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HomeMy WebLinkAboutMiscellaneous - 360 FOREST STREET 4/30/2018N O w l Lot & Street (' Map/Parcel 16 1,1,,7, CONSTRUCTION APPROVAL Has plan review fee been paid: <ai) Plan Approval: Date:_,.�/,/�/ Designer: W -%oCs1yr Conditions: Water Supply Well Permit: Town Well Driller: NO Permit# % Approved by: Z6AIL Plan Date: Q1FI / Well Tests: Chemical. _ Date Approved Bacteria I ----,—Date Approved Bacteria II Date,.Approved Plumbing Sign -Off: Wiring -Sig n -off: Comments: Form "U" Approval: Date Issued Conditions: Final Approval: Approval to Issue: By:_ YES NO All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: CONDITIONS: Is the installer licensed? Type of Construction: New Construction: Issuance of DWC permit: DWC Permit Paid? DWC Permit # Begin Inspection: Excavation Inspection: Needed: rassed: SEPTIC SYSTEM INSTALLATION Constructio nspeCtion: Needed: le^l �-, to-, &0(1K" ilt Plan Satisfactory: n By: Uui)N vk ry Approval of Backfill: Date: By: Final Grading Approval: Date: By: Final Construction Approval: Date: By- Certificate of Compliance: Approval: I t: Qi Date: �� YES NO Certified Plot Plan Review NEW REPAIR Floor Plan Review YES NO Conditions of Approval from Form U YES NO YES NO YES NO YES NO Installer: YES NO Constructio nspeCtion: Needed: le^l �-, to-, &0(1K" ilt Plan Satisfactory: n By: Uui)N vk ry Approval of Backfill: Date: By: Final Grading Approval: Date: By: Final Construction Approval: Date: By- Certificate of Compliance: Approval: I t: Qi Date: �� 7196 ti I G Fd�� BTE' T4is eS 00T 4 Of 'f 4 E '5,4 e UC4--Gg 94roy.L t,Yt,Tert. rT Is A R&t0" of rrl& la�rb,� "Hrow&04 rv. J aW:AaL, ry LI IG aN DANIEL. IWRAV06 CIVIL N0.37752 _kft _Dc 17 AS SILT KLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN Ljog:M AwPOV512 AS PREPARED FOR FQE� DE�oi�t "ri-i I oLa DATE: Qj-Z2-62I SCALE: I 's c{ -d MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS 66 PARK STREET 4 ANDOVER. MASSACHUSETTS 01610 4 TEL (617) 475-3553, 373-5741 " 220 Fd�� BTE' T4is eS 00T 4 Of 'f 4 E '5,4 e UC4--Gg 94roy.L t,Yt,Tert. rT Is A R&t0" of rrl& la�rb,� "Hrow&04 rv. J aW:AaL, ry LI IG aN DANIEL. IWRAV06 CIVIL N0.37752 _kft _Dc 17 AS SILT KLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN Ljog:M AwPOV512 AS PREPARED FOR FQE� DE�oi�t "ri-i I oLa DATE: Qj-Z2-62I SCALE: I 's c{ -d MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS 66 PARK STREET 4 ANDOVER. MASSACHUSETTS 01610 4 TEL (617) 475-3553, 373-5741 Town of North Andover %tooil RTp Office of the Health Department Community Development and Services Division . f � 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Public Health Director TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 04%12/02 This is to certify that the distribution box and connection pipe constructed 0 or repaired (X) by Todd Bateson at 360 Forest Street Telephone (978) 688-9540 Fax(978)688-9542 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Brian J. LaGrasse Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; ( 9�`repaired: located atO was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # dated with an approved design flow ofJ 11V 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. Bed inspection date: 0-t ;� I Final inspection Installer: Design Engineer: li-<_; Engineer Representative 0 . Qcol_� Engineer Representative Lic.#: Date: K d- j ` c Date:. g�Z2-rn� F� � 2 2002 1 N & M Job number 1770/ g TOWN OF NORTH ANDOVER INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Site: ClG E 51"-,* Installer: 73 A 7`Zz-5o e✓ Date A. Bottom of Bed 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation, etc. Comments: (Use back of sheet for diagrams.) Final Date: Tel: Yes No Initials B. Retaining Wall 1. Wall height and width apsspecified 2. Watef - 3. W_aH minimum 10' to,leaciiing facility 4. all meetsspecifi ations of plan - Co ents: -- C. Building Sewer 1. Pipe diameter minimum 4" M„-10 2. Schedule 40 pipe 3. Inlet to tank cemented 4. Slope minimum 0.01 or 1/8" per foot minimum - 5. Pipe properly set on compact firm base 6. Pipe laid on continuous grade in straight line N -V,' 7. Cleanouts precede all change in alignment and grade "V 0 8. Manholes at any 90° change ---- 9. 10' minimum offset to water line +Z - Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to w/in 6" of grade 5. Manholes over center and each tee �..� 6. 3-20" manholes 7. Outlet line cemented 8. 2" — 3" drop from inlet to outlet 9. Pipe set 10. Compact base with 6" of 3/4" crushed stone under tank 11. Tank is watertight —�- 12. Tees 12" off side of tank N & M Job number 1770/ Date Comments: E. Pump Chamber Yes 1. If separate from tank, compact base with 6" of stone underneath 2. Minimum 2" pipe to d -box if gravity system 3. 20" access manhole 4. Tank level 5. Watertight — 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present N pN- 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch `,�.► 12. Pump delivers liquid to d -box Comments: , F. Distribution Box I. D -box level 2. Minimum 0.1 T' (2") drop from inlet to outlet 3. Minimum 6" sump 4. Outlet pipes show equal distribution 5. Compact base with 6" of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe 9. First 2' from box laid level Comments: G. Soil Absorption system 1. All stone double -washed - %" –1 '/" - pea stone Bucket test done? 2. Minimum 2" of pea stone above distribution lines 3. Minimum 6" stone beneath pipe 4. Distribution lines capped or connected together 5. Toe of slope stops minimum 5' from edge of property; 5a. if not, then swale. Comments: 2c7 n 4 4-� No Initials 111 & M Job number 1770/ Date H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agrees with plan. (Max. length 100') 3. Width of trenches agrees with plan - Minimum 2'; maximum - 4'. 4. Vent present if>50 feet or specified 5. Minimum distance between trenches 10' 6. Pipe slope minimum 0.005 or 6" per 100' 7. Depth of trenches below outlet invert minimum of 6". 8. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6" per 100' 3. Separation between pipes 6' maximum 4. Pipes connected at end & vent end raised 5. Separation between adjacent fields 10' minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines Comments: J. Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12" and 48" wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement 6. Comments: Yes No Initials K. Final Grade f 1. Slope over soil absorption system minimum 0.02 C/f'la (p 2. All system components covered by at least 9" soil_ ` 3. Cover soil free of stones larger than 6"_ 4. Grading slopes away from dwelling 5. No areas over system that may pond 6. Grading meets 3:1 slope :�t 7. Minimum of 9" of fill graded over system_ 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 LOCATIONS OF WELLS, DRAIN ,WATERCOURSES WITHIN 150' OF SYSTEM y 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 V LOCATION & ELEVATIONS OF BENCHMARK USED 3 6o roa-iT mit' AS -BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM, INCLUDING BMSEMIM N A. TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA ;;'I von LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, @ft,(ELECTRIC LINES, CABLE) t4A 67\10'e4soty 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 m w c 6 Uz 0 Z 0 E CL 0 0 UJ IN 0 ui LL. z LU ce tA LA rd F— u < ce CA LLJ L 4) LLI CL < > m o c 0z LL 0 0 u 0 u 0 <ce N z o co 0 c 0 4- u 0 0 < 0 tA LA 33 IV u LA 0 E W BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 'y CURRENT INSTALLER'S LICENSE# LOCATION: T -d fz s i �S/- LICENSED INSTALtJZ4: � �av e 1 QSd�✓ SIGNATURE: CHECK ONE: REPAIR: v TELEPHONE# NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Administrative Use Only Yes 1'1� No _Foundation As=Built? Yes No Floor -Plans?-- Yes No Approval Date: • X a t.;AY - 4 2001 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer/for the construction of the septic system for the property at ����e �7 relative to the application Of / Joy✓ dated S— �/— for plans by�t t ^^^ �< moi. and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Unde tgn,pdLicensed Septic Installer X"�4 Date: 7( Q Works Construction Permit # :N North Andover, MA 01845 Ms. Sandra Starr, R.S., C.H.O. Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 April 24, 2001 Dear Ms. Starr: Due to an oversight on my part, I neglected to submit the $60.00 fee for the revised plans dated 2/8/01 for the repair of the septic system for 360 Forest Street. Enclosed is a check for this amount. Please accept my sincere apologies. Yours truly, Frederick W. Dekow, M.D. Town of North Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director March 2, 2001 Bill Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 360 Forest Street Dear Bill: Telephone (978) 688-9540 Fax(978)688-9542 This is to notify you that the revised plans dated 2/8/01 for the repair of the septic system for 360 Forest Street have been approved. A variance to depth of ground water from four feet to three feet was granted March 1, 2001. Please note that because of ground water variance, there may be no additional rooms added on to the structure as long as lot served by on-site subsurface sewerage disposal system. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, 7 Sandra Starr, R.S., C.H.O. Health Director SS/Smc cc: Dekow File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL (978) 475-3555, 373-5721 • FAX (978) 475-1448 • E-MAIL: merreng@aol.com February 8, 2001 Ms. Sandra Starr, R.S., C.H.O. Health Director Town of North Andover 27 Charles Street North Andover, MA 01845 RE: 360 Forest Street Dear Ms. Starr: We are in receipt of your review letter dated December 14, 2000 for the above referenced project. You noted 3 technical deficiencies. Our response to these deficiencies are as follows: We adjusted our local upgrade request for groundwater offset from 3.5 ft. to 3.0 ft. to meet the offset from the highest existing grade. The entire leach field cannot be raised as designed because grading would extend beyond the property limits (note the narrowness of the lot) also raising the system would cause drainage problems at the building foundation and the front stairs would become buried. 2. 310 CMR 15.232 (3)(2) requires an inlet tee or baffle extended 1 inch above the outlet invert. Note the plan profile specifies a tee to be installed inside the D. Box which will extend 1 inch above the outlet invert as such this requirement has been met. Only one test pit was performed within the system location because the proposed system is halfway within the existing system location thus precluding us from conducting a second deep hole. We request this requirement be waived given the space limitation on site. We hope we have adequately addressed your concerns regarding this design. Please contact us if you have any further comments or concerns. Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufresne Project Manager FEB 1 2 2001 Town of North Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director December 14, 2000 William Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 360 Forest Street Dear Bill: Telephone (978) 688-9540 Fax(978)688-9542 This is to inform you that the proposed plans for the site referenced above have been disapproved and have technical deficiencies as followed: • Groundwater separation not adjusted to the highest existing grade as required by 310 CMR 15.240 (1). It appears that the leeching field needs to be raised by approximately 0.55 feet. • Inlet baffle not provided for distribution box as required for a dosed system in 310 CMR 15.232 (3)(a). • Minimum of two deep observation holes not provided as required by 310 CMR 15.102(2). If you have any questions, please do not hesitate to call the Board of Health Office. Sincerely, 7C Sandra Starr, R.S. C.H.O.''- Health Director cc: Dekow file BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 Dec -13-00 05:27P Paul D. Turbide, PE/PLS PTOR ENGINEERING, Civil Engineers & Land Surveyors One Harris Street Newburyport, MA 01950 (978)465-8594 December 8, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School Street North Andover, MA 01845 978-465-0313 P.02 RE: Title V review for SDS upgrade at 360 Forest Street Dear Sandra, Enclosed find our review of the "Checklist for North Andover Septic System Plans" for the septic system upgrade at the above-mentioned site. The following is a list of technical deficiencies that Port Engineering has found. o Groundwater separation not adjusted to the highest existing grade as required by 310 CMR 15.240 (1). It appears that the leeching field needs to be raised by approximately 0.55 feet. ❑ inlet baffle not provided for distribution box as required for a dosed system in 310 CMR 15.232 (3)(a). ❑ Minimum of two deep observation holes not provided as required by 310 CMR 15.102(2). If you have any questions or comments please feel free to contact me. incerely P t : en �t i . Cb Paul D. T rbi e, PE/PL '° 9fCTo ``' f'�' ASemr P° WARMP2884Torest St 360.DOC SEPTIC PLAN SUBMITTAL FORM LOCATION: �v �2,��T -�,Ti2EEr NEW PLANS: $125.00/Plan REVISED PLANS: YES SITE EVALUATION FORMS INCLUDED: DATE: 'i 1-21-m� $ 60.00/Plan TEY NO DESIGN ENGINEER: HC ypjAcj�,'-t*;W,1 p3EzZI*, DATE TO CONSULTANT: *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. m I f4l. . Page 1 of 5 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving AuthorityBoard of Health: For the upgrade of a failed or non -conforming system with a design flow of <10,000 gpd, where full compliance, as defined in 310•CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non -conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000, 1) Facility/System Owner: Name: rrte o D e; k -o ►A Address: 3(00 r� yT- ,;,TrL/pip. Arjrcv CW_Mq{y _ e71-5 Phone k (00'7,- Salq-7 Address of facility: 2) Applicant (if different from above) Name: Address: Phone k 3) T�Ype of Facility: L/ Residential _ (Specify) Commercial School Institutional 4) Type of Existing System: _privy cesspools) other(describe) Page 2 of 5 - conventional system Type of soil absorption system (trenches, chambers, pits, etc.) F eW? 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system_ ++ogpd Approved: des Approval date: tag no Why: b) Design flow of proposed upgraded system bpd c) Design flow of facility NA. gpd Why 6) Proposed upgrade of existing system is: a) i%Voluntary required by order, letter, etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: 1st It Cryri. t2ut2p MA &--V- r tri F-gig-lOoCyri, I-MJk--IZke vW) c) Which of the following are applicable to the proposed upgrade? ,41A Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) AfAL Percolation rate of 30-60 minutes per inch (state actual perc rate) M Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) _Afiq.- Relocation of water supply well (identify well, describe relocation) Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) if the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater �,5; feet As determined by: Evaluator's name: !�M�,� Evaluator's Signature: Date of evaluation:-Z�-. 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Date notified Address Abutter Name Address Abutter Name Address Date notified Date notified Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: 14!x, u; TNr, aJ&tj E5T 'f'►.i c 4 YS1-c--H C oir.S 1 N5Y(WUW J fri iy L -L) a o-ifJ6 5 i -re &Nbr/PhUrk-W-3-7 6 f2"N)IL16 I-AJkL" TG H r % g►1ak--cur KCCO iI ►�F...isuT b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. c) A shared system is not feasible. d) Connection to a sewer is not feasible. 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? yes ✓no 01, Page 5 of 5 11) Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, Dppdlties or fine and/or imprisonment for knowing violations." du s Signature Name �I u 121A OtE47,56 I l- t7- Name of Preparer Date Telephone No. & Address of NOTE: Title 5,310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. FORAi Q - IAT RELEAcg FORM INS UC7fIONS: This form a �I is Used to verify that all have been/ob ainedfrom Boards andents necessary land ow er from compliance w. This �th not relieve the j�isdiCtipn re ions or requirements. y aPPlicable localic"t and/°r or state law, ****************Applicant fills out this section***********#***** APPLICANT: �5c, C Phone ?: LOCATION: Assessor's Ma y` p Number Subdivision Parcel Lot s Street -- � ) N u :ro a IS St. Number:S6(1 .. icial Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Date Approved Comments Date Rejected ,Town Planner Comments \'. Food ins c or -Health v is nspector-Health Comments -C Public Works -sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Approved Date Rejected Date Approved Date Rejected Date Approved 51, Date Re' f �ected Date 0 °v Z 0 U LL Q Z N Q M . y Its 01 Z m C �► �ZIC 00 O + � � Lo W Luca ���tn�a>pmo1'�n ?�ca. as (Az N QL6 met O $ 440CM —0 A C�mL 9z d W n ).owe8 C LIJ 3% �L V M• w pMp m p _ w a w Z 2 rtW,. r 4&-* m^ � o �oa ab w u'! b _T �.. o(D �� o 0-05 C Me �t�.s Q Q h 90.00' 0 °v Z 0 U LL Q LU CY w Z 1 � . Its 01 Q 0 °v Z 0 U LL Q LU CY w Z �•+� oo to sw: w QL6 CC O $ M zO A a~� bin" '' W n w sus me LIJ 3% �L V M• two, pMp m p _ w a w Z 2 rtW,. 4&-* m^ � o �oa ab w u'! b �.. o(D �� o 0-05 C Me �t�.s Q Q h N O44 '1 W 2 us ace 4 d. w n wZ e • ii CLC ro A&~ V* O "A O Z Z Q I%Sam.+>> o•hIP• 4� 34 O d� • w 1 go "o Ll axi LU H ai ao a ++w w .�+ • a rw o O W • m � C6 X W 9a al is t U .- %Z r �. L---~ (� r AT aa 28'91 � ' 8 LU CY w Z WELL DATABASE i ADDRESS: or AGE OF WELL: WELL DRILLER: WELL PERMIT r: WELL LOCATION: WELL PERMIT DATE: DEPTH OF WELL: TYPE OF WELL: a.. DRILLED b. DUG c. UNKNO TYPE OF WATER BEARING ROCK. WATER ANALYSIS DATE: jqT ANG SE: Y N HIGH IRON: Y N OTHER CONT : Y N 1/0 WELL DATABASE I ADDRESS: AGE OF WELL: ? WELL DRILLER: WELL PERMIT 4: ? WELL LOCATION: WELL PERMIT DATE:: DEPTH OF ELL: ? TYPE OF WELL: a.. DRILLED b. DUG �c: tINKi�1 TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: HIGH MANGANESE: HIGH IRON: Y N OTHER CONTAMINANTS: Y Y N N Town of North Andover, Massachusetts Form No. 2 Of No"*M BOARD OF HEALTH t � w a � s DESIGN APPROVAL FOR �SS"`""� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant `-Ah /— D -IJ-- Test No. 9 T cl Site Location Reference Plans and Specs. ' .16 % ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD of HEALTH Fee 5 Site System Permit No. Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Applicant _ <::21l_l_ NAME " Site Location c� 64 (� Engineer NAME Test/Inspection Date and Time I C AI�,BOADOFIHILEALI-11 Fee f � Test No. S.S. Permit No. f%� D.W.C. No. C.C. Date Plbg. Permit No. BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS 16 DATE: q- t�; `'�C--' LOCATION OF SOIL TESTS:T Assessor's map & parcel number t o&A 1 7 OWNER: 6�15-V61LIGe lGp TEL. NO.: _Co,027- -5'lc7'? ADDRESS:_ ;ice ENGINEER: f",I IAAC -�t 9C�t it hh. TEL. NO.:__ 4h r - -221j 5; 15 CERTIFIED SOIL EVALUATOR: Fj i ,-V Intended use of la nVresidential subdivision, single family home, commercial Repair testing ,,// �. Undeveloped lot testing !- �V N. A. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of J2Z5-00 per lot forep w construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. COM �04 as Z z c {L. ni co m g m tD z 0 H Z O n N O 1 p� M O K1 % Q � a 10 Oh- O � • � 7 V 00 Na o_ omG'1 a 00 0-' = o. 6 Z o fo t!3 o i- r Do aJew o ~ an r sm0 o w rw w u in �� so ,•• 4 S In: .+• ae o N O .7 m0 M X z D' 10 �o r z In �. M • �m e _ .tv rn n" o� 00 .D 7 M a� <cr m " d w g Z c O In n O z 0 0.O 3p Q � a O 'p o_ omG'1 a $ (pcm H N 6 Z o fo t!3 <(ps� dl m C=CIO C (� I �. '.� % ,r � ' .���� ���� ___�� � .� %1��' � ��4iTi�_- � 11:�6L� _ f �G�L% �tli���9t%i,��Li!f��l �����/;�Il/IfI%/ is •` �� / ,��� III/I� � r I. �IL.�S'r �� _o>•h� I�_ ��, IS�i�"�i� � i .� i � ��VtC� � _ _ � - � I r O �-iON - " 0 i ICON Si = l �0 % (== s i _ l I fIvI Location: Owner's Name: l Map/Parcel:– `j�j�.l 1 UG•, 9A,4 1`12 Address:_ Installer: Tel #: New 01501 Repair Date: --27-cc Wetlands Zone II •' Soil Symbol C�' Soil 1Qame C ' ---�'�— Soil Class Deep Observation Hole Logs Obse Deptl Start Time Time Time Time Rate Performed By: - 1:jt✓12�,4m1j� Witnessed By: ` ., Elevation Depth Soil Horizon Soil Te=re Soil. Color Soil Mottling %Gravel, Stones, etc: �' 1�`' ��, SSV. tn�(►�1/� . - �4>.1z Parent Material De th to Bedroc6 'f Standing P Nater in the Hole: Keeping from Pit F lf( U0- FfmA. I YLNI ,� � Face ESHG%V: t Parent Material Depth to Bedrock Standing water in the Hole: Nyee in p ., from Pit Face ESHGIy. Date Percolation Tests Obse Deptl Start Time Time Time Time Rate Performed By: - 1:jt✓12�,4m1j� Witnessed By: ` ., 1\ I 145,4(, L C� T A = '.O1 " Fri 0 �2N (/50) X = /50 — _ ........................... ,. DES/C7N EC EV.4T/ON .47 .......... (TOP OF 57-01VE) = .............. EX/5T/N!� Cl -D 4T/ON .47 ......... l2EQU/2E0 4/LL = 6Z&.1.11T/ONS DES/�:N 4.5 ,001LT /NV PIPE OL/T OF 1/0U5E /NV P//OE /NTO T4NK 3z q /NV PIPE OUT OF 74NK 132,7q /NV PIPE /NTO D. BOX 3Z. E� 5 /NV PIPE OUT OF D. BOX (32,40 /NV END OF P/PEZ, l F''' too 132.08 ,) i3/,8Z waTE2 EL EV.4 TION AVE2Q6E STONE DEPTH ,47 />eOBE N 40 T (-A Ro4657 GoAf'-' 6 4 SUB-S&RFACE !J/SPO 4TLC-kf Sf *.W /N NO r rH A/V 1-/l O VEP, M A . F02 5C.4L E 'Z' 40 / D4 r&.- Mf( V /L /9B NOTE. 7-1//5 PZ -,4N /5 NOT ,4 N,41C1e.41v7-Y C14815TIA NSEN 5El9 Gl , INC. OF T1/E SYSTEM BUT ,4 k E�2/F/C,4T/ON 1&0 SUMMER STREET HAVERAULL , MASS. OF TI -IE LOC.4TION OF 711E EY1,5T/1V6 S7-WC702E5. ( ��D of N .iEF-j c 0 Nol�TN 4tiPOUei�, MA, LaT" 1- -- �PP�� Cgti I (ATOS Scup V7 Q Fbwt l D WEE[.t_ ss 5,rPrIC Sy S IEA A 17ES16,&3 4PPKpvf:�v PATr' DI54PPKovED RQsofos = AP6z0UPJ6 Aurhol'?,Ty P��� D�Si �aNC�� �4M(-IE(l5T SvRv, CG�� DATA C,'iVITo,J5 Z, SCPT(c SYSTEM 1 J STA U ,QTI©" A5-YCAV4-f (dam 94 C Q 1;l5S Q F)QIL- (VSPEcrro� PAPE Ft7o/-\ t: Ivc)5& j U TA0r Ll PASS `Q F/OJL 4PPROOED ATC APPr�0v(tiG AUTHo/��Ty G'� w �1"KILDIAL (AASH j (jN I NS l4(,LG(� �.9� S DISAPtMO\J&D DaTC I�E✓J5� N.S ' RA APPROVAL 0AJ-C�6-� LO i �(&A �A I �6A.)C TG��1 �l 5�v?M r ii&--