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Miscellaneous - 31 JAY ROAD 4/30/2018 (2)
0 1 v ti v J • S�gSL'ED�6Q6 ♦ PUBLIC HEALTH DEPARTMENT Town of North Andover p v Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: August 30, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: New Construction of an On-Site Sewage Disposal System By: Todd Bateson — Bateson Ent At: 31 Jay Road Map 98.A Lot 56 North Andover, MA 01845 tichele ance of this c s not be construed as a guarantee that the system will function satisfactorily. Grant Public Health Agent 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov • �� Yr �' , Commonwealth of Massachusetts Map-Block-Lot .Y 098.A0056 BOARD OF HEALTH Permit No North Andover BHP-2016-0280 ------- ------- -- FEE $350.00 ----------------------- DISPOSAL WORKS CONSTRUCTION FERMI i Permission is hereby granted Todd Bateson (� O --------------------------------------------------- to ------------------------------------------------to(Upgrade)an Individual Sewage Disposal System. at No 31 JAY ROAD 4 as shown on the application for Disposal Works Construction Permit No. BHP-2016-028 Dated September 12,2016 ----------------------- ---------------------------- -------------------- - OPY-------- Issued On: Sep-12-2016 B E ✓ Application for Septic Disposal System TODAY'AY S DATE Construction Permit —TOWN OF $ 0X0–Full Repair NORTH ANDOVER, MA- 01845 $ ,25.00-Component Important: ADolication is herebv made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use epair or replace an existing on-site sewage disposalsystem* only the tab key Repair or replace an existing system component–What? to move your cursor-do not use the return A. Facility Information key. J tH Address or Lot#&I M� Cityfrown Ne A-Javk!- tt SEP 12 2016 ' 2.-*TYPE OF SEPTIC SYSTEW: TOWN OF NORTH ANDOVER ➢ B-pvmp ❑Gravity(choose one) HEALTH DEPARTMENT —if pump system,attach copy of electrical permit to application*** ➢ ❑Conventional System (pipe and stone system) ➢ © ltrator or Biodiffuser(Gravel-Less)(Attach a copy of your cerfificafion to install this type of system.) Tnfi ➢ ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes� No If yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) what is the Make? :2,1L L_ What is themodll� 2. Owner Information Name Address(if different from above) k,1 ,q,,,, ,V c n_ /d— Cityrrown State Zip Code Dr Telephone Number 3. Installer Information 1/ � �,yT,GSd/� Name d Name of CompaWATE ON ENTERPRISES,INC. L.A I q ru. 11A- P4. 111 ARa -nnn Address d ANDOVER,MA 01810 .fid✓'tsZ- /I"A- o fY/d State Zip Code Td17f FO Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company f 5— �dK�rry �R Address H Ci own State Zip Code bv3 - Ylr,) - d.1-9 r Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 dRTN Apolicatiota..for Septic Disposal SVstern �- Al c �: TODAY'S DATE aCons#ruc#ion P rm TONT O O:RTH 1�ND OV�� MA 01845 $.250.00* T Full Repair ���•,*.•� .�i $725.00.-Component sstG11115 PAGE 2 OF 2 A. Facility.. nformation continued.,.. 5. TVpe'of Building: esidentialDweliing or ECommercial B. Agreement The undersigned agrees to ensure the construction and maintenanc • e of the afore-described on-site sewage disposal systemin accordance with the.provislons of Title:5 of the Environmental Code,as well as the Local Subsun°ace Disposal Regulations for the Town of AI North Andover,and not to place the system In operation until a Certificate of Compflance has been Issued Is Board of Health. Name Date Appli loAppr' d By: (Boardof Health Representative) (Z,/ Name Date Application Disapproved.for the following reasons: For Office.Use Only: " 1 'FeeAtwcbedp: Yes t/ ' No 2.- Project)Ukdager Obligation Form Atwchcd? Yes No 3.: J�Uw,lLSvstem? If soi Attach eony ofElectrical Permit'... Yes No 4. Foundation As-Built?(few construction-ronly); :Yes No (Same scale as approved plan) — .5 F1oorPlaas?thew construction only). Yes_ No 4-Pi6tion'lor-p(spg5al Systeri5:06nstrudlon Permn Pace 2 rit 7 s tc s c ►+t ' xo r LMBN'�941GATIPM As flWNqt&Audurerlcmmed&4uLUet frsxawmtate t-AothtaTdc gttem fat tAMdftd heptopa3ya� Re]ativa m th�sppl�dau of �G�- ems,►. �� . nsc«t /© — 7 fY : A Wft ievwom&Md (Lase revised dm) I nndetQtaad the fouowlpt ObUgetions fot tr agemcut of this project: I. As the fnmtue4 I=' .obltg w io 6bta6 sapemm, asd'BOxvd ofl=Ith apprnvad phmpft to .pafonW ony woA on a db-p . 4. As$ie h tter;.I, i tall �y and Vis: Uhco6qwoet*ontmcq4pzqor sm a Y-� ma�age� Y no# as �y o�ur,p � my P' mapecdoas and the system to sot then J 3. As �bCd t1D tfft4E WorTCVQUVAgdd•pr to thegg to b�f�, ►�►i D •. F.. 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'� .- . . •..:ate. . . . • ., • g�TTL'ED��c � \r North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 31 Jay Road MAP: 98A LOT: 56 INSTALLER: Todd Bateson DESIGNER: Doug Smith PLAN DATE: 7/8/14, Rev. 10/7/14 BOH APPROVAL DATE ON PLAN: 10/16/14 INSPECTIONS TANK INSPECTION: 9/20/16 DATE OF BED BOTTOM INSPECTION: 9/20/16 DATE OF FINAL CONSTRUCTION INSPECTION: 9/29/16 DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ® Contractor reports any changes to design plan ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SEPTIC TANK ® Building sewer in continuous grade, on compacted firm base ® Cleanouts per plan ® Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ® Monolithic tank construction ® Water tightness of tank has been achieved by visual testing ® Inlet tee installed, centered under access port r -�A A • 1 , Outlet tee installed, centered under access port (gas baffle/effluent filter) 24" inch cover to within 6" of finish grade installed over one access port ® Neoprene boots around inlet & outlet Comments: PUMP CHAMBER ® Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1000 gallon Pump Chamber installed ® H-10 loading ® Monolithic tank construction ® Inlet tee installed, centered under access port ® Pump(s) installed on stable base ® Alarm float working ® Pump On/Off floats working ® Separate on/off floats ® Drain hole in pressure line ® 24" cover at final grade installed over pump access port ® Water tightness of tank has been achieved by Visual testing ® Neoprene boots around inlet & outlet Comments: CONTROL PANEL ® Alarm & Pump are on separate circuits ® Alarm sounds when float is tripped ® Location of control panel: outside of house ® Alarm signal located outside of house Comments: DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: E r. SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan N/A 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan N/A Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: C33 sand, 60x20 with overdig SOIL ABSORPTION SYSTEM (Presby) ® Brand and Model of Chamber: Presby Enviro- Septic ® Number of pipes per row: 5 ® Number of rows (trenches): 7 Comments: Total Pipes = 35 FINAL GRADE ® Loamed ® Seeded ® Cover per plan Comments: DOCUMENTS NEEDED X Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer X As-Built Plan BM = 98.64 H R = 6.45 HI = 105.09 SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT 7.20 97.54 98.00 Septic Tank IN 7.36 97.38 97.63 Septic Tank OUT 7.63 97.11 97.38 Pump Chamber IN 7.66 97.08 97.32 2" Pump Chamber OUT 8.01 95.91 97.07 2" Distribution Box IN 3.61 101.31 101.27 Distribution Box OUT 3.58 101.16 101.10 Lateral 1 TOP 3.75 Lateral 1 INVERT 100.99 100.93 Lateral 2 TOP 3.75 Lateral 2 INVERT 100.99 100.93 Lateral 3 TOP 3.75 Lateral 3 INVERT 100.99 100.93 Lateral 4 TOP 3.75 Lateral 4 INVERT 100.99 100.93 Lateral 5 TOP 3.75 Lateral 5 INVERT 100.99 100.93 Lateral 6 TOP 3.75 Lateral 6 INVERT 100.99 100.93 Lateral 7 TOP 3.75 Lateral 7 INVERT 100.99 100.93 Bottom of Bed/Chamber 100.41 100.35 c CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib.to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains(Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws V-' S��x Ell'�6 • RECEIVED DEC N 2016 o TOWN OF NORTH ANDOVER �Rareo a�`� HEALTH DEPARTMENT r I PUBLIC HEALTH DEPARTMENT (ommunity&Economic Development TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System(x )constructed;( )repaired; By: 0Ck N�,A /-e-soN (Print Name) Located at: 31 Jay Rd. North Andover,MA For Suzanne White (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan,originally dated: July 8,2014 and last revised on October 7,2016,with a design flow of_550 gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310.CMR 15.000,Title 5 and local regulations,and the final grading agrees substantially with the approved plan.All work is accurately represented on the As-built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: Sept.21,2016 Engineer Representative(Signature) Douglas J.Smith And-Print Name Final Construction Inspection Date: Sept 23,2016 I' Engineer Representative(Signature) Douglas J Smith And-Print Name Installer: (Signature) Date: And-Print Name Engineer: 1 /-� ( ignature) Date:12/14/2016 Douglas J. Smith And-Print Name 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov Commonwealth of Massachusetts W City/Town of North Andover lo Certificate of Compliance �M Form 3 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. This is to Certify that the following work on an On-Site Sewage Disposal System Important:When filling out forms ❑ Construction of a new system on the computer, ® Repair or replacement of an existing system use only the tab ❑ Repair or replacement of an existing system component key to move your cursor-do not use the return Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): key. DSCP Number DSCP Date wv III���III Suzanne White Facility Owner � 31 Jay Rd Street Address or Lot# North Andover MA 01864 City/Town State Zip Code Designer Information: Douglas Smith Soilsmith Designs Name Name of Company 12/07/2016 Signature Date Installer Information: Name Name of Company Signature Date Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. Approving Authority Signature Date t5form3.doc•06/03 Certificate of Compliance•Page 1 of 1 FILE COPY North Andover Health Department (ommunitY Development ment Division October 16, 2014 Suzanne White 31 Jay Road North Andover, MA 01845 Re: Subsurface Sewage Disposal System Plan for 31 Jay Road,Map 98A,Lot 56 Dear Ms. White: The proposed wastewater system design plan for the above site dated July 8, 2014 with a final revision date October 7, 2014 received on October 14, 2014 has been approved. The design has been approved for use in the construction of a replacement onsite septic system for a 5-bedroom(max 11-room)home utilizing a Presby system. This plan is generally good for 3-years from the date of approval however, as this is for a repair system,this is reduced to 2- years. The plan received the following local upgrade approval. 1) A reduction to ground water from the bottom of the soil absorption system of 1 foot to 22 inches 2) A reduction of the inlet and outlet of the tank to less than 12 inches to the estimated ground water During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. In the event an imminent health problem, such as sewage backup into the dwelling is occurring,the North Andover Board of Health may reduce the time period for which this plan is valid. This approval is also subject to the following conditions: 1. Please keep the attached DEP Form 9b for your records (attached) 2. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 31 Jay Road October 16, 2014 Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 3. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Since y, us awy , RE S Pu is Healt irec r Encl. Form 9B Installers list cc: Doug Smith, RS File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 n Commonwealth of Massachusetts City/Town of North Andover Z Y m o Local Upgrade Approval a Form 913 M DEP has provided this form for use by local Boards of Health if they choose to do so. The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. A. Facility Information Important:When filling out forms 1. Facility Name and Address on the computer, use only the tab Suzanne White key to move your Name cursor-do not 31 Jay Road use the return key. Street Address North Andover MA 01845 r� City/Town State Zip Code 2. Owner Name and Address(if different from above): Name Street Address City/Town State Zip Code Telephone Number 3. Type of Facility(check all that apply): x Residential ❑ Institutional ❑ Commercial ❑ School 4. Design flow per 310 CMR 15.203: 440 gpd 5. System Designer: Douglas Smith PE ®RS Name 15 Foxberry Drive New Boston NH 03070 Address Cty/Town State,ZIP B. Approval 1. Local Upgrade Approval is granted for: ❑ Reduction in setback(s)—specify: ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction 31 Jay Road Local Upgrade Approval* Page 1 of 2 Commonwealth of Massachusetts City/Town of North Andover N � F a Local Upgrade Approval Form 9B 41M Syey`er B. Approval (continued) ® Reduction in separation between the SAS and high groundwater: Separation reduction 1 feet ft. Percolation rate 20 min/inch min./inch Depth to groundwater 22 inches ❑ Relocation of water supply well (explain): ® Reduction of 12-inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: North Andover Health De pt Approving Authority Susan Sawyer October 16, 2014 Print or Type Name and Title tignature Date 31 Jay Road Local Upgrade Approval* Page 2 of 2 North Andover Health Department Community and Economic Development Division II 8/25/16 Suzanne White 31 Jay Road North Andover, MA 01845 RE: Subsurface Sewage Disposal Plan for 31 Jay Road, Map 98A, Lot 56 Dear Ms. White: Your proposed wastewater system design plan approved on 10/16/14 will be expiring on 10/16/16. A permit must be pulled by a permitted septic installer by 10/16/16. After this date, the plans will expire and you would need to go through the entire septic approval process again. If you have any question, please contact the Health Department at the phone number listed below. Since* , w fan LaGrasse Director of Public Health Cc: File Enc: Approval Letter dated 10/16/14 List of Septic Installers Page 1 of 1 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT , 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER,MASSACHUSETTS 01845 978.688.9540—Phone Susan Y.Sawyer,RENS/RS 978.688.8476—FAX Public Health Director E-MAIL:healthdept _townofnorthandover.com WEBSITE:htt :Hwww.F fn , ndovervech mi -t �0 SEPTIC PLAN SUBMITTAL FORM OCT 1 � 2014 Date of Submission: J U 1 }h 2 D k TOWN OF NURT'H ANDOVER U HEALTH DEPARTMENT Site Location: S 1 � Engineer: © v .� -n,\ ►�"� S o v l._S'YY\Vt-h fj_e S 1 S✓\ 5. New Plans? Yes $225/Plan Check# (includes I'submission and one re- J review only) �n 0� oho '1 o =Revised ?Yes $75/Plan Check# 1-� E✓ V'%-e_✓� o Site Evaluation Forms Included? Yes_/ No n\vee s -© to �vv Local Upgrade Form Included? es No Telephone#: y 3 2L 2cl$ax#: E-mail: So\ Lsyy-��fiI) P vl� o L - Oyy1 Homeowner Name: S U 2 i/ o v f= w VN \'}-t OFFICE USE ONLY When the submis ' n is complete(including check): ➢ _ Date stamp plans and letter ➢ Complete and attach Receipt ➢ Copy File;Forward to Consultant ➢ Enter on Log Sheet and Database 411- �. S�'KSCLU'7�6 k k�rik 114 ti Worth Andover Wealth Department (ommunity Development Divis 6 August 18,2014 rr�� V� Douglas J. Smith,R.S. Soil Smith Designs 15 Foxberry Drive New Boston,NH 03070 Re: 31 Jay Road(Map98A Lot 56) Dear Mr. Smith: The proposed wastewater system design plan for the above site dated July 8, 2014 and received on July 30,2014 has been reviewed. Unfortunately,the plan cannot be approved until the following items are corrected. The specific section in Title 5'3 10 CMR 15.000,or North Andover regulation that is not met by this design;follows each item. (/1. Please include the abutter names for the properties located to the south of the project site (NA 32). 2.- Please indicate if there are wetland resources.located within.150' of the proposed septic system(NA 3:2); V3. On sheet 1 of 2,proposed contours appear to be missing from the site plan view(NA 3.2).. t/'4. On sheet 2 of 2,please clearly depict the existing grade and finish grade lines on the profile view. It is very difficult to distinguish between them as currently shown. (/5., On sheet 1 of 2,please indicate the location of the utility pole that is being used as the benchmark. 1,46: Please specify the required annual maintenance for the effluent filter(3 10 CMR 15.227(7). C-*"7. Please indicate that the distribution box shall be made watertight(3 10 CMR 15.221(1). L,A. On sheet 2 of 2,the buoyancy calculations appear to be incorrect based on the proposed tank elevations, ESH.WT of 96.85' (TP-4)and proposed cover material above the tanks. Please revise the buoyancy calculations accordingly. Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover,MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 'Q- V9. t V9. Based on the ESHWT of 96;85' it appears the inlet and outlet invert elevations of the septic tank and pump chamber arelessthan 12" above the seasonal high groundwater table. A Local.Upgrade Approval is required (310 CMR 15.227(5). L110.Adequate cover material does not appear to be proposed above the distribution box. The top of the distribution,box appears to be 102.45' and the proposed finish grade is approximately the same elevation. 11. On sheet 1 of 2,please indicate the float elevations in the pump chamber. tm_�eq..s 2 On sheet 2 of 2,it appears the pump performance curve is below the operating point of 10 ME:3F C-i n ft TOH @ 60 gpm., .Please provide a pump that will meet the required pump parameters. -i V Cv� J�-"Please indicate the size and material of the access covers above the septic tank and pump t� ti 5 a K chamber. The profile view should also indicate the access covers to finish grade. 1,,Y4.There are no existing spot elevations at the southwest coiner of the existing dwelling. Therefore, it is unknown ifthe proposed finish grading is directing runoff towards the existing dwelling. L-'V5. On sheet 1 of 2,the distance from the existing dwelling to the proposed. septic tank is incorrect. L-1.6. On sheet 1 of 2,TP-1 is missing the depth of the C layer. �l 7. The inlet elevation of the pump chamber is 97.32' and the outlet is proposed at 97.30' It is preferred to use the precast knockouts in the tank for the outlet instead of coring new holes into the tank. However,if this is not proposed then.please describe in detail the proposed method to install the pump chamber outlet at 97.30'. Please feel free to contact the office with any questions you may have. We look forward to working with you.to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover: Sincerely-, S san Y. Sa er HS/RS Public Healthirector .CC4 Suzanne;White. i l Page 2 of.2 North Andover Health.Department, 1600 Osgood Street. Suite 2035, North Andover,NIA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Page 1 of 2 Subj: Re: second thought Date: 8/20/2014 To: ssawver townofnorthandover.com Perfect thank you Doug on another note I will be dropping off the As Built today for 121 Famum Thanks Doug 6�- 'r"Anak /VPu� ay�l?i,A 03070 603-487-2298 �vcvsn�aa8/79/207 1:14:23 . . Doug, checked with the Conservation Dept. on the Jay Road. In regards to the wetland.We don't want to have to flag the wetland across the street; so in lieu of that Heidi and I suggest the following. Note"no wetlands within 100 feet" rather than 150". She is ok with that since they are across the road and on someone else's property.Too much issues with'that for no real gain. Thank you, Susan t Susan Sawyer Public Health Director Town of North Andover 1600 Osgood Street ti Suite 2035 ' North Andover, MA 01845 Phone 978.688.9540 Fax 978.688.8476 Wednesday, October 08, 2014 AOL: SOILSMITH Of NORip 1y 6616 • : Town of North Andover HEALTH DEPARTMENT ,SSACM�Stt CHECK#: DATE: LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: Septic-Soil Testing $3 10o!, ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DW0 $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ti •- s Town of North Andover ` '•_,,.;,T:` HEALTH DEPARTMENT ,SSACHUS e MMc. CHECK#: DATE: . 2) LOCATION: ) H/O NAME: 1 � CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ t ❑ Dumpster $ r ❑ Food Service-Type: $ ❑ Funeral Directors $ " ❑ Massage Establishment $ r ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ .Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ 'SEPTIC S.s t tems: Septic- Soil Testing ❑- Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ 0 Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER,MASSACHUSETTS 01845 Susan Y.Sawyer,RENS,RS 978.688.9540-Phone Public Health Director 978.688.8476-FAX healthdeptgtownofnorthandover.com www.townofnorthandover.com APPLICATION FOR SOIL TESTS DATE: 10/7/2013 MAP&PARCEL: 210/098 A 56-0 LOCATION OF SOIL TESTS: 31 JAY RD OWNER: SUZANNE WHITE Contact#: 978-557-8222 � APPLICANT:SUZANNE WHITE Contact#:978-557-8222 ADDRESS: 31 JAY RD, NO. ANDOVER, MA 01845 ENGINEER: DOUGLAS SMITH contact#: 603-487-2298 RECEIVED CERTIFIED SOIL EVALUATOR: DOUGLAS SMITH OCT 17 2013 Intended Use of Land: Residential Subdivision Single Family Is This: Repair Testing:X Undeveloped Lot Testing: Upil I In the Lake Cochichewick Watershed? Yes No� I THE FOLLOWING MUST BE INCLUDED WITH THIS FORM1��" , -*"➢ Proof of land ownership(Tax bill,or letter from owner permitting te: ' �➢ 8.5"x 11"Plot plan&Location of Testine(please indicate test pit sil ✓➢ Fee of$425.00 per lot for new construction. This covers the minimf two percolation tests required for each disposal area. Fee of 360.00 GENERAL INFORMATION' ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass.Registered Sanitarians and Professional Engineers can de ➢ At least two deep holes and two percolation tests are required for eacl ➢ Repairs require at least two deep holes and at least one percolation tel representative. ➢ Full payment will be required for all additional tests within two week ➢ Within 45 days of testing,a scaled plan(no smaller than I"-100')sha�]'be`sutimiueu-tu-tiju, �-- - showing the location of all tests(including aborted tests). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A.Conservation Commission Approval Date: — 1 Signature of Conservation Agent:< A Date back to Health Department: (stamp in): TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES z HEALTH DEPARTMENT , ,- 1600 OSGOOD STREET; SUITE 2035 4)ru NORTH ANDOVER,MASSACHUSETTS 01845 Susan Y.Sawyer,RENS,RS 978.688.9540-Phone Public Health Director 978.688.8476-FAX healthdept@townofnorthandover.com www.townofhorthandover.com APPLICATION FOR SOIL TESTS DATE: 10/7/2013 MAP&PARCEL: 210/098 A 56-0 LOCATION OF SOIL TESTS: 31 JAY RD OWNER: SUZANNE WHITE Contact#: 978-557-8222 APPLICANT:SUZANNE WHITE Contact#:978-557-8222 ADDRESS: 31 JAY RD, NO. ANDOVER, MA 01845 ENGINEER: DOUGLAS SMITH Contact#: 603-487-2298 RECEIVED CERTIFIED SOIL EVALUATOR: DOUGLAS SMITH OCT 17 20 13 Intended Use of Land: Residential Subdivision Single Family Home CommercialT0Wt QF NORTH ANDOVER fiIERI°� PARTMENT Is This: Repair Testing:X Undeveloped Lot Testing: Upgrade for Addition: - In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM -"> Proof of land ownership(Tax bill,or letter from owner permitting test) I"➢ 8.5"x 11"Plot plan&Location of Testing(please indicate test nit sites on the plan) ✓➢ Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of3$ 60.00 per lot for repairs or uaerades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass.Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test,at the discretion'of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. ➢ 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). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval Date: L Signature of Conservation Agent: �� — c� 01, Date back to Health Department: (stamp in): J 1�C lJ h- • Al� North Andover MIMAP 31 Jay Rd September 16,2013 098.A-0017 098.A-0058 57 JAY RD 098.A-0057 098.A-0016 1 N t 098.A-0033 43 JAY RD 098.A-0015 098.A-0059 : 098.A-0056 31 JAY RD 098.A-0004 �� N 420 40'04.7" {W 71°06'07.1" 098.A-0014 P v� 30 JAY RD 098.A-0060 098.4-0013 098.A-0012 ,atrr ...... 098.A-0011 _.;G .:::.:`-;••' ::_:..; .:_=_:=s lli....... 166 REA ST 154 REA ST —Rail Line C3 Exempt Lands Interstates Interstate Horizontal Datum:MA Stateplane Coordinate System,Datum NAD83, —Major Roads - Meters Data Sources:The data for this map was produced by Merrimack t 00111i Valley Planning Commission(MVPC)using data provided by the Town of Roads 9ti North Andover.Additional data provided by the Executive Office of Ci Easements u� •a CD Environmental Affairs/MawGlS.The information depicted on this map is O MVPC Boundary C for planning purposes only.It may not be adequate for legal boundary definition or regulatory interpretation.THE TOWN OF NORTH ANDOVER 0 Municipal Boundary F – % MAKES NO WARRANTIES,EXPRESSED OR IMPLIED,CONCERNING – Trails # • THE ACCURACY,COMPLETENESS,RELIABILITY,OR SUITABILITY OF THESE DATA.THE TOWN OF NORTH ANDOVER DOES NOT El Parcels # o �� i ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF 0 Hydrographic Features 11,Qo��rE°�oa`4to3 THIS INFORMATION Streams SSAC14U5� Floodplain C3 700 Year Floodplain Z2 500 Year Floodplain 1"=77 ft "w Wetlands SEE REVERSE SIDE FOR IMPORTANT INFORMATION TLlC!`l1AARRll2k1lA/C w 1 T{,i!1C AA A CC A(`Lli ICCTT.0 TOWN OF NORTH ANDOVER gill No, 4378 Fiscal Year 2014 2nd Quarter Make checks Payable To: Preliminary Real Estate Tax gill Town of North Andover Office of Collector of Taxes Collector of Taxes Jennifer Yarid, Treasurer/Collector P.O. Sox 184 Medford,MA 02155-0002 Office Hours: Mon. 8:30-4:30 Tues. 8:00-6:00 Wed.8:00-4:30 Thurs.8:00-4:30 gcffi7766 NoAndRESgI T28 Pb•••••••AUTO-•5-DIGtT01845 Fri.8:00-12:00 TAX COLLECTOR: 978-688-9550 "IIII"'IIIII111„L,I'III'II111111111111111111 IP'1't'li,lllll ASSESSOR: 978-688-9566 WHITE, DAVID A Pay online at SUZANNE D WHITE 31 JAY RD www.townofnorthandover.com NORTH ANDOVER MA 01845-5502 Please use the enclosed lockbox envelope to expedite your payment. This will assist us in processing your payments more efficiently. I The Tax Collector's Office is located at 120 Main Street_ Town of North Andover 2nd Quarter Receipt Fiscal Year;2014 2nd Quarter Preliminary Real EstateTax Bill gill No. 4378 PROPERTY DESCRIPTION Jennifer Yarid,Collector of Taxes A"- LOC.-31 JAY ROAD Preliminary RE Tax 52901.78 CLASS CODE: 101 Interest at the rate of 14%per annum will accrue Preliminary CPA $66.48 MAP-LOT-PLOT:210-098.A-0056-0000.0 on overdue payments from the due date until a� BOOKIPAGE:4977/ 201 payment is made. Subtotal $2968.26 r RES.EXEMPT: $O A LAND AREA: Y TOT TAXABLE VAL 423000 111111111111II'II��'�IIW IN Mill I'I�I lilt No 11111 1st Qtr..Due 8101/2013 51484.13 E 2nd Qtr.Due 1,1101/2013 $1484;13 Payments_Made $1484.13 Assessed Owner as of January 1,2013: WHITE,DAVID A �+ SUZANNE D WHITE 31 JAY ROAD 0 NORTH ANDOVER,MA 01846 AMOUNT DUE P. 1111113 $1484.13 Y - Town of North Andover 2nd Quarter-Pavment Fiscal Year 2014 2nd Quarter gill No. 4378 Preliminary Real Estate Tax Bill R PROPERTY DESCRIPTION Jennifer Yarid,Collector of Taxes < LOC:31 JAY ROAD Preliminary RE Tax 52901.78 1 CLASS CODE: 101 Preliminary CPA $66.48 MAP-LOT-PLOT:210.098.A-0056-0000.0 Subtotal $2968.26/ 201 RES.EXEMPT. 00 1111111 IN IIIIt Hill II'!11111 mill(11111 loll lIII IN -TT _= LAND AREA: A TOT TAXABLE VAL:423000 1st Qtr:Due 810112013- $1484.13 2nd Qtr.Our.11/01/2019 01484.13 �. Payments Made $1484.13 E, Assessed Owner as of January 1,2013: WHITE,DAVID A SUZANNE D WHITE Ci 31 JAY ROAD AMOUNTDUE .. NORTH ANDOVER,MA 1111113 UE 01845 $1484.13 ,P P4pnggLASSatll.Unnnn.fill.A-tJnnLitt-flflrinnnnnninnnnUa7Allrlr)t nni.UAUlq-n.aC North Andover Health Department Community Development Division August 18, 2014 C000 Douglas J. Smith, R.S. Soil Smith Designs 15 Foxberry Drive New Boston,NH 03070 Re: 31 Jay Road (Map98A,Lot 56) Dear Mr. Smith: The proposed wastewater system design plan,for the above site dated July 8, 2014 and received on July 30, 2014 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item. 1. Please include the abutter names for the properties located to the south of the project site (NA 3.2). 2. Please indicate if there are wetland resources located within 150' of the proposed septic system(NA 3.2). 3. On sheet 1 of 2,proposed contours appear to be missing from the site plan view(NA 3.2). 4. On sheet 2 of 2,please clearly depict the existing grade and finish grade lines on the profile view. It is very difficult to distinguish between them as currently shown. 5. On sheet 1 of 2,please indicate the location of the utility pole that is being used as the benchmark. 6. Please specify the required annual maintenance for the effluent filter(3 10 CMR 15.227(7). 7. Please indicate that the distribution box shall be made watertight (3 10 CMR 15.221(1). 8. On sheet 2 of 2, the buoyancy calculations appear to be incorrect based on the proposed tank elevations, ESHWT of 96.85' (TP-4) and proposed cover material above the tanks. Please revise the buoyancy calculations accordingly. Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 1 9. Based on the ESHWT of 96.85' it appears the inlet and outlet invert elevations of the septic tank and pump chamber are less than 12" above the seasonal high groundwater table. A Local Upgrade Approval is required(3 10 CMR 15.227(5). 10. Adequate cover material does not appear to be proposed above the distribution box. The top of the distribution box appears to be 102.45' and the proposed finish grade is approximately the same elevation. 11. On sheet 1 of 2, please indicate the float elevations in the pump chamber. 12. On sheet 2 of 2, it appears the pump performance curve is below the operating point of 10 ft TDH @ 60 gpm. Please provide a pump that will meet the required pump parameters. 13. Please indicate the size and material of the access covers above the septic tank and pump chamber. The profile view should also indicate the access covers to finish grade. 14. There are no existing spot elevations at the southwest corner of the existing dwelling. Therefore, it is unknown if the proposed finish grading is directing runoff towards the existing dwelling. 15. On sheet 1 of 2,the distance from the'existing dwelling to the proposed septic tank is incorrect. 16. On sheet 1 of 2, TP-1 is missing the depth of the C layer. 17. The inlet elevation of the pump chamber is 97.32' and the outlet is proposed at 97.30'. It is preferred to use the precast knockouts in the tank for the outlet instead of coring new holes into the tank. However, if this is not proposed then please describe in detail the proposed method to install the pump chamber outlet at 97.30'. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincere y� jSsanY. Sawyer HS/RS Public Health irector cc: Suzanne White Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 °f"°eT 6963 F:, f : Town of North Andover HEALTH DEPARTMENT ,SSACHUSt� CHECK#: DAT LOCATION: Wh H/O NAME: CONTRACTOR NAME: Ty_Pe of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTICSystems : ❑ Septic-Soil Testing $ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ,AOR,. 6963 . o � a Town of North Andover HEALTH DEPARTMENT ,SSACHU CHECK#: X DAT LOCATION: H/O NAME: CONTRACTOR NAME: i Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $-a-0 Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer �gcrnur TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES ` HEALTH DEPARTMENT 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER,MASSACHUSETTS 01845 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.8476—FAX Public Health Director E-MAIL:healthdept@townofnorthandover.com WEBSITE:http://www.townofnorthandover.com SEPTIC PLAN SUBMITTAL FORM Date of Submission: � 2.� I ?09 Site Location: '31 Sr+-i f2o\4 J Engineer: 0Ylr1 ►'}' S 0 �'}` �es Ptei Vl New Plans? Yes�225/Plan Check# (includes 1St submi n-and-one-re- review only) RECEIVE® Revised Plans?Yes $75/Plan Check# JUL 3 0 2014 T6WN OF NORTH ANDOVER Site Evaluation Forms Included? Yes_ No HEALTH DEPARTMENT Local Upgrade Form Included? Yes__V No Telephone#: 603 4 �2� Fax#: (SGVy� �� So\� Syv\kt� (� t�oL-�O✓►7 E-mail: 5 O 1 L 5vv,. {'i1 (,4 a L - Co VVI Homeowner Name: �()Z ��fn-G OFFICE USE ONLY When the submission is complete(including check): - ➢ jZ Date stamp plans and letter ➢ Complete and attach Receipt ➢ 1� Copy File;Forward to Consultant ➢ _Enter on Log Sheet and Database i l i i Douglas J. Smith 15 Foxberry Drive New Boston, NH 03070 Phone (603) 487-2298 Email: Soilsmith@aol.com .........................:..................................... Sand Filter System Certification (Designer) This document is prepared to satisfy the requirements of Section II.18 of the Standard Conditions for Alternative Soil Absorption Systems, General Use and Remedial Use Approvals, Revised Date: March 19,2013. Technology: Presby Environmental, Inc. Enviro-Septic Leaching System Approval: General Use Approval MA-DEP Transmittal Number: X233394 Date of Issuance: Revised March 19,2013 Designer: Douglas J. Smith, RS Soilsmith Designs On February 16, 2006, I satisfactorily completed the required training by Presby Environmental, INC. for the design and installation of the Enviro-Septic Leaching System. I certify that the design conforms to the Approval, the Enviro-Septic Wastewater Treatment System Massachusetts Design and Installation Manual (Updated March 2011) and 310 CMR 15.000. System Owner: Suzanne White Site of System: 31 Jay Rd, North Andover, MA 01845 Plan Date: Fe6FuagF10r-70314 Revised: 5v L-t S, 20 I`I D glas J. Smit , S 1155 Soilsmith Designs Douglas J. Smith 15 Foxberry Drive New Boston, NH 03070 Phone:(603) 487-2298 Email:Soilsmith@aol.com ................................................................ Sand Filter System Certification (Owner) This document is prepared to satisfy the requirements of Section II.18 of the Standard Conditions for Alternative Soil Absorption Systems, General Use and Remedial Use Approvals, Revised Date: March 19,2013. Technology: Presby Environmental, Inc. Enviro-Septic Leaching System Approval: General Use Approval MA-DEP Transmittal Number: X233394 Date of Issuance: Revised March 19,2013 Owner of Record: Suzanne White Site Address: 31]ay Rd, North Andover, MA 01845 Plan Date: February 10,2014 Revision Date: I have been provided a copy of the Title 5 I/A technology approval, the owner's manual, and the Operation and Maintenance Manual and agree to comply with all terms and conditions. I will fulfill the responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) and the approval. I will provide written notification of the approval to any new Owner, as required by 310 CMR 15.287(5). It is understood that the system design does not provide for the use of a garbage grinder. Whether or not covered by warranty, the system owner understands the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303. It is understood that notification within 24 hours by the System Owner to the Local Approving Authority of any system failure is required. <�IQ,rOJED- 711h Signature Date Commonwealth of Massachusetts City/Town of North Andover v o Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health.Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd,where full compliance, as defined in 310 CMR 15.404(1), is not feasible. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.415.. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 19=8 Codssor 31.0=GMR 1000. RECEIVED A. Facility Information JULImportant: U 3 0 2014 When filling out 1. Facility Name and Address: TOWN OF NORTH ANDOVER forms on the computer,use Suzanne White }1EAt T K DEPARTMENT only the tab key Name to move your 31 Jay Rd cursor-do not Street Address use the return key. North Andover Ma 01845 City/Town State Zip Code teb 2. Owner Name and Address(if different from above): Name Street Address City/Town State Zip Code Telephone Number 3. Type of Facility (check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: 5 bedroom house 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): stone and pipe field upgrade NORTH ANDOVER JAY RD•rev.7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of North Andover v o Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: 550 gpd Design flow of proposed upgraded system 550 gpd Design flow of facility: 550 gpd B. Proposed Upgrade of System 1. Proposed upgrade is(check one): ® Voluntary ❑ Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: date of inspection 2. Describe the proposed upgrade to the system: a 1500 gallon tank, 1000 gallon pump chamber+ Presby enviroseptic System 3. Local Upgrade Approval is requested for(check all that apply): ❑ Reduction in setback(s)—describe reductions: ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction ® Reduction in separation between the SAS and high groundwater: 1' Separation reduction ft Percolation rate 20 min/inch min./inch Depth to groundwater 22" } upgrade NORTH ANDOVER JAY RD-rev.7/06 Application for Local Upgrade Approval* Page 2 of 4 Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater ❑ Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test ❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation,an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by: Doug Smith 10-30-2013 Evaluator's Name(type or print) Signature Date of evaluation C. Explanation Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: this will help with grading towards house etc. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: cost prohibitive on this site upgrade NORTH ANDOVER JAY RD•rev.7/06 Application for Local Upgrade Approval, Page 3 of 4 Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval o DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: not possibile 4. Connection to a public sewer is not feasible: muncipal sewer is not available 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ® Application for Disposal System Construction Permit ® Complete plans and specifications Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other(List): D. 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 to, penalties or fine and/or imprisonment for deliberate violations." IpFacility Owner's Signature Date Suzanne White Print Name Doug Smith July 8. 2014 Name of Preparer Date 15 Foxberry Dr. New Boston Preparer's address City/Town NH 03070 603 487 2298 State2lP Code Telephone upgrade NORTH ANDOVER JAY RD•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4 Commonwealth of Massachusetts City/Town of North Andover r Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal MassDEP has provided this form for use by on-site professionals and local Boards of Health. Other forms may be used, but the information must be substantially the same as provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information Suzanne White Owner Name 31 Jay Rd map 98A lot 56 Street Address North Andover Ma 01845 City State Zip Code B. Site Information 1. (Check one) ❑. New Construction ® Upgrade ❑ Repair 2. Published Soil Survey Available? ® Yes ❑ No If yes: web soil survey 260 B Year Published Publication Scale Soil Map Unit Sudbury Soil Limitations 3. Surficial Geological Report Available? ❑ Yes ® NO If yes: Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ® No Within the 500-year flood boundary? ❑ Yes ® No Within a velocity zone? ❑ Yes ❑ No 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name north andoverjay rd soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal B. Site Information (Continued) 6. Current Water Resource Conditions (USGS): Oct 30,2013 Range: ElAbove Normal ® Normal F-1Below Normal 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: 1 Oct 30,2013 9:00 rain Date Time Weather 1. Location. Ground Elevation at Surface of Hole: 96.40 Location (identify on plan): 2. Land Use existing house 6% (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) wooded Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body none' Drainage Way none Possible Wet Area none feet feet feet Property Line feet Drinking Water Well none Other feet 4. Parent Material: till Unsuitable Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ® Yes ❑ No If yes: 82 Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 20 94.74' inches elevation north andoverjay rd soil form-rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal -Page 2 of 8 &1\1 Commonwealth of Massachusetts City/Town of North Andover R Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 1 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other Depth Color Percent Gravel Cobbles& (Moist) Stones 0 -13" A 10YR 3/3 sandy granular friable loam 13"-20" B 10YR 5/6 loamy granular friable 20- 120" C 2.5Y5/4 20" 7.5YR5/8 5% sandy loam Additional Notes: north andoverjay rd soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 2 Oct 30, 2013 10:00 rain Date Time Weather 1. Location Ground Elevation at Surface of Hole: 96.33 Location (identify on plan): 2. Land Use existing house 6% (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) wooded Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body feet Drainage Way fete Possible Wet Area none et e Property Line feet Drinking Water Well feet Other feet 4. Parent Material: till Unsuitable Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 78 5. Groundwater Observed: ® Yes ❑ NO If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 13" 95.87 inches elevation north andoverjay rd soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 2 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other Depth Color Percent Gravel Cobbles& (Moist) Stones 0- 111, A 10YR 3/3 SANDY GRANULA FRIABLE LOAM R 11"- 16" B 10YR5/6 SANDY granular friable LOAM 16"-120" C 2.5Y6/4 13" 7.5YR5/8 5% LOAMY SAND Additional Notes: north andoverjay rd soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: ❑ Depth observed standing water in observation hole A. B. inches inches ❑ Depth weeping from side of observation hole A. B. inches inches ® Depth to soil redoximorphic features (mottles) A. # 1 20" B. #2 13" inches inches ❑ Groundwater adjustment(USGS methodology) A. B. inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed? Upper boundary: inches Lower boundary: inches north andoverjay rd soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 Commonwealth of Massachusetts City/Town of North Andover r Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal B. Site Information (Continued) 6. Current Water Resource Conditions (USGS): Oct 30, Range: ❑ Above Normal ® Normal ❑ Below Normal 2013 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: 3 Oct 30,2013 10:00 rain Date Time Weather 1. Location Ground Elevation at Surface of Hole: 98.65 Location (identify on plan): 2. Land Use existing house 4% (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) wooded Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body none' Drainage Way none possible Wet Area none feet feet feet Property Line Drinking Water Well none Other feet feet feet 4. Parent Material: till Unsuitable Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ® Yes ❑ No If yes: 96 Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 32" 95.99' inches elevation north andoverjay rd 3-4soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8 Commonwealth of Massachusetts City/Town of North Andover P Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal ,rte C. On-Site Review (Continued) Deep Observation Hole Number: 3 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other Depth Color Percent Gravel Cobbles& (Moist) Stones 0 -12" A 10YR 3/3 sandy granular friable loam 12"-120" C 2.5Y5/4 32" 7.5YR5/8 5% sandy granular friable loam Additional Notes: north andoverjay rd 3-4soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 4 Oct 30, 2013 13:00 rain Date Time Weather 1. Location Ground Elevation at Surface of Hole: 98.68 Location (identify on plan): existing house 4% 2. Land Use (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) wooded Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body feet Drainage Way none Possible Wet Area none feeProperty Line feet Drinking Water Well feet Other feet 4. Parent Material: till Unsuitable Materials Present: ❑ Yes ® No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ® Yes ❑ No If yes: 105" Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 2211 96,85 inches elevation north andoverjay rd 3-4soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) Deep Observation Hole Number: 4 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other Depth Color Percent Gravel Cobbles& (Moist) Stones 0-07" A 10YR 3/3 SANDY GRANULA FRIABLE LOAM R 07"-120" C 2.5Y5/4 22" 7.5YR5/8 5% LOAMY SAND Additional Notes: north andoverjay rd 3-4soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City/Town of North Andover F Form 11 Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: ❑ Depth observed standing water in observation hole A. B. inches inches ❑ Depth weeping from side of observation hole A. B. inches inches ® Depth to soil redoximorphic features (mottles) A. #3 32" B. #4 22" inches inches ❑ Groundwater adjustment(USGS methodology) A. B. inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed? Upper boundary: inches Lower boundary: inches north andoverjay rd 3-4soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Cf F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. I)A Oct 30, 2013 Signature of Soil Evaluator Date Douglas J. Smith se 2267 Nov. 11, 1999 Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam Michelle Grant North Andover Name of Board of Health Witness Board of Health Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. north andoverjay rd soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Field Diagrams Use this sheet for field diagrams: north andoverjay rd soil form•rev. 10/07 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 8 of 8 Commonwealth of Massachusetts City/Town of North Andover Percolation Test Form 12 �M Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. Important: A. Site Information When filling out forms on the computer,use Suzanne White only the tab key Owner Name to move your 31 Jay Rd cursor-do not Street Address or Lot# use the return key. North Andover Ma 01845 City/Town State Zip Code 978 557 8222 Contact Person(if different from Owner) Telephone Number B. Test Results 10-30-2013 9:30 10-30-2013 10:49 Date Time Date Time Observation Hole# P-1 P-2 Depth of Perc 43" 43" Start Pre-Soak 9:30 10:49 End Pre-Soak 9:45 11:05 Time at 12" 9:46 11:05 Time at W 10:00 11:49 Time at 6" 10:21 12:47 Time(9"-6") 21 /3=7 58/3=20 Rate(Min./Inch) Test Passed: ® Test Passed: Test Failed: ❑ Test Failed: ❑ Doug Smith Test Performed By: Michelle Grant BOH North Andover Witnessed By: Comments: t5form12.doc•06/03 Perc Test•Page 1 of 1