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Miscellaneous - 322 BOSTON STREET 4/30/2018 (2)
I 322- E)OST(�1\1 cbTIZ-ECT oe7 North Andover Board of Assessors Public Access Page 1 of 1 pOR7N North Andover Board of Assessors F A 'SS C.ou et roperty Record Card Click Seal To Return Parcel ID:210/107.D-0024-0000.0 FY:2010 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlarge Search for Parcels Search for Sales Summary Residence "y Detached Structure a� Condo 322 BOSTON STREET ` J Commercial Location: 322 BOSTON STREET Owner Name: BELSON,DAVID&HEATHER Owner Address: 322 BOSTON STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6-6 Land Area: 1.31 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1508 sqft i ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 394,100 420,200 Building Value: 184,800 209,200 Land Value: 209,300 211,000 Market Land Value: 209,300 Chapter Land Value: LATESTSALE Sale Price: 480,000 Sale Date: 10/17/2004 Arms Length Sale Code: Y-YES-VALID Grantor: KERR,STUART Cert Doc: Book: 9124 Page: 260 http://csc-ma.us/PROPAPP/display.do?linkld=1519952&town=NandoverPubAcc 1/19/2010 NORTHaa JCoDtVa Q� t�.ED I6-7�� . o t T D tOCMit MMwKM�1' ADAATIE SSACHUg� PUBLIC HEALTH DEPARTMENT (ommunity Development Division f-IFRTI FICA2'F OE CO9VIPGI. qXC'E As of: May 25, 2010 This is to cert that the individua(su6surface d4osal system received a SArIIS FACTORT INS(PEMOV of the: ftairl!Xqhcement of an On Site Sewage Disposa[System By� ToddBateson At: 322 Boston Street Wap-107.D; (Parcel 24 9Vorth Andover, 9WA 01845 The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. i usan T Sawyer, REKS/ j Pu6Cac Ylealth Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com f i pORTM z �SSwtHuSEs MAY 17 2010 PUBLIC HEALTH DEPARTMENT TOWN OF NORTH ANDOVER Community Development Division HEALTH DEPARTMENT TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( )constructed;( )repaired; By: ©t7y ?I kTEGIOo (Print Name) Located at: 37i7/ gTi7� YL,E�T (Installation Address) I I Was installed in conformance with the North Andover Board of Health approved plan,originally dated and last revised on with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 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: '(Y �`�-t�s, ..►� �o Engineer Representative(Signature) O G V4EU-ftX'- And—Print Name Final Construction Inspection Date: E2. 67). Engineer Repres tative(Signature) And—Print N Installer: (Signature) Date:.5-- �� b And—Print Name Enginer: 41MPW'41011/(Signature) Date: And—Print Name 1600 Osgood Street, North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com r AS-BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP &PARCEL NUMBER LOT LINES &LOCATION OF DWELLINGS LOCATIONS &DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES &PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION 7,1 LOCATIONS OF WELLS,DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS,ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX ORIGINAL STAMP& SIGNATURE IMPERVIOUS AREAS -DRIVEWAYS, ETC. NORTH ARROW , LOCATION&ELEVATIONS OF BENCHMARK USED t1ORT1i q 0 ~ 1� OCoCNIc"k- 1 ��SSACHUS���� PUBLIC HEALTH DEPARTMENT (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 322 Boston Street MAP: 107D LOT: 24 INSTALLER: Todd Bateson DESIGNER: Vladimir Nemchenok PLAN DATE: 2/3/10 BOH APPROVAL DATE ON PLAN: 3/25/10 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION. ICQ l DATE OF FINAL CONSTRUCTION INSPE TION: 5/10/10 DATE OF FINAL GRADE INSPECTION: ��aa�) SITE CONDITIONS NA Contractor reports any changes to design plan ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered SEPTIC TANK ® Building sewer in continuous grade, on compacted firm base NA Cleanouts per plan ® 1500 gallon tank has been installed H-10 loading mono construction ® Water tightness of tank has been achieved by Visual testing ® Inlet tee installed, centered under access port ® Outlet tee installed, centered under access port (/effluent filter) 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form lune 2008 pORTF4 O0 CIO .Q SSACH S PUBLIC HEALTH DEPARTMENT Community Development Division ® 24" inch cover to within 6" of final grade installed over one access port ® Hydraulic cement around inlet & outlet Comments: DISTRIBUTION-BOX ® Installed on stable stone base NA Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) Comments: H-20 D-box installed. SOIL ABSORPTION SYSTEM (General) ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan ® 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 NA Retaining wall (boulder/concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) Z Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ® Number of chambers per row: 11 ® Number of rows (trenches): 4 Comments: Total Chambers = 44 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 NORTH j t�cc 16 3'? 6`'1'- F 6 OL O * �ER � O COCMIC HIwK• 7' SSACHU`���I PUBLIC HEALTH DEPARTMENT (ommunity Development Division BM = 100.00 HR = 1.90 HI = 101.90 SYSTEM ELEVATIONS ROD ELEVATION AS-BLT INVERT ELEV DESIGN INVERT ELEV Benchmark 1.90 100.00 Building Sewer OUT 96.75+/- Septic Tank IN 5.15 96.40 96.39 Septic Tank OUT 5.40 96.15 96.14 Distribution Box IN 5.84 95.71 95.70 Distribution Box OUT 6.02 95.53 95.53 Lateral 1 TOP 6.06 Lateral 1 INVERT 95.49 95.50 Lateral 2 TOP 6.06 Lateral 2 INVERT 95.49 95.50 Lateral 3 TOP 6.08 Lateral 3 INVERT 95.47 95.50 Lateral 4 TOP 6.06 Lateral 4 INVERT 95.49 95.50 Top of Chamber 6.02 95.88 95.83 Bottom of Bed/Chamber 7.02 94.88 94.83 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 pORTi4 J' 40-So t6,S O 3r e.., .." ° OL ti o .,.. COCMIC lwKM� CH PUBLIC HEALTH DEPARTMENT Community Development Division 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 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh,Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib.to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains(wat. supply/trib.) 50 100 ® Drains(intercept g.w.) 25 50 ® Drains(Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnarthandover.com Inspection Form lune 2008 Commonwealth of Massachusetts Map-Block-Lot 107.D0024 ----------------------- Board of Health Permit No a BHP-2010-0565 North Andover -------- FEE P.I. $250.00 • :�a ----------------------- S.s�cwu4 F.I. DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson ---------------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. , atNo 322 BOSTON S_T_REET ---------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. - - - - ---- -- p BHP-20010-M-r--Dated M y 4,2010-------- -------------�I 1..� 0-- ---------------------- Issued On:May-04-2010 Board of Health --------------- e 0 •,;',:0.�o-R_T�,..•,�ooc ion for /0 pplica Septic Dis osal S stem Construction Permit - TOWN OF TOAAYS DATE ��• ., .f« ORTH ANDOVER, MA 01845 $250.00—Ful!Repair �►�S+,....� 6906 110=12-ampolamf S�c� RE Important: Application is hereby made for a permit to: When filling out — ❑ Construct a new on-site sewage disposal system* HAY — 3 W O forms on the computer,use [�')?pair or replace an existing on-site sewage disposal syste only the tab key TOWN OF NORTH AN�V� to move your ❑ Repair or replace an existing system component—What? HEALTH DEPARTMENT cursor-do not use the return key. A. Facility Information y=�l Address or Lot# Clty/Town p r 2.-*TYPE OF SEPTIC SYSTEM*: Pum choose El Pump Gravi ty( ere) ***If pump system,attach copy of electrical permit to application*** ❑ Conventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑Pressure Dosed(D-Box Present)S.A.S. 2. Owner information A- -�e Name Address(if different from above) City/Town State Zip Code 1'2b' `��.s - a3s"7 Telephone Number 3. Installer Information Name Name-o TCo`mpany Address City/Town State Zip Code 17? F«— a,),, Telephone Number(Cell Phone#if possible please) 4. Designer Information f ."-plcJ Name Name of Company k. Address M City/Town State Zip Code 3 sss Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page t of 2 1 8 1 °RTM Application for Septic Disposal System _ �o _ p Construction Permit — TOWN OF TODAY'S DATE ORTH_ANDOVER, MA 01845 $250.00-Full Repair CN„5 $125.00 -Component PAGE 2OF2 A. Facility Information continued 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issuedPby7is Board of Health. Name Date — Application Prov: d By: (Board of Health RepresenA( - ti Name G Dat Applicatio Disapproved,for the following reasons: For Office Use Oniy� 1 Fee Attached. Yes✓ _ No 2. Project Manager Obligation Form AtiachedP Yes --- No 3. Pum -SY—ste—P If so.Attach copy ofElectrical Petmit Yes i� No 4. Foundation As-Built. (new construction ronly): Yes (Same scale as approved plan) No 5. Floor Plans?(new construction only). Yes_ No Application for Disposal System Construction Permit•Page 2 of 2 y SEPTIC SYSTEM.INSTALLgR°PROJECT.MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system:for the property at: (Address of septic system) For plans by 'n (� (Engineer) Relative to the.application of to d4g 2Sw\J . (Installer's name) j And dated -a— ngina ate) Dated —�� �p Iociay's ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am.obligated to obtainall permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the perinit on site when any work is being done. 2. AS the installer, I.mustto for any and all.inspections. If homeowner, contractor,_project other person not associated with my compmanager, or any any schedules an inspection and the system is not ready, then item three shall..be applicable. 3.` As the installer,.I atn required to.have the necessary work.completed prior.to the applicable inspections as indicated below. .I understand that rouesting:an in� .without completion of the items in accordance with Title 5 and-the Board of Health Regulailons xray result in a$50 OO fine being levied against me and/or my company a Bottom:of Bed:=Generally,this.is the first(Vo n unless.:there is a"retaining wall,which: should be done:first. The install er must request the inspection n but does not have to be present. b. Final:Construction Inspection—Engineer must first_do their inspection for elevations;ties,etc. As-built of venial OK (or e-mail to:healdidept@townofnorthandover com from the engineer m be submitted to:the B gm. ust Board of.Health,after which installer.calls for an inspection time. Ins be resent for this inspection.. p taller must pWith a pump system,all electrical work,must be ready and able to cause pump to work and alatm.to function. C.. Final Grade—Installer m..ust request'inspection when all grading cpm lete. gr g Installer does have to be on-site.. p not 4. As the installer,I understand that only I may perform the work(other than rimple excavation)and I am required to complete the installation of the system identified in the attached *application for installation: ':I further understand:that work done b others unlicensed to install se tics stems..in North Andover tali constitute reasons for denial of the s stem and/or.,.revocation or sus ension of m . license•to o elate in the Town.of North Andover significant fines.to all persons involved are alsoossilile. S.. As the.mstaIler,I understand that must`be on-site during theperformance of the.following construction a steps: a. Determination that.the proper elevation of the excavation has been reached A Inspection of the sand and stone to be used. C. Final inspection by Board ofHealth staffor consultant. d. Installation,oftank,D-Box,pipes,stone, vent,.pump cham components. her, tetainirrg wall and other 6. As the installer I riders and that I.a n s6l ly res onsible for the installation of the s stem as er the a roved dans. No instructions b the homeowner tion or an other ersons shall-absolve me of this obli tion. Undersigned Ucensed Septic Installer: (Today's Date) 4/.. ame:— .reit r TOWN OF NORTH ANDOVER Permit Number NORTH ANDOVER,MASSACHUSETTS 01845 �oR* Date Issued Expiration Date K Teo n SS�cµug� Jackie's Law — Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION of Applicant - Phone Cell [N:ame et Address //f �•gam` /.� v� ity/fown MA ZIP Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s)of Property Phone Cell �-E,e..�►.S�e.� i�(Som Street.Address City/Town MA ZIP OVs AJ- Other Contact Permit Fee Received No yes Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench(eg;pipes/cable lines etc..).Please use reverse side if additional space is needed. yS , Insurance Ce tiffcate#: + Name and Contact Information of Insurer: M�L RL- Q R Policy Expiration Date: Dig Safe#: c� o �Su /GSA Name of Competent Person(as defined by 520 CMR 7.02): t Massachusetts Hoisting License# License Grade: Expiration Date: BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L.c. 82A,520 CMR 7.00 et seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF TTS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLIC T SIGNATURE DATE EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNA>TUpRE(IF DIFFERENT) DATE: 2 J P a g e M - _eg�n 7 f1:411 i W6] 9F9 0 WIN P S SIX 11�_!: ........... IM INS, CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the application,the applicant understands and agrees to comply with the following; i. No trench may.be excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including,but not limited to,the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164(DIG SAFE); Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws,an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety.hazards which may include covering, iii. barricading or otherwise protecting open trenches from accidental entry. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR iv. 1926.650 et.seq.,entitled Subpart P'Txcavations". , Excavators engaging in any trenching operation who.utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for,accepting.and signing this permit,the applicant hereby attests to the following:(1)thatthey have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related-excavations and trench safety; (2)that he has.read and understands the federal safety standards Promulgated by the Occupational Safety and Health Administration on excavations:29 CMR 1926.650 etseq.,entitled Subpart P"Excavations" as well as any other excavation requirements established by this municipality,and(3)that he is aware of and has,with regard to the proposed trench excavation on private property or Proposed excavation Of a city or town public way that forms the basis of the permit application,complied with the requirements Of sections 40- 40D of chapter 82A. vi. This permit shodi be posted in plain view on the site of the trench, For additional information please visit the Department of Public Safety's website at_1vvW .m�s 0 3 P a g e r Summaly of Excavation And Trench Safety Regulation(520 CMR 14.00 et segs This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L,c.82A and does not include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82Ao to www/mass,gov/dps g g ps Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety,jointly with the Division.of Occupational Safety, drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code.of Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction-related purpose on public or private land or.rights-of=-way, All municipalities must establish a local permitting.authority for the purpose of issuing permits for trenches within their municipality, Trenches on land owned or controlled by a public(state)agency requires a permit to be.issued by that public agency unless otherwise designated. In addition to the permitting requirements mandated by statute, the trench safety regulations require that all excavators,.whether public or private,take specific precautions to protect the general public andprevent unauthorized access to unattended trenches. Accordingly,unattended trenches must be covered, barricaded or backfilled, Covers must be road plates at least'/."thick or equivalent;barricades must be fences at least 6'high with no openings greater than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators may choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who will be present during times when the trench will be unattended by the excavator. The regulations further provide that local permitting authorities,the Department-of Public of Occupational Safety may order an immediate shutdown of a trench in the event of a death or seri ups in to a Dthe failure to obtain a permit, or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown until reinspected and authorized to re-open provided, howethe excavators shall ver,. have the right to appeal an immediate shutdown. Permitting authorities are further authorized suspend or revoke a Public Safety for identified violations, r, permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of Summary.of 1926 CTR Subpart P-OSHA Excavation Standard This is a worker protection standard,and is designed to protect employees who are working summary was Prepared b rkin inside a trench, p P y the Massachusetts Division of Occupational Safety and not OSHA for informational This purposes only and does not constitute an offi aspects of the standard. cial interpretation by OSHA of their regulations;and may not include all For further information or a full copy of the standard go to www.— °S- Trench Deflniti on per the OSHA standard: o An excavation made below the surface of the grotuid,narrow in re Wion itsngth o In general,the depth is greater than the width;but the width of the trenchtis ofgreater than fifteenfeet. • Protective Systems to-prevent soil wall Collapse are always red in tren required in trenches less than 5'deep when the compel nt personrdeterminescthat ahes ehpa d eanxi5sts Paot colon Options include: o Shoring. Shoring must be used in accordance with the OSHA Excavation standard a equipment manufacturer's tabulated data,or d appendices,designed �the o Shielding d by are 'st tongr ered r g(T. ch Boxes), Trench boxes must be'-used Professional engineer, manufacturer's tabulated da . or a re ' e used in accordance with the equipment o Sloping b?stered professional engineer. p ping or.Benching. In Type C soils(what is most extend horizontally 1 /feet for eve' foot of trench depth on both encountered) smidesel)the foot for must and'/,foot for ry p Type A soils. , Type 13 soils, o A registered professional engineer must design protective systems for all excavations greater than 20'in depth, continued 4 1 P a g e --__.-_-•- -•—.._____ ---------____ -- �. _..----------_ ._ __ • Ladders must be used in trenches deeper than 41. o Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed lateral travel for every worker in the trench. o Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the ladder. • Inspections of every trench worksite are required: o Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm. o Inspections must be conducted by the competent person(see below), • Competent Person(s)is: o QMable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the trench,and other working conditions which may pose a hazard to workers,and o utho 'zed by management to take necessary corrective action to eliminate the hazards. Employees must be removed-from hazardous areas until the hazard has been corrected. • Underground Utilities must be: o Identified prior to opening the excavation(e.g.,contact Dig Safe). o Located by safe and acceptable means while excavating. o Protected,supported,or removed once exposed. • Spoils must be kept back a minimum of 2'from the edge of the trench. • Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep heavy equipment and heavy material as far back from the edge ofthe trench as possible. • Stability of Adjacent Structures: o Where the stability of adjacent structures is endangered by creation of the trench,they must be underpinned,braced,or otherwise supported. o Sidewalks,pavements,etc.shall not be undermined unless a support system or other method of Protection is provided. • Protection from water accumulation hazards: o It is.not allowable-for employees to work in trenches with accumulated water. If water control such as pumping is used to prevent water accumulation,this must be monitored by the competent person. o If the trench interrupts natural drainage of surface water,ditches,dikes or other means must be used to prevent this water from entering the excavation.. • Additional Requirements: o For mobile equipment operated near the edge of the trench,a warning system such as barricades or stop >�to must be used, o Employees are not permitted to work underneath Ioads. Operators may not remain in vehicles being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6). o Employees must wear high-visibility clothing in traffic work zones. o Air monitoring trust be conducted in trenches deeper than 4'if the potential for a hazardous atmosphere exists. If a hazardous atmosphere is found to exist(e g.,02<19.5%or>23.5%,20% LEL;specific chemical hazard),adequate protections shall be taken such as ventilation of the space. o Walkways are required where employees must cross over the trench. Walkways with guardrails must be provided for crossing over trenches>6'deep. o Employees must be protected from loose rock or soil through Protective barricades, protections such as scaling or 5�P a g e________....___....._.._._..._. _.—.__......._---•--�_ —._._._.—_.—_.__._..._....__._._..__._._.__.._ __.. 1 TOWN OF NORTH ANDOVER Permit Number NORTH ANDOVER,MASSACHUSETTS 01845 %40R,rh Date Issued x REOWE TP iration Date .4 °^wn° .Sig {Ni t��^ pr�1qI,7!151 Ss�Cµll �IA1 i it 5 !rM 1 V TOWN OF NOPtTH AN DOVER HEALTH DEPARTMENT Jackie's Law Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7,00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant Phone Cell Street Address CitylTowp MA ZIP � Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s)of PropertySDpj Phone ^ Cell Street Address -- 3 City/Town MA ZIP Other Contact Permit Fee Received No Yes Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and itsu s be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side If additionalispace is tided,ption otwhat is(oris intended)to Insurance Certificate#: 1 Name and Contact Information of Insurer: 111i C'A__ 0 l"q— P.®. 8 r A43 , r7� ocB'ys Policy Expiration Date: _ e Dig Safe#: ^ Name of Competent Person(as defined by 520 CMR 7.02): Massachusetts Hoisting License# � License Grade: Expiration Date: BY SIGNING THIS FORM, THE APPLICANT; OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L.c. 82A,520 CMR 7.00 et seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH-WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND.SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TS TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF IAGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTIOi,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON.OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLIC p�SIGNATURE DATE EXCAVATOR SIGNATURE(IF DIFFERENT) DATE SI A (IF DIFFERENT) DATE: 2 P a g e-------------------- -------_ _---—_ .._•__.-__ ____ _ ------ _—_ t � r �6.,'ar'�.m� 7$?''R�?��.'a'� �.,(.F,...���1� �NY�.AA��.. ..f�. .lr - ...?��?�!1k���°�.-:."a'',"-'ir i�-.s':..=<3�"ff/�--✓'^.;;•.'-�r���;� �,.-'L��'.".''.-� xYr.,�- .+-;�-•. .r�rz� _ .p;F�' _ �r:..-s?-G^c�:-y, �,a,. ��� ;.�,'•:,�,.d4M,.i'���'.:r;u��r Y-:�'�. ,�'�5. ...k �� n �.-.r"- - r•.„ .,,K7✓. ! w-:3�.c ON,v"�fi .���F,y-,: -�7 .c -� -' .:moi._ ..:��t�.:�7 �-=x�%`�'r%;G�^'� ;r,�,:r_ ..'.`�fic�' ,e-.•` -7'�.,,s _ ... 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'' �.''": w�^:-�-;rf.-����,,��•' §. .�,�.'h�+l'��-/=,.�;:�.a' n ltd-�' ur� ..r7"-e_^TxG`s1 .._•..��Ji�. :,�:..'T?-5„_,.�=ro ''���,-'.��. 5r-ci'.�ur.J �'�i'.�'^..eo-� "3?'f - „<.::c-.co,.n'.x'�"'; .r,..:a-�-,t.,.".::", ''-.<`.'���^ _�y'S?';�`1t;`�r_�� 1-.r`aa.�-..f�w.,.lc�',•,.� ; �...�}-,, ;�-.., - '?. ��'�;�z5.".•,,, -..r"_ta--r _ .s��r �;�, •-'.u'"✓ �%°'r"'3c.--s;:.:�� -�":-.,rN .r s ms..ca'.E..-..;,_.,,r�.�G.al...,.-.Y.•'✓`'r"=4� ..r.^� 'uy��.s=i£',.��.;X<n++•=�``'_'._ •gy.�.��.`�„^r.>iT�s.^,.'�F'`;_:� �:� �.w.�`"..�'tYr-�:�sX �.-. r.�.�.r.9_'i.-. ,,�,��-�3,G�':��� �� �'w f^�' ..� J.`�rt��K+:t ,�v`3.•..,.. --7f.7.`^.%uj ,-r...'K°i=?�`�.�c--'1���.%:'�•-��>`.r :v.rY::-,",,.�`..._�-.':il" _ -.`-�G'�J"/^r.%w:.Gsr`�'�.:5. --"u'�-.w.:��..�'�1�.� �3��?....- ....x.:.: - ,.^.-,>....•..r..r.s..a;:s"'.": ..,.-.ir..'�`.':.:-r...-..:^�,:...f..rTsr"��,�..`zf'--•;>�rr, =^,.�'�;��.,a'c;� �c� - CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the application,the applicant understands and agrees to comply with the following: i. No trench may be excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including,but not limited to,the establishment of a valid excavation number with the underground plant damage prevention system as ii. said system is defined in section 76D of chapter 164(DIG SAFE); Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws,an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR 1926.650 et.seq.,entitled Subpart P"Excavations". iv. Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for,accepting and signing this permit,the applicant hereby attests to the following;(1)that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety.; (2)that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CMR 1926.650 et.seq.,entitled Subpart P`Excavations"as well as any other excavation requirements established by this municipality;and(3)that he is aware of and has,with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at tY m s d t y Summary of Excavation and Trench Safety Regulation(520 CMR 14.00 et seg.) This summary was prepared by the Massachusetts Department of Public Safety pursuant to Q.L,c.82A and does not include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A,go to www/mass,gov/dps Pursuant to M.G.L. c. 82, § 1, the Department of Public Safety,jointly with the Division of Occupational Safety, drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code.of Massachusetts Regulations, The regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction-related purpose on public or private land or rights-of-way, All municipalities must establish a local permitting.authority for the purpose of issuing permits for trenches within their municipality, Trenches on land owned or controlled by a public(state)agencyrequires a permit to be.issued by that public agency unless otherwise designated. In addition to the permitting requirements mandated by statute, the trench safety regulations require that all excavators,.whether public or private,take specific preeaution�to protect the general public andprevent unauthorised access.to unattended trenches. Accordingly,unattended trenches must be covered, barricaded or backfilled, Covers must be road plates at least'/."thick or equivalent;barricades must be fences at least 6'high with no openings greater than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators Wray choose to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who will be present during times when the trench.will be unattended by the excavator. The regulations further provide that local permitting authorities,the Department of Public Safety,or the Division of Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure to obtain a permit, or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown until re-inspected and authorized to re-open provided, however, the excavators shall have the right'to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a permit following a hearing. Excavators may also be subject to administrative Ernes issued by the Department of Public Safety for identified violations, Summary.of 1926 CFR Subpart P-OSHA Excavation Standard This is a worker protection standard,and is designed to protect employees who are working inside a trench. This Purposes only and does not constitute an official sumMarY was Prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational aspects of the standard. interpretation by OSHA of their regulations,and may not include all For further information or a full copy ofthe standard go to_www,_ ostiagov. Trench Definition per the OSHA standard: o An excavation made below the surface of the groturd,narrow in relation to its length. feet. o In general,the depth is greater than the width,but the width of the trench is not greater than fifteen • Protective Systems to-prevent soil wall collapse are always required in trenches deeper than 5',and are also required in trenches less than 5'deep when the competent person determines that a hazard exists. Protection options include: o Shoring. Shoring must be usedin'accordance with the OS equipment manufacturer's tabulated data,or designed by aregiHA Excavation standard stered professional engineer1��the o Shielding(Trench Boxes). Trench boxes must be used in accordance with the manufacturer's tabulated data,or a registered professional engineer. �uipment o Sloping or zoBenching.alIn Type C soils(what is most typically encountered)the excavation must extend horizontally 1 %feet for every foot of trench depth on both sides, 1 foot for Type B soils and'/foot for Tape A soils. o A registered professional engineer must design 20'in depth, 1 Protective systems for all excavations greater than continued 4 1 P a g e __--- t • Ladders must be used in trenches deeper than 4'. o Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed lateral travel for every worker in the trench. o Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the ladder. • Inspections of every trench worksite are required: o Prior to the start of each shift,and again when there is a change in conditions such as a rainstorm. o Inspections must be conducted by the competent person(see below). • Competent Person(s)is: o C,gpable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the trench,and other working conditions which may pose a hazard to workers,and o Authorized by management to take necessary corrective action to eliminate the hazards. Employees must be removed.from hazardous areas until the hazard has been corrected. • Underground Utilities must be: o Identified prior to opening the excavation(e.g.,contact Dig Safe). o Located by safe and acceptable means while excavating. o Protected,supported,or removed once exposed. • Spoils must be kept back a minimum of 2'from the edge of the trench. • Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep heavy equipment and heavy material as far back from the edge of the trench as possible. • Stability of Adjacent Structures: o Where the stability of adjacent structures is endangered by creation of the trench,they must be underpinned,braced,or otherwise supported. o Sidewalks,pavements,etc.shall not.be undermined unless a support system or other method of protection is provided. • Protection from water accumulation hazards: o It is.not allowablefor employees to work in trenches with accumulated water. If water control such as pumping is used to prevent water accumulation,this must be monitored by the competent person. o If the trench interrupts natural drainage of surface water,ditches,dikes or othermeans must be used to prevent this water from entering the excavation. • Additional Requirements: o For mobile equipment operated near the edge of the trench,a warning system such as barricades or stop logs must be used. o Employees are not permitted to work underneath loads. Operators may not remain in vehicles being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6). o Employees must wear high-visibility clothing in traffic work zones. o Air monitoring must be conducted in trenches deeper than 4'if the potential for a hazardous atmosphere exists. If a hazardous atmosphere is found to exist(e:g.,OZ<19.5%or>23.5%,20% LEL,specific chemical hazard),adequate protections shall be taken such as ventilation of the space. o Walkways are requi*ed where employees must cross over the trench. Walkways with guardrails must be provided for crossing over trenches>6'deep. o Employees must be protected from loose rock or soil through protections such as scaling or protective barricades. 5 P a g e _....----.._.._.__...—.... DelleChiaie, Pamela From: Marianne Peters[mpeters@millriverconsulting.com] Sent: Friday, May 07, 2010 1:43 PM To: DelleChiaie, Pamela Cc: Sawyer, Susan; Grant, Michele Subject: RE: 322 Boston Street- Final Const. Request This is scheduled to be done on Monday @ 9:30 with Isaac. Have a great weekend all! From: DelleChiaie, Pamela [ma!Ito:pdel lech @townofnorthandover.com] Sent: Friday, May 07, 2010 1:37 PM To: 'Daniel Ottenheimer'; 'Isaac Rowe'; Peters, Marianne; 'Randy Burley' Cc: Bill Dufresne (brdufresne@comcast.net) Subject: FW: 322 Boston Street- Final Const. Request Importance: High Hello, Please call Bill Dufresne to schedule the Final Const. at 322 Boston Street. Thank you. His number is: (978) 502-6206. Have a wonderful weekend everyone! It is gorgeous outside today!!!!! ew wjr w, , "We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20;Suite 2-36 North Andover,MA 01845 978.688.9540-Phone 978.688.8476-Fax pdellechiaie@townofnorthandover.com-E-mail http://www.townofnorthandover.com/Pages/index-Website Notes.- If otes.If copied to BOH Members-Reference Copy Only-no response requested at this time From: Grant, Michele Sent: Friday, May 07, 2010 12:49 PM To: DelleChiaie, Pamela Cc: Sawyer, Susan Subject: 322 Boston Street 1 i )Hi, the following is ready for a final inspection. Please call Mill River. Bill Dufresne called I i i i i z 4 DelleChiaie, Pamela From: Sawyer, Susan Sent: Wednesday, April 14, 2010 8:27 AM To: Sawyer, Susan; 'dbelson@gmail.com' Cc: DelleChiaie, Pamela Subject: RE: 322 Boston Street Attachments: SKM BT_60010040513570.pdf Pam, I sent this email on the 5th. Did this get sent regular mail as well? If so, do you know when? Thank you Susan Susan: You noted over a week ago that you would be mailing the approval letter, and we have not yet received the hard copy of it. Has it been mailed out yet? Thanks... --David On Mon,Apr 5, 2010 at 2:14 PM,Sawyer, Susan<ssawver@townofnorthandover.com>wrote: Mr. Belson,We will have this approval letter in the mail as well tomorrow. Thank you for your patience. Susan Sawyer Health Director http://www.townofnorthandover.com/Pages/NAndoverMA Health/septicinstallers.pdf From:noreply@townofnorthandover.com [mai lto:noreply@townofnorthandover.com] Sent: Monday,April 05,2010 2:57 PM To:Sawyer,Susan Subject: Message from KMBT_600 From: Sawyer, Susan Sent: Monday, April 05, 2010 2:15 PM To: 'dbelson@gmail.com' Cc: DelleChiaie, Pamela; 'brdufresne@comcast.net' Subject: 322 Boston Street Mr. Belson,We will have this approval letter in the mail as well tomorrow. Thank you for your patience. 1 J, ' Susan Sawyer Health Director http://www.townofnorthandover.com/Papes/NAndoverMA Health/septicinstallers.pdf From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Monday, April 05, 2010 2:57 PM To: Sawyer, Susan Subject: Message from KMBT 600 I 2 pORTF� d `E D 16'�OQ O t O coc LAKS .�It 140 ORArea PPa,�'�y SSACHUSO PUBLIC HEALTH DEPARTMENT Community Development Division March 25, 2010 David and Heather Belson 322 Boston Street North Andover, MA 01845 RE: Septic System Design, 322 Boston Street, Map 107D lot 24 Dear Mr. and Mrs. Belson, The North Andover Board of Health has completed the review of the septic system design plans, for the above referenced property, submitted on your behalf by Merrimack Engineering Services, dated February 3, 2010, last revised March 18, 2010. This plan has been approved. The approval includes a Local Upgrade approval granted by the North Andover Health Department for the use of a single deep hole within the proposed disposal area. Please keep a copy of this approval with your household records. The design has been approved for use in the construction of an onsite septic system for a 3- bedroom house (maximum 7-room). In accordance with local subsurface disposal regulations "Acceptable plans and any variances shall expire two years from the date approved unless construction on the lot has begun". 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 subject to the following conditions: 1. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit. 2. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector,Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe or imply compliance with any of the aforementioned requirement. To: 322 Boston Road SAS approval letter March 25, 2010 Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you may have. Sincerel , Susan Y. Sawyer,REH7SS Public Health Director Encl: list of licensed septic system installers Form 9B Cc: Merrimack Engineering Services I i . Commonwealth of Massachusetts City/Town of Local Upgrade Approval Form 913 by V 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 David and Heather Belson key to move your Name cursor-do not 322 Boston Road use the return Street Address key. 40 North Andover MA 01845 City/Town State Zip Code 2. Owner Name and Address (if different from above): I�f�l Name Street Address City/Town State Zip Code Telephone Number 3. Type of Facility(check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 330 4. Design flow per 310 CMR 15.203: gpd 5. System Designer: Vladimir Nemchenok ® PE ❑ RS Name 66 Park Street North Andover MA, 01810 Address City/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 322 Boston Road form9b 3.17.10•rev.7/06 Local Upgrade Approval* Page 1 of 2 Commonwealth of Massachusetts City/Town of Local Upgrade Approval Form 913 M B. Approval (continued) ❑ Reduction in separation between the SAS and high groundwater: Separation reduction ft Percolation rate min./inch Depth to groundwater ❑ 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 Dept. Approving Authority Susan Sawyer, Health Director r March 17, 2010 Print or Type Name and Title g ature tDate 322 Boston Road form9b 3.17.10•rev.7/06 Local Upgrade Approval* Page 2 of 2 r►ORTH Ot�t,-eo 06�ti0 O 4 T o l n . .,. 'QQ COCNIC CWKR,V tsATEI)% PUBLIC HEALTH DEPARTMENT Community Development Division March 1,2010 Vladimir Nemchenok Merrimack Engineering Services 66 Park Street Andover,MA 01810 Re: Subsurface Sewage Disposal System Plan for 322 Boston Street,Map 107D,Lot 24 Dear Mr.Nemchenok: The proposed wastewater system design plan for the above site dated February 3,2010 and received on February 10, 2010 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. A Local Upgrade Approval for only having one test pit in the soil absorption system area must be requested. Please revise the Form 9A and note the Local Upgrade Approval request on the design plan(3 10 CMR 15.405(1)(k)). 2. It appears that the bottom of the septic tank may be below the ESHWT. Please determine the ESHWT elevation in the proposed tank location and provide buoyancy calculations if required(3 10 CMR 15.221(8)). 3. A riser to within 6 inches of finish grade is required above the distribution box if greater than 9 inches below grade. Magnetic tape cannot be used as an alternative to providing a riser. Please modify the note in the"Graphic Scale"on sheet 2. 4. Please specify all system components shall be marked magnetic marking tape including the septic tank(3 10 CMR 15.221(12)). 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, Susan Y. Sawy ,REHS Pub7� lic HealtDirector cc: David&Heather Belson File 1600 Osgood Street HEALTH DEPARTMENT Page 1 of 1 Building 20;Suite 2-36 E-Mail: healthdept@townofnorthandover.com North Andover,MA 01846 Phone:978.688.9540 Fax:978.688.8476 MERRIMACK ENGINEERING SERVICES, INC, ` PROFESSIONAL ENGINEERS LAND SURVEYORS PLANNERS 66 PARK STREET• ANDOVER,MA 01810• (978)475-3555,373-5721 • FAX(978)475-1448• E-MAIL info@merrimackengineering.com March 9, 2010 Susan Y. Sawyer Public Health Director 1600 Osgood Street Kh Building 20, Suite 2-36 ' North Andover, MA 01845 RE: 322 Boston Street. TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Dear Susan, We received your letter dated March 1, 2010, regarding the above referenced site. We have revised the plan to include a note requesting an L.U.A. for only one test pit and modified the Form 9A application, copy enclosed. With regard to item#2 of your letter,the bottom of the tank is at the same elevation as the more conservative e.s.w.t. el. 92.4, as such,buoyancy calculations are not necessary. ��' The reviewer should have been able to easily determine this from the plan details and specifications. G��'° �"'''' C 5 -p 1 46 0- X With regard to item#3 of your letter,the soil absorption system and the distribution box are being constructed entirely in fill, as such,the minimum cover of one foot is proposed over the leach field elevation 96.8. The top of the proposed distribution box is at /' 7 elevation 96.45. The top of the distribution box is only 4 inches deep and therefore no W riser is required. The plan specifies that magnetic mark-in-g-1apu be provided or a riser and ✓ { cast iron cover if the depth is in excess of 9 inches. The requirement for the riser was shown on the plan because in the past,your reviewer continuously makes this comment, when in fact, no riser is necessary at all. The plan, as designed, complies with Title 5, and the reviewer should be able to easily determine this by the details and specifications shown on the plan. I With regard to item#4 of your letter, magnetic marking tape or a comparable means, 15.221 (12) is specified on all system components. The plan specifies 2 cast iron covers over the inlet and outlet of the septic tank, magnetic tape over the distribution box and magnetic marking tape over the leach field. This satisfies all requirements of Title 5 and the reviewer should have been able to easily determine this from the details and 6 specifications shown on the plan. Page 2 March 9, 2010 (Susan Sawyer) On behalf of our client, we respectfully request that the plan be approved as re-submitted as we feel it is in compliance with all requirements of Title 5 and of the NA Board of Health Regulations. Very true yours, William Dufresne,Project Manager Merrimack Engineering Services MERRIMACK ENGINEERING SERVICES,INC. 66 PARK STREET•ANDOVER,MASSACHUSETTS 01810 Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval c,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. 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 1978 Code or 310 CMR 15.000. A. Facility Information Important: When filling out 1. Facility Name and Address: forms on the computer,use David & Heather Belson Residence only the tab key Name to move your 322 Boston Street cursor-do not use the return Street Address key. North Andover MA 01845 City/rown State Zip Code 2. Owner Name and Address(if different from above): SAME 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: 3 BDRM. 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): field t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of North Andover a Form 9A - Application for Local Upgrade Approval ;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. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: unknown gpd Design flow of proposed upgraded system 330 gpd Design flow of facility: 330 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: New 1500 gal septic tank, gravity flow to a leach field with 44 Infiltrator Chambers 3. Local Upgrade Approval is requested forcheck all that apply): ( pp Y): ❑ 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: Separation reduction 0.5 ft. Percolation rate 17 min./inch Depth to groundwater .5 — ---- _ _ t5form9a.doc•rev.7/05 Application for Local Upgrade Approval* Page 2 of 4 Commonwealth of Massachusetts City/Town of Form 9A - Application for Local Upgrade Approval ;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. 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: Isaac Rowe 2-1-10 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: Full compliance would result in raising the system even higher requiring a pump and additional fill and grading resulting in unreasonable financial hardship. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 3 of 4 i Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval 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. C. Explanation (continued) 3. A shared system is not feasible: 4. Connection to a public sewer is not feasible: None 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 1, 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 fo berate violations." 2-5-10 w i rs*haturY Date David Belson Print Name Bill Dufresne/Merrimack Engineering 2-5-10 Name of Preparer Date 66 Park Street Andover Preparers address City/Town MA/01845 (978)475-3555 x-20 State/ZIP Code Telephone t5form9a.doc-rev.7106 Application for Local Upgrade Approval* Page 4 of 4 tAORT11 0 4 TLED '9 by �OO O L t` A O ca«ihiwu• 1• ��SSAC PUBLIC HEALTH DEPARTMENT Community Development Division March 1,2010 Vladimir Nemchenok Merrimack Engineering Services 66 Park Street Andover,MA 01810 Re:Subsurface Sewage Disposal System Plan for 322 Boston Street Map 107D Lot 24 Dear Mr.Nemchenok: The proposed wastewater system design plan for the above site dated February 3,2010 and received on February 10, 2010 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. A Local Upgrade Approval for only having one test pit in the soil absorption system area must be requested. Please revise the Form 9A and note the Local Upgrade Approval request on the design plan(3 10 CMR 15.405(1)(k)). 2. It appears that the bottom of the septic tank may be below the ESHWT. Please determine the ESHWT elevation in the proposed tank location and provide buoyancy calculations if required(3 10 CMR 15221(8)). 3. A riser to within 6 inches of finish grade is required above the distribution box if greater than 9 inches below grade. Magnetic tape cannot be used as an alternative to providing a riser. Please modify the note in the"Graphic Scale"on sheet 2. 4. Please specify all system components shall be marked magnetic marking tape including the septic tank(3 10 CMR 15.221(12)). 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 Susan Y. SawyeFr,RENS '= , Public Heald Director cc: David&Heather Belson File 1600 Osgood Street HEALTH DEPARTMENT Page 1 of 1 Building 20;Suite 2-36 E-Mail: healthdept@townofnorthandover.com North Andover,MA 01845 Phone:978.688.9540 Fax:978.688.8476 � r Y � TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT A 0 _ ' b 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 "SS,a,,,5 4`y Susan Y.Sawyer,REBS/1ZS 978.688.9540—Phone978.688.8476—FAX Public Health Director E-MAIL:healthdept@townofnorthandover corn WEBSITE:http://www.townofnorthandover.com SEPTIC PLAN SUBMITTAL FORM /711-i` Date of Submission: 2- q 10 Site Location: �j,2 �1�L d� _�ff'j,F�� _Ht TM11,IN Engineer: �I l.l% I�U ���� FXIrdC�� �iN ffa AJti>�I New Plans? Yes/$295/Plan Check# 2 13 0 (includes 1"submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes ✓ No Local Upgrade Form Included? Yes 1' No Telephone#: 70) �UC2' S 54� Fax#: 670 ) 'f'I S- l4ete E-mail: Homeowner Name: k2 F1'y EL Giffin 1 OFFICE USE ONLY When the submis on is complete(including check): Date stamp plans and letter Complete and attach Receipt " Copy File;Forward to Consultant Enter on Log Sheet and Database 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. 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 1978 Code or 310 CMR 15.000. A. Facility Information Important: When filling out 1. Facility Name and Address: forms on the computer,use David & Heather Belson Residence only the tab key Name to move your 322 Boston Street cursor-do not use the return Street Address key. North Andover MA 01845 City/Town State Zip Code 2. Owner Name and Address(if different from above): SAME Name Street Address Citylrown State flZ Zip Code Telephone Number �. 2it Type of Facility(check all that apply): La c ® Residential ❑ Institutional ❑ Commercial ❑ School Ue W Describe Facility: 3 BDRM. 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): field t5forrn9a.doc•rev.7/06 Application for Local Upgrade Approval*Page 1 of 4 IN ,Y'1 Commonwealth of Massachusetts City/Town of North Andover a Form 9A - Application for Local Upgrade Approval wM 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: unknown gpd Design flow of proposed upgraded system 330 gpd Design flow of facility: 330 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: New 1500 gal septic tank, gravity flow to a leach field with 44 Infiltrator Chambers 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: Separation reduction 0.5 ft. Percolation rate 17 min./inch Depth to groundwater 3.5 ft. t5form9a.doc•rev.7/0E Application for Local Upgrade Approval Paye 2 of 4 Commonwealth of Massachusetts City/Town of North Andover a Form 9A - Application for Local Upgrade Approval �M 5 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: Isaac Rowe 2-1-10 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: Full compliance would result in raising the system even higher requiring a pump and additional fill and grading resulting in unreasonable financial hardship 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: t5form9a.doc•rev.7/06 Application for Local Upgrade Approval, Page 3 of 4 Commonwealth of Massachusetts City/Town of North Andover a Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C.'Explanation (continued) 3. A shared system is not feasible: 4. Connection to a public sewer is not feasible: None 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 "l, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment fo berate violations." 2-5-10 Awi4mwdirs SlighaturY Date David Belson Print Name Bill Dufresne/Merrimack Engineering 2-5-10 Name of Preparer Date 66 Park Street Andover Preparers address Cityrrown MA/01845 (978)475-3555 x-20 State/ZIP Code Telephone t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4 Commonwealth of Massachusetts R��EIVED City/Town of fi 0 2010 a Form 11 - Soil Suitability Assessment for On-Site Sewage Di po TOWN OF NORTH ANDOVER HEALTH DEPARTMENT M DEP 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 1. Facility Information Owner Name Map/Lot Street Address EA Cityrrown State Zip Code B. Site Information 1. (Check one) New Construction ❑ Upgrade Ne-_� Repair ❑ 2. Published Soil Survey available? Yes &2/ No ❑ If yes: A-7e2 _ Year published Publicatio Scale Soil Map Unit /, ItrV0, Soil Name *—" Soil limitations 3. Surficial Geological Report available? Yes ❑ No Z/ If yes: Year Published Publication Scale Map Unit 4112- Wolf-Ao, 16 Geologic Material Land�rm 4. Flood Rate Insurance Map: Z{j- D 010 CIO4016_ . J upe 2 e 19115 Above the 500 year flood boundary? Yes No ❑ Within the 100 year flood boundary? Yes ❑ No Within the 500 year flood boundary? Yes ❑ No C Within a Velocity Zone? Yes ❑ No 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 1 of 7 • Commonwealth of Massachusetts City/Town of a Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal 6. Current Water Resource Conditions (USGS) Range: Above Normal ❑ Normal [ Below Normal ❑ Mon hNear 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 S-1 —tO �'!.Apj Date Time Weather 1. Location Ground Elevation at Surface of Hole Location (Identify on Plan ) 2. Land Use: (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Vegetation Landform Position on landscape lattach sheet) 3. Distances from: Open Water Body >14�0' Drainage Way"714:PCO Possible Wet Area,-71 feet feet feet -Property Line Drinking Water Well�` Other feet feet 4. Parent Material: L'L' Unsuitable Materials Present: Yes ❑ No'/ If Yes: Disturbed Soil[] Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes E No ❑ If Yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 0% It,, DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 2 of 7 Commonwealth of Massachusetts City/Town of M ' a Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal ' M inches elevation Deep Observation Hole Number: 1 I Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Structure Soil Depth Horizon/ Color-Moist (mottles) Texture %by Volume Consistence Other (In ) Layer (Munsell) (USDA) (Moist) Depth Color Percent Gravel Cobbles &Stones 6WA0ULAW F44AilgL gf' Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 7 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal GM C. On-Site Review (Cont.) Deep Observation Hole Number: Date Time Weather 1. Location Ground Elevation at Surface of Hole Location (Identify on Plan ) r✓ L.dirw..� y 2. Land Use: ►.� ®_z�a� (e.g.woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) i-< �s. a �iUn �'°'�lt,�+ I L-, Vegetation — No Landform Position on landscape(attach sheet) 3. Distances from: Open Water Body 1�CaD` Drainage Way `l Possible Wet Area fe et feet feet k feet Property Line 0 F2 , Drinking Water Well _?LQ!g� Other feet feet 4. Parent Material: L'L" Unsuitable Materials Present: Yes ❑ No If Yes: Disturbed Soil[] Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑ 5. Groundwater Observed: Yes E No ❑ If Yes: Depth Weeping from Pit Depth Standing Water in Hole ee Estimated Depth to High Groundwater: 7 s� -11 •e4 inches elevation DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal - Page 4 of 7 Commonwealth of Massachusetts City/town of ' Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal �M Deep Observation Hole Number: -2 Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Soil Depth Horizon/ Color-Moist (mottles) Texture % by Volume Structure Consistence Other Layer (Munsell) (USDA) (Moist) (In') Depth Color Percent Gravel Cobbles &Stones Additional Notes DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal- Page 5 of 7 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal G'M 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 inc es [Depth to soil redoximorphic features (mottles) A. B. 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, ccurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes No ❑ Z�_it I t9 Z� b. If yes, at what depth was it observed? Upper boundary: Lower boundary: I 1 7%l inches inches 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. I 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 throllah 15 .W7 Signature of Soil Evaluator Date Typed or Printed Name of Soil Evaluator 'Date of Soil Evaluator Exam � , 190w is �ax &Jig i!,i ro C ►.r � 15v r 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. DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page 6 of 7 Commonwealth of Massachusetts u Citylfown of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal o� M Use this sheet for field diagrams: DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal•Page 7 of 7 Commonwealth of Massachusetts City/Town of = Percolation Test Form 12 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 1 ,�.� a computer,use 1•� A only the tab key er Name to move your 2 Z cursor-do not treet Address or Lot# use the return key. lL�� City/Town State Zip Code Contact Person(if different from Owner) Telep noh a Number B. Test Results Date Time Date Time Observation Hole# llet ca a w ' Depth of Perc rr li_t Xx LU M Start Pre-Soak Uj Uj LU aQ End Pre-Soak Time at 12" Time at 9" I ® � Time at 6" t Time (9"-6") Rate(Min./Inch) Test Passed: Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ Test Perfor ed By: Witnessed By: Comments: r t5form12.doc•06/03 Perc Test•Page 1 of 1 �V TOWN OF NORTH:ANDOVER eoer.+r Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT JK 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 . .� NORTH ANDOVER, MASSACHUSETTS 01845 Susan V.Sawyer,REHS,RS 978.688.9540-Phone 1-V ED Public Health Director 978.688.8476-FAX healthde townofnondhan vers ft www.townofnorthandover. to APPLICATION FOR SOIL TESTS '���°�NORTH� ��m��� DATE: MAP&PARCEL:T? 2 LIA _ LOCATION OF SOIL TESTS: OWNER:SIN[ FAU 6 p/ az622 '�_ Contact#: " APPLICANT-__ Contact#: ADDRESS: i_ ENGINEER Ir t� .t f'Yl Y Contact#• -4 70 q14 '775� CERTIFIED SOIL.EVALUATOR (l.V QO&Z 2 Intended Use of Land: ResidentialSubdivision Ingle Family Hom Commercial Is This: Repair Testing: V 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) ➢ &S"x II!Plot glen&Location of Tesdnr(lease indicate lest net ska on the plan) Fee of$42M per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$360.00 per lot for agaiis or aparades. 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 bests are required for each septic system disposal area ➢ Repairs require at feast 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, Y 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.Conservateon Cor/rmtrsseonApproval D Signature of Conservation Agent: Date back to Health Department:(stamp in):' rl 1p . o 'ism ?�Y,rV� G • I ADO 5T JOHN S' 034311 ` c 11 0400 'ffil hylcc:b i)AA7 7 Ww i ,DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Friday, January 15, 2010 4:09 PM To: Hughes, Jennifer Cc: Gaffney, Heidi Subject: Septic-Soil Testing Application -322 Boston Street Hi Jen, Attached is a request for soil testing. Can you check the property and provide me with feedback next week? Once I get your response, I will forward it on to Mill River Consulting to schedule the soil testing with Bill Dufresne. I left a hard copy in your inbox as a reference. Thank you for your assistance. Fax W9"41 "We can never see the path of our life i we are too bus ocusin on thepebbles under ourfeet."--Anonymous mous .f Yf g P f Y Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20;Suite 2-36 North Andover,MA 01845 978.688.9540-Phone 978.688.8476-Fax pdellechiaie@townofnorthandover.com-E-mail http://www.townofnorthandover.com/Pages/index-Website Notes: If copied to BOH Members-Reference Copy Only-no response requested at this time From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Friday, January 15, 2010 4:59 PM To: DelleChiaie, Pamela Subject: Septic- Soil Testing Application - 322 Boston Street Id 5 ey� SKMBT_600100115 16590.pdf Tracking: 1 LdIt- - CD-tZ JPIK - T P- +'t M.5 I ( ©-/o J - ' Q � f _ 10 Z4kir -'il.N�It Y,yLS IOyR s/g r _ 12)4 M�. v - �-zn zo-04 MS -33 I i I 4.-o o - t TP ---40 pl[b�, ea+4'i' Liv r -Z4 sa cS U-rzo� i- .4)' e-zz w 64 E '°-Z4 s� 2sy:51 Z4 o-zo QA ~ t SUMMARY OF INVERTS BUILDING TIES SEWER ® FDTN. PRE-EXIST. BLDG. CORNER A B C NOTE: THIS PLAN & CERTIFICATION IS NOT SEPTIC TANK IN 96.42 SEPTIC TANK OUT 31.8 50.7 A WARRANTY OF THE SUBSURFACE DISPOSAL SEPTIC TANK OUT 96.16 DIST. BOX 54.8 88.8 SYSTEM. IT IS A RECORD OF THE LOCATION DIST. BOX IN 95.72 AND ELEVATION OF THE EXISTING SYSTEM DIST. BOX OUT 95.55 COMPONENTS. INV. IN CRAM. 95.50 BOTT. CHAM. 94.85 J law >L4Ll (57,148 S.F.) HENT INV. PORT y r � MARK US11K# SALLY BAMENT LEACH FIEte w 335 BOSTON SIRMT � 44 MNLTRATd1 CHAMBERS o�¢�Yuil..1rRC I g 1,500 0AL SWM TANK .k ��.T6.�100.0 4 '•� It CHRI$1OPHER k CAROL MARSHALL 3I4 BOSTON STREET e} 1, ^gg���•����� :Y,i i t. � r 150.00' OF BOSTON STRMT •- .Fj AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NORTH ANDOVER, MASS. 322 BOSTON STREET AS PREPARED FOR DAVID & HEATHER BEISON TM: 107D DATE: 5-10-10 TL: 24 SCALE: 1"=40' 0 20 40 80 MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 r NEW ENGLAND ENGINEERING SERVICES INC i i December 15, 1999 IIS North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 322 Boston Road,North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The systemap sses our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjamin C. Osgood�rT. President DEC 21 099 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1 COMMONWEALTH OF MASSACHUSETTS FILE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS (� - DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617) 292-5500 TRI DY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Co�.oner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART A CERTIFICATION Property Address: 3aa BG'STO- %T N, e/VOGJc f2 Name of Owrscr -/j9ALONCY' —Rao Address of Owner: Date of Inspection: ///.8r -7-7 U I.. c u( e STB 2 , M tt O I c? 30 Name of Inspector: (Please nt) Benjamin C. Osgood, Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000) Company Name: New England Engineerig S nrvires, Inc. MaAng Address: 60 Beechwood r, MA 01845 Telephone Number 686-1768 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposed system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _L/asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _. Fails Inspector's Signature: Date: ks The System Inspector shall submit a copy of s inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is 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 Department oK-nvironmentA Protection. The original should•ba sent to-" system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS l,��t_ti LOc (�iti� � r �lZi)Nl S,,siLM . LIJ ft1v t2 TC S—IC- G�+ revised 9/2/98 P.ec I of 11 h ' `J Pnn,cd o Rccyckd Pape, SUBSUOACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: -Rj,,, s-IZ6t i ,u. AN.9v"tp Owner: P-gFtZ ugft /YI P Z-0 A) y- F3 Ro r�.tJ Date*of kupection: I , INSPECTION SUMMARY: Check A, B, C, of D: PASSES:- I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated era indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the -Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y. N. or ND). Describe basis of determination in all instances. If "not determined', explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipets) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping-mare than four-times n yeardue to broken of obstraeted pipets). The system will Van inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed revised 9/2/98 Page 2ofit J TION FORM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART A CERTIFICATION(continued) Property Address: 3;2 7 13✓STJni �T(�G G I �', ()�. C 2 Date of Irisppcton. PAT RLt4R mAf.o vEY—;�i:Or✓N 23)q q 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 td protect the public health, safety and 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 WHICKYOLL PROTECT THE PUBUC HEALTH AND SAFETY AND THE ENVSBONMEMT: _ Cesspool or privy is within 50 feet of 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 tS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not vefid). 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 22 �jv Sf�n� �ff2E t I, lo ,IAj DC. tz Owner: PO-ral C I A /VwN t:I A r(' — a RW a A/ Date of Inspection: t 319`t r D. SYSTEM FAILS: r , You must indicate either "Yes" or "No" to each of the following:' 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine whet will be necessary to correct the failure. Yes No Backup of xwage into iecilirror-mtem component-due to an overloaded or-cbgged SAS or•cesspool. - '- _ _ Discharge or ponding o1 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any Portion of a cesspool or privy is within 100 feet o1 a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system-is-within 200 (eat of-*-Mibutery-to a aurfeoc-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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforptation. I revised 9/2/98 Page 4ofII I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST I ProP°ftY A 322 13-5'0X/ ST-04 6 LN. Y9 A)001Jc�L Owner: ��T�► b/Zo >"�V: Date of k&peeoon: I1� 23�q�1 - t Check if the following have been done: You must indicate either "Yes" or 'No" as to each of the following: Yes/ No ✓ Pumping information was provided by the owner, occupant. or Board of Health. I _ Nona of the system compoasrus.I.aLa.baan po np, d oratleast Xwo weake arsd&the ryctem hatlsa.oxecuo:rag wasaaal liow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees• material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: I Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / 115.302(3)(b)) Y - _ The facility owner (and-occupaus.if diHerent from.owner).wore,ptauided.with;nfnrmmtioann t <nrnpar mintan—,^f Subsurface Disposal Systems. revised 9/2/98 Pace.of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 Z 2 177uST N c ra-C -r� N - I\N D uvt 2 Owner: P07 RIC%A /N+94vN&t- kz".Zaw.v Date of Inspection: 1' FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. r r Number of bedrooms(design):= Number of bedrooms (actual):31 Total DESIGN flow Number of current residents:_ Garbage grinder(yes or nol: Laundry(separate system) (yes or no):A&): If yes, separate ins p-ection.required Laundry system inspected (yes or no) Seasonal use (yes or no):M Water meter readings,if available (last two year's usage (gpd): 6- Sump Pump(yes or no): MO Last date of occupancy: ! G, �-Maj',rn COMMERCIALRNDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present: (yei or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: - Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: l9NK N^vsN System pumped as part o1 inspection: (yes or no)_ If yes,volume pumped: gallons Reason for pumping: 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,ii any) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed{if known)-and source of•infornsation: re Sewage odors detected when-arriving at the site:(yes or no)[�C> revised 9/2/98 Page 6ertl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE&nom FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 L Z /V. AA.; Z.i - !� owrxr: PWTu«.I A nn AL_"v Date of Inspection: BUILDING SEWER: _ (Locate on site plan) Depth below grader / Material of construction: ✓ cast iron_40 PVC_other (explain) Distance from private water supply well or suction line /o� Diameter A_ Comments: (condition of joints,venting, evidence of leakage,-etc.) Pi PC- L--0V,f- SEPTIC TANK:_ (locate on site plan) Depth below grade:_ Material of construction:Zoncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is (petal,list age_ Is.age.confwmed by Certificate of Compliance_ (Yes/No) Dimensions: %op c l }I LOti Sludge depth: Z1. Distance from top of sludge to bottom of outlet tee or baffle:3 -' Scum thickness: L)n Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom o1 outlet tee or baffle: �a How dimensions were determined:/VI OA G.,IZ E 5T+C Y. Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles. depth of liquid level in relation to outlet invert, structurel-integrity, evidence of leakage,etc.) TRA-71,11% 1..-/ NIX+ COti J r T"+ Ad _ e r`c,-,s goq-c-Fu: 1— &,c)z'n .°0N +nv v. 2EC0--QP I--S7 9"d-7-2Js -F SCH Yo F>0C 7W-/..=5 n ti. GREASE TRAP: (locate on site plan) Depth below grade:_ 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 o1 last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORD PART C SYSTEM INFORMATION(continued) Property Addras:: 3 Z Z 13 v TJ / S i R e t t /l,. �}/V J G✓G Owner: i?&I-,Z1 C,6 /VI/a 1.O.,1..•Ey — g IZO VVAJ Date of kupecf K>n: r 2 � TIGHT OR HOLDING TANK:N0 (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) r Depth below grade: Material of construction:_concrete_metal_Fiberglass_Polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:— (locate on site plan) r Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidence of solids carryover• evidence of leakage into or out of box, etc.) — — R�7x /A/ 0J!< <J vl�I J�JN Alt)!V/DCitJCC OF �ci9J�f16c�2 nrli 91s7'/2iR.70-V !s F"�✓AL PUMP CHAMBER: (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 a1,2gefterlt ` r r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMA T ION(continued) Property Address: 32-2 Lk'S Tbr✓ 57Yz E e// /l1. owner: �pTQIL rt+ Date of Inspection: C $ SOIL ABSORPTION SYSTEM(SAS):— (locate SAS)—(locate on site plan.-if possible:excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries,number:_ leaching trenches, number,length: leaching fields, number, dimensions: / f�ELe� �!3'QOX ?O X 3i�' overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) f}(�Er4yF k4s 6-00p A)C) E0+j9E.vc"e- vi- ?on:Ori•' (r- DiQ 1JAMP Sort t1rCTETt?T1J�i /VZ, 2n4A4. CESSPOOLS (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of.vegetation, etc.) = PRIVY: (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9of11_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ST-acc--r /tl. Ae,-9c UC'1'— owner: OATRfc rR IK A/-J vEy— .82�w ni Date of kupecti<m: SKETCH OF SEWAGE DISPOSAL SYSTEM: , include ties to at least two permanent refererice landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) V I v�eV G a a 3 �l VKA' revised 9/2/98 Page 10 or II t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: %;Z 2 o v-57v" ST A/. d9 NO3 Jc A Owner: P.4-T 2 rc f A M A c.p.vcY- C3�2.7v�'v Date of knPection- NRCS Report name Soil Type_ s Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 13 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record `R Observed.Site (Abutting property, observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 1.� 7C g�w G- 2 �tQ)c`c c..T i-V I 7U (Zr f}12 i>t ��� ►'►1 d� � �" ��PNX .� I, �jCWw Sall-�l4GG� revised 9/2/98 Page 11 of it