q7 r -All 7 j Land Surveyors Civil Engineers Environmental Planners � �� /�,© / I CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS N&M Job 1770/ � ��/'� The following is a checklist that incorporates all Title 5 and local regulations for septic plans. Name of Applicant:ol � iZ G 7% � -;Wme of Designer: Plan Date-JtW IX Z 9,2�r't Revision Date: Date of Review: 7 G Z— Map: V/ Lot:Pro Property yAddress: +� BOH Reviewer. !/ Type of Plan(new orgra Number of Bedrooms in Assessor's Records: gpd)Garbage Disposal Allowed: General Information: N.A.=-North Andover Septic Regulations Other numbers refer to Title 5 OK Problem N/A f� Street number and map/lot-220(4)(u) •Y� Maximum scale of 1"'=40'for plot plan-220(4) Maximum scale of 1 =20'for profile and component details-220(4) Legal boundaries of the facility being served-220(4)(a) Names of abutters from recent tax map- NA 8.02j �— Number of bedrooms, - lesign calcs., NA 8.02i Name&address of record owner&applicant- NA 8.02k Q---- Name&address of designer-NA 8.021 Holder and location of all easements-220(4)(b) ✓ Date plan drawn&any revision date- NA 8.02m All dwellings and buildings,existing and proposed-220(4)(c) v— Location of all existing or proposed impervious areas-220(4)(d) ✓�— All distances on site plan—NA 8.03a-c Elevation of proposed driveway-NA 8.02t -- Location and elevation of foundation drain-NA 8.02y Location and dimensions of the system incl.reserve(new const.)-220(4)(e) Limits of excavation of leach area on site plan-NA 8.02z Locus plan-220(4)(t) (Not to scale) North arrow-220(4)(g) Existing and proposed contours-220(4)(g) ' Locations and logs of deep holes-220(4)(h) Locations and logs of percolation tests-220(4)(i) Date(s)of soil testing-220(4)(h)&(i) Existing grade elevation of each deep hole-220(4)(h) Elevation of percolation tests—N.A. 8.02n Name of approving authority representative-220(4)(h)&(i) Name of soil evaluator-220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines,drains,and subsurface utilities-220(4)(m) ✓� Observed and adjusted g.w.elevation in the vicinity of the system-220(4)(n) - Complete profile of the system to scale-220(4)(o),NA 8.02c Cross section of leaching facility-NA 8.02w (Not to scale) Location of benchmark(s) within 50-75 feet of facility-220(4)(q) Note listing all variance requests with proper citations-220(4)(p) Local upgrade approval request form submitted-403(1) Original R.S./P.E. stamp,signature&date-220(1)&(2) If P.E.,discipline specified within stamp. MGL C. 112 s. 81M sfc. supplies(w/in 400'),pub. wells(w/in 250'),pvt. wells(w/in 150')-220(4)( Location of watercourses,wetlands,wells,etc. Win 150'of system—NA 8.02r Wetland disclaimer—NA 8.02s �l RLS plan reference&certification required(prop line setbacks)-220(3) 7 Use approvals/standards checked for I/A system-DEP docs., r 2 c--- Perc rate>30 MPI-not allowed for new,LUA for upgrade-245(1)&('3) Perc rate>,60 MPI-must use modified tight tank or IIA technology-245(4) Proposed system qualifies as "shared"system-002(definitions) �— Flow is over 2,000 gpd-No R.S.allowed-220(1) Design flow was set in accordance with code-203 z Existing system location and note on proper abandonment-354 ✓ Leaching facility at least 1' above Base Flood elevation–NA 9.05 f All piping Sch 40 minimum–NA 10.01 Basement floor minimum 1' above groundwater elevation–NA 5.04 Foundation drain present with.elevation–NA 8.02y On-site Soil and Groundwater Review OK Problem N/A ,.� Proper deep observation hole logs on plan-220(4)(h) All deep holes and peres shown,including aborted tests–NA 8.02n Soil evaluation forms submitted within 60 days of field work-018(2) •�' Proper percolation test log-220(4)(i) Ample deep observation holes in primary disposal area(minimum 2)- 102(2) Ample deep observation holes in secondary disposal area(minimum 2)- 102(2) Ample perc testing(one in each disposal area,3 in prim.>2,000 gpd)- 104(4) Deep hole testing conducted within two years–NA 7.05 Hole Identification Numbers: ground elevation el. acceptable soil el. Leach facilitv invert el. ground water el. refusal el. bottom of leach facility el. thickness of acceptable soil before&after soil R&R separation to groundwater separation to refusal soil class perc rate / loading rate septic tank below g.w.table / (yes or no) pump tank below g.w.table (yes or no) l.f in fill �_ -255(l) Setback Distances(Given in feet) 15.21 1 YES NO Is the lot in the Lake Cochiewick Watershed? NA 6.00&5.02 OK Problem N/A Septic Tank Leach Facility ®� Property line 10 10 Cellar wall 10 20 2 3 Inground pool 10 20 Slab foundation 10 10 Deck,on footings,etc. 5 10 Waterline 10 10 Private drinking well 75 100 4 Irrigation well 75 100 Wetlands 75 100 Public well 400 400 Wetlands bordering surface 150 150 water Supply or trib. (in Watershed) Trib.To Surface Water supply 325 325 Reservoirs 400 400 �^ Tributaries to reservoirs 200 200 Drains(wat. supply/trib.) 50 100 Drains(intercept g.w.) 25 50 _ Foundation drains 10 20 Drains(Other) 5 10 �--- Drywells 20 25 Downhill slope 15'to 3:1 slope w/o barrier i Building Sewer OK Problem N/A Grease trap required for certain uses(check 230 for details) _ Pipe diameter listed(4"minimum)-222(1) �G Pipe schedule listed-222(3) Pipe cast iron or Sch 40 PVC—NA 11.02 Watertight joints specified-222(3)&(4) Pipe laid on compact,fin base-222(5) Pipe laid on continuous grade in straight line-222(7)@ �j Cleanouts precede all changes in alignment and grade-222(8) Cleanout provided every 100 feet-222(8) Manhole at any 90 degree alignment change-222(8) jInvert elevation at building: ^� Invert elevation at septic tank: Length of run: t/ Slope: (minimum of 0.01 -0.02 desired)-222(6) 10'offset to private well or suction line-222(2) 3 4 Septic Tank Oma_Problem N/A Tank is accessible-228(3) No structures above tank—(228(3) Tank can accommodate both primary&reserve—NA 9.04 200%of flow(required&provided given. 1500 min.)-220(4)(f)&223)(1)(a) ✓ 2-3"drop from inlet to outlet-227(5) Minimum of 4'liquid depth-223(2) 3"air space above tees/baffles(minimum)-227(4) ✓ 9"air space above flow line(minimum)-227(4) Tees are not to be replaced by baffles-227(1) Tees extend 6" above flow line-227(1) Inlet tee extends 10"below flow line(minimum)-227(6) Outlet tee extends 14"below flow line(more for deeper tanks)-227(6) Gas baffle installed on outlet-227(4) Access manhole cover above center of tank&each tee(except 2 compart)228(2) 3-20"manholes-228(2) 1 childproof,24"riser/manhole w/in 6"of final grade if<1000gpd-228(2) Inlet and outlet tees on center line-227(1) Soil compaction.below tank specified(if soil is non-native)-221(2) 6"of<=3/4"stone beneath tank specified-221(2)&22 8(1) If> 1,000 gpd AND not a single fam.dwell. must be 2 tks or 2 comp. -223(1)(b) If plan specifies disposal must be 2 tanks in series or 2 compart.tank-223(1)(c) Buoyancy calcs.required if tank at or below water table-221(8) Tank is watertight-221 (1) 9"of cover over tank(minimum)-228(1) H- 10 loading(min.)-H-20 if traffic-226(3) s Top of tank<=36"below grade-221(7) iL All pumping to tank(if applies)in accordance with-229 Tank is set to keep old system in service during install if possible Distribution Box(Check here if not present: OK Problem N/A Inlet elevation: Outlet elevation: 0.17'drop from inlet to outlet(minimum)-232(3)(b) 6" sump(minimum)-232(3)(e) All outlets-at same elevation-232(3)(b) Outlet pipes laid level for first 2 ft.-232(3)(c) Pipe Sch 40-NA 10.01 Number of outlets: Number of laterals: Size of outlets: Inlet baffle/tee min. 1"over outlet invert for all d-boxes-232(3)(a), Soil compaction below distribution box specified(if soil is non-native)-221(2) 6"of stone beneath distribution box specified-221(2) Box is watertight-221 (1) Top of box<=36"below grade-221(7) f Buoyancy calculations required if box is at or below water table-221(8) PumpChamber(Check here if not present: ) OK Problem N/AA . Volume specified: 220(4)(r) Pump on elevation- 220(4)(r) Pump off elevation: 220(4)(r) Alarm on elevation: 220(4)(r) Number of c r day-220(4)(r)(also 254(1)(d)if gravity from d-box) delivery line to d-box if gravity-254(1)(c) 4 5 Pressure dosed l.f.if flow>=2,000 gpd-254(1)(a)&254(2)(a) Cycles per day is consistent with chamber volume-23 1 Volume calculations include flowback volume-2') 1(2) 24 hour storage capacity above pump on elevation-231(2) Number of pumps: 2 if system serves>2 dwelling units-231(6) Capacity of pump(s)- m @ 'TDH-220(4)(r) Pump can pass 1 1/4 "solids nimum)-231(7) Pump controls specified- 0(4)(r) Alarm equipment spec' ed-231(2) Alarm is in buildin and powered on separate circuitfr pump-2') 1(9) Pump sequence rrect(off-lead on-lag on-alan-n -231(8) Pump perfo nce curves included-220(4)(r Manual o ating switch-NA 12.01 Check ve,bleeder hole-NA 12.01 1 ch' proof,24"riser/manhole to al grade-2'31(5), S compaction beneath pum amber specified(if soil is non-native)-221(2) "of<=3/4"stone beneath br. specified-221(2)&228(1), oyancy calculations' chamber is at or below water table-221(8)@ 9"of cover over ch ber(minimum)-228(1) H- 10 loading( n.)-H-20 if traffic-226(')), Chamber is watertight-221 (1) Top of chamber<=36"below grade-221(7) Leaching Facility(general-complete for all designs) OK Problem. N/A 50%larger if garbage disposal-240(4) Trenches to be used whenever possible-240(6) No vehicle or imperv.area above l.f.unless unavoidable-240(7);NA 13.02 Vented if under impervious cover-241 (1) Vented through same pipes as distribution system-241 (1)(a) Vent protected from precipitation/animal entry-241 (1)(b) Vent is placed beyond traffic or impervious area-24 1 (1)(c) /— All lines connected to vent if bed or trenches-241(1)(d) ' 9"cover over peastone-240(9) ----� Reserve area provided(new construction)-248(1) Reserve 4'from primary leach area—NA 9.04 C 4'(5'if perc rate<=2 MPI)separation to g.w.-212(a)&(b) Rte' 4'(down to 2'with variance or I/A-upgrades only)of natural soil under l.f. / -- GW separation is adjusted to highest existing grade if facility cuts into a hillside Pipe slope minimum of 0.005 -251(9) Require 5'removal and replacement if in fill-255(5) Top of leach facility<=36"below grade-221(7) A^ Final grade over l.f.minimum 0.02 ft/ft-240(10) Surface&subsurface drainage away from l.f. -240(1 1)&245(5) Minimum design flo without deed restriction—NA 13.01 �G 3:1 slope where grading required-255(2) Toe of fill slope stops 5'from property line or swale installed-255(2) t----- Impermeable barrier if<3:1 slope or< 15 feet to—3:1slope-255(2) Impermeable barrier/retaining wall poured concrete—NA 9.02 Retaining wall stamped by P.E.-255(2)(b) Top of retaining wall>=top of peastone elevation-255(2)(f) '-- 10'offset from edge of leach facility to edge of ret. wall-255(2)(g) Perc test(s)done in most restrictive layer- 104(2) Perc test 4' below leaching elevation—NA 7.06 Design flow listed and required/provided leach area given-220(4)(f) ✓' Leach pipes SCH40 PVC—NA 10.01 Leach pipes minimum 4" diameter except for dosed system—NA 14.04 `�— Leach lines capped,vented,or connected together-251(9) Pressure dosing guidance followed if pressure distribution-254(2)(c), Pressure dosing required over 2,000 gpd or with I/A remedial use-231(1) 5 r 6 Leaching Trenches(Check here if not present: 1 OK Problem N/A ti Number of trenches: Minimum of 2 trenches-NA 9.01(2) Depth of trenches(max eff.2'): -247(l) Width of trenches(2'min.,4'max.): -251 (1)(b) Length of trenches(100'max.): -25 1 (1)(a) Trenches are vented(when>50')-251 (11) Trenches follow contour lines-251(2) Trench spacing 3 times effective width or depth minimum-251 (1)(d) j In fill or reserve between trenches, 10' min.-NA 14.01& 14.03 Available leach area given(Min.500 s.f.)-NA 9.01(2) Bottom=L x W x# - s.f. Sidewall=L x D x# x2= s.f. r Effective leach area given �— Loading factor: Effective area=total area s.f. x LTAR = g/day .- Effective area is>=design flow of facility being served 2"of 1/8"- 1/2"2x washed peastone.-247(2) Trench depth of 3/4"to 1 1/2"double washed stone-247(1) Leach Fields(Check here if notresent: P ) OK Problem N/A Number of fields: (need dosing chamber if> 1,231 (1)) Length(100'max.1��252(2)(b) Width: Total area,:-r x W = s.f. Minimum 900 square feet-NA 9.01(1) istribution lines connected with solid pipe-NA 15.01 Effective leach area given Loading factor: Effective area=total area s.f x = g/dav Effective area is>=design flow of ' y being served Minimum of two distributio i es-252(2)(a) 6'line separation(m -252(2)(d) 4'maximum se ation from edge of field to line-252(2) e 10'mini separation between adjacent leach fi - 52(2)(f) Be en 6" and 12" of 3/4- 1 1/2" stone b field-252(2)(g)&247(2) of 1/8"-1/2"2x washed peaston (2) Final Grading OK Problem N/A Slope over leach area minimum of 0.02 feet/foot-240(10) i Grading shall divert drainage away from leach area-240(l 1) Grading slopes away from dwelling 5/24/01 f-/office/forms/tonackltr.doc 6 Project Request Record Town of North Andover Date: 6 �- Client Id:ToNA Card Id:ToNA Client/Company Name: oard of Health Card Type-Client Contact Name: Ms..Sandra.Starr Phone: 978-688-9540, Title:Director Fax: 978-688=9542` Ad'd'ress: 27 Charles Street Email:sstarr@townofnorthandover.com Notes: Town:. North Andover., ';,.State: MA Zip Code:. 01845• Other,contacts if,applicable::ie Engineer/' nstaller 1.Name: i F �` �`f� :- S e__` Phone: ;r Title:. Fax: Address: Email: Notes: Town: State•. Zip Code: Pro iect: Project Id: 1770 Project Title: Town of North Andover.Board of Health (JOB NO) (PROJECT NAME&STREET ADDRESS) Manager:NOW Billing Group: i Billing CodJ:Fixed Fee j Contract Info.Project Description for each billing group BG/ Applicant 7' Assessors Map ' Lot Z J-_ Street 3,i�'F-:2 TIs > 7 Type of service s f ..• E: r r Offic&forms/j brq utona Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non-conforming system with a design flow of<10,000 gpd,where full compliance, as defined in 310•CMR 15.404(1);is not feasible. To be submitted to DEP: For the upgrade of a failed.or non-conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: P. Address: Phone#: � Address of facility: 2) Applicant (if different from above) Name: Address: V/s�CNI Phone#: 3) TJJpe of Facility: Residential Commercial School Institutional (Specify) Page 2 of 5 4) Type of Existing System: _privy cesspool(s) ✓ conventional system other(describe) Type of soil absorption system(trenches,chambers, pits, etc.) n6 rt g W4Z tr 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system U Q k�k1- gpd Approved: _yes Approval date: J A)PO. no Why: b) Design flow of proposed upgraded system c) Design flow of facility gpd 6) Proposed rpgrade of existing system is: a) Voluntary required by order, letter, etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: C®trv'CV 11KII SYST��-1 1,5&9 6A-L,, t ri4w t -o c) Which of the following are applicable to the proposed upgrade? ffA Reduction of setback(s)(list setbacks to be reduced with proposed setback distances) Ar�L Percolation rate of 30-60 minutes per inch(state actual pert rate) Up to 25%reduction in subsurface disposal area design requirements (state required&proposed size) Relocation of water supply well (identify well, describe relocation) Reduction of required separation between bottom of SAS & high groundwater(specify proposed reduction&perc rate) `� ai` 17 P-1 .) Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404& 15.405,or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) 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 round water elevation PP ground pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater �7 feet As determined by: Evaluator's name: !�74lUVRA- �l YLIZ Evaluator's Signature: Date of evaluation: '- 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on thea agenda. Such notice shall g sal include the date,time andlace where the upgrade P PTp' approval will be discussed. If the department is the approving authority,then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: ii A—A. b) An alternative system approved pursuant to 310 CMR 1'5.283-15.288 is not feasible. c) A shared system is not feasible. d) Connection to a sewer is not feasible. 10)An application for a disposal system construction permit, including all required attachments(e.g. plans & specifications, site evaluation forms), must.accompany this application. Is the DSCP application attached? yes no Page 5 of 5 11)Certification "I, 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 Timited t , nalties or fine an or imprisonment for knowing violations." Facility Owne s ignature Date Print Name 1, �l,F Ffi� = ►t3 t-l�t� �l tiJ��CZII �r r�O Name of Preparer Date �17Ra' Telephone No. &Address of Preparer NOTE: Title 5,310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. NoonanIll - N X fk Eck Tools 12ata jJaintan Process Yiew 1leport 2nd 1Lrndows Help `New Office Document Billhig Groups f3 =X Project: 1770 I ?F OAice;(Health Departm rit 27>WFtai7es. treet,:'M1ro:ArrdoVer, Billing Group ID: mmn'J x. Billing Type: I Fixed Fee r., BiIIIngfee: _ 150.00 Card.ID:: To NA Mein BIIIing Info contract Info Classification 'Ij OLAccotgnts l Billing Messages Alerts Staffing At;tiyities Assign To Proposal Number: Department ` Contract Number: Contract Date: 6121(02 f , Work Start Date: 6121!02 I Expected Finish Date: 715102 r'Use Oovernment lnvoice:Style Description: ti f Engineering services required for plan review. VJ Engineer.Merrimack Engineering Services Assessors Map 64,Lot 25 Applicant J&M Realty Trust 300 Dale Street t'9 1 aVB clos8_ _Notes... Location: owner's Name: PC r_1 Map/Parcel: '�►�1 (� �(,7i5 Address: �.�c L'' Installer•. Tel 447 RVNew tSisol Repair Date: -rl2. Wetlands {sone II Soil Symbol �Soil Rame Soil Class, Deep Observation Hole Logs Elevation Depth Soil Horizon Soil Texture Soil Color Soil Mottling % Gravel,Stones,etc t.2� IV V, l vt F: It p''jO7it 1 Vr, „5Y �(� ' � a� �-'1-•E�t v � Parent hiaterial (—L„ Depth to Bedrock: Standing Water in the Hole: Weeptng from Pit Faee -1 ESHG%V: 2��1 7.5 ' I/�w 3^I l /�( ��v�i I�'t�YL'�/1 `^" L/'7 L�%�✓"./Y 6 7�.I . Parent Material +I 1. Depth to Bedrock: Standing eater in the Holr. «eeping from Pit Face 1 ESHMY: L7 Date Percolation Tests Observation Hole r Depth of Perc Start Pre-soak- Mme at 12" `�O Time at 9" Time at 6" Time(9"-6") Rate Min/Inch Performed Bv:_ Witnessed By: P_OrTo�o Location: owner's Name: PC tri Map/Parcel:_ "�NI (ey1_706 Address:_ 4V 40910-4�0 L Installer. I Tel#• �nNew(siso) Repair woo" Date: 7r�I -d0-► Wetlands 714WLne Il Soil SYmbol�i _Soil Rhme-4 oil Class Deep Observation Hole Logs Elevation Depth Soil Horizon Soil Texture Soil Color Soil Mottling % Gravel,Stones,etc: —7. 99-Yeo I, vF ZI- F2s Parent Material Depth to Bedrock Stsnding.Nater in the Hole: Weeping.froth Pit Faee 1-7 ESHG%Y: 2011 V Frziek :: e Patent Material +1 LA- Depth to Bedrock Standing.Waterin the Hole•. Weepin:from Pit Face ESH Date 15; 7l'f%- Percolation Tests Observation Hole: Depth of Perc _ Start Pre-soak: Time at 12" ( ',:a I Time at 9" Time at 6" ' Time(9"-6") Rate Min/Inch- • I Performed By: 0, � i" V Witnessed By- �,. ���� SEPTIC SYSTEM INSPECTION FORM ADDRESS ` y � DATE INSPECTED PROPERLY FUNCTIONING? N WEATHER CONDITIONS COMMENTS : WATER QUALITY TES E•b DYE TEST PERFORMED? Y N DATE? SKETCH: WATERSHED RESIDENTS QUESTIONNAIRE 1. Name t. l U�� JL)77 2. Street Address 3yy 7C), 4 ! J r ' 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool `51 septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no 'S do not know _ 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years `S7 over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes '0 no ❑ do not know If yes, approximately how long ago? years. What was done? i 8. Ho frequently is your se age disposal system pumped out? El annually every 2-4 years ❑ over 10 years El never 9. Have you had any problems with your sewage disposal system? ❑ yes 1_fl no If yes, what problems? ❑ repeated pump-outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher garbage disposal dehumidifier drain sump pump toilet — roof/pavement drains shower/bathtub 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher clotheswasher'j i De G 2A 1-7 � 12. Does your property have a lawn? C�, yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/2 acre 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres - 13. How often do you fertilize your lawn? No. of applications per year J - Season(s) of the year 10 y 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: ❑ Check here if your lawn is maintained by a professional landscape contractor. - --- TOWN OF NORTH ANDOVyE BOARD OF`HEALTH.f SYSTEM PUMPING RECO'. FEB - 1 2002 DATE. �— SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED � � GALLONS j CESSPOOL: NO YES SEPTIC TANK: NO YES �— NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) r SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: Address Title of File Date t=ile Open: Pageofi Date file closed:— Doc Documeint/Action Title Date of action 6tefer to other PurP.ose of Docume to /A� 01 n and notes wum. Document/ document/ -- Action De artment Board of Appeals - Board of Health Planning Board — Conservation Commie _ ssion B il-di,ig D epartrneOlt i 111L1�1T 1:5 Nce o OYE, T�I� �� G[+rrf1 GiGA-rTo►,1 14 L1o7 a A a3 G Z �i � LL {,,►.x*�it.a.rlTY p!='r►�tC 'Sv85u�eG� oma►.. 4*,TeH . ZT I S �, tre.ewco OP 1'�+E La*row A u0 >;Le V^-InOLJ of TN>: ON-n►Nc5 sr�-r S l . 60HF0 W Lk fly. 0 Loco Live p u ►� Y 1 � � M ►� w y ► v� o�S �0x D zoic '� ' Tor1 _ ,e�lh A -z ' AS SUI LT PLAN OF. SUBSURFACE DISPOSAL SYSTEM LOCATED IN 110 u D 04 e_7 2 ��1-4 Oo t20-\ ZM OF M'9S AS PREPARED FOR DANIEL cn KORAVOS -+ I ► �"'I ��1 � � CIVIL u, j •TENo.37752 DA . _ 9-Zo 02 �M (p�' SCALE: Vol y.p► .>' 1. �G✓ 9�G MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01610 or TEL (617) 473-3553, 3MS721 i 1111111111111111 �► � ` ' �- 1 1111111111111 N _ Mill 111111E 11 11 11 11 11111 11 1 1 1 11 - M 11�l1 �1 1� 111 , it illi INS 11r 1111111 , 1111 111 1 it 1oII 111111 1� � 1 1� 1 1 1111111111 /1/11111 Id 1 C� 1 11111111 �. 11 11 1 1111111 �E_11 Iii 1111 11� 1 1111l III , 111. 11 IIIIIIIIi�; � ► - 11111 1 IIIle11111 1(1 11111 11 11 1 l�IN!��, `11 11/1/ 11111 1 11 11 1 III` 1 1111 1 1 11 E411 RA' 1 �IIQ1 1 e 11 111 111E 111 ► ( � , 11!.. � VIII 111 ► X111 1 1111111��:� � 1►]L1� 11 �� , IIIIIIIIIII IL�IfI 1 Town of North Andover, Massachusetts Form No. 1 ' Q NORTH BOARD OF HEALTH F '9A �SIED y 'YO 0 °q APPLICATION FOR SITE TESTING/INSPECTION n°RATED PPP`�y 9SSACHUSE� Applicant NAME ADDRESS TELEPHONE Site Location l�56D "Wzl�f— Engineer �&// Z)Wl"e 199 NAME ADDRESS TELEPHONE Test/Inspection Date and Time f- a®�� AQ L3d f I CHAIRMAN,BOARD OF HEALTH Feed/ Test No. /O'°y) S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. e,A3 i I i t Town of North Andover, Massachusetts Form No. 1 Y RNORTH BOARD OF HEALTH rQST�E° .6 q�•O � O A a APPLICATION FOR SITE TESTING/INSPECTION r; S CHus���y Applicant���/ NAME ADDRESS TELEPHONE Site Location J ` i " Engineer_ i NAME ADDRESS TELEPHONE Test/Inspection Date and Time t; CHAIRMAN,BOARD OF HEALTH ,I Feed/ r Test No. 1600 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. a Town of North Andover, Massachusetts Form No.2 ' 10RTM BOARD OF HEALTH o —az.) w P t DESIGN APPROVAL FOR b+.r.e.r�• ;,SS4CHUSft� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant `d'/�I�' 'GT,Y ��US/ Test No.--- Site o.Site Location Reference Plans and SpecsAeZ A4A9-Q)*%?5A45 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. CHAIRMAN,BOARD OF HEALTH Fee Site System Permit No. ��9f FORM 4 - SYSTEM P'UMPLNG RE OR Commonwealth of Massachu ett -ec', Massachusett Svstena 'um rng ,RecordagvW" , W LAGAystem ocatio JVSIf it caner � 3W D4 le s Te' Emergency Type EEl Routine C � � Cessp( ,)I: No ❑ Yes ❑ S(.ptic Tank: No ❑ Yes Date r. : Pumpine: 7-17- �U Quantiry Pumped: �SZ.Y� _ gallons BORACZEK'S` l_._y_ Permit =: Svster.: Pumped by (Company): Contc AS transferred to: Cont: .it.s disposed at: J-/rtin cP D` 7 /7- 4 Pumper e S i en a ru re t� Condition of system other comments: d DFS APPROVED FORM• 1:/0795 ^TK^ �v^M � •. r 1 � { � Tf� �, a - Commonwealth of Massachusetts W City/Town of No.Andover System Pumping Record Form 4 M 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. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from accordance with 310 CMR 15.351. A. Facility Information Important: [HEALTH WN OF NORTH ANDOVER When filling out 1. System Location: DEPARTMENT forms on the n computer, use Mx ' y - only the tab key Address to move your No.Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System OWn ray 0 7;� Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1 1 1. Date of Pumping Date ( L 2. Quantity Pumped: anon 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: LeD603L 6. System Pumped B . a Vehicle License Number Stewart's Septic Service i Company 7. Location where contents were disposed: Stewart's Pre- atment Plant, 20 So. Mill Bradford, Ma 01835 i Signature of H Date Signature of a wing acility Date I t5form4.doc•03/06 System Pumping Record•Page 1 of 1 i 7; s � �.{ H i •. '1 Commonwealth of Massachusetts fEC�lV j W City/Town of No. Andover 11011 a System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT M 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. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer, use 300 Dale St only the tab key Address to move your No. Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: &� Robbins Name ' Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 4/13/11 2. Quantity Pumped: 1000 Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: riding high 6. S stem Pumped BY: p Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 I Signature oful Date//k� Signature of iving Facility Date' I t5form4.doc•03/06 System Pumping Record•Page 1 of 1