HomeMy WebLinkAboutMiscellaneous - 37 OLYMPIC LANE 4/30/2018�- 41
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community and Economic Development Division
CERTIFICATE OF
COMPLIANCE
As of: 9/16/16
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Full Replacement of an
On -Site Sewage Disposal System
By: Peter Breen
At:
37 Olympic Lane
Map 106.B Lot 142
North Andover, MA 01845
The Iss e of t ' icate shall not be construed as a guarantee that the system will function satisfactorily.
Br' n Grasse
Public Health Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community and Economic Development Division
CERTIFICATE OF
COMPLIANCE
As of: 9/16/16
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Full Replacement of an
On -Site Sewage Disposal System
By: Peter Breen
At:
37 Olympic Lane
Map 106.B Lot 142
North Andover, MA 01845
The Iss e oft ' icate shall not be construed as a guarantee that the system will function satisfactorily.
Br' n Grasse
Public Health Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
PUBLIC HEALTH DEPARTMENT
Community Development Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (/) repaired;
By: -'L-�Z= e N
(Print Name)
Located at: 3 -7 011 z m;, r c � O'l e-
(nstalla on Address)
RECEIVED
SEP 16 2016
TOWN HEALTH DEPARTMENT
ANDOVER
Was installed in conformance with the North Andover Board of Health approved plan, originally dated
Qt, *9 o l (, and last revised on > � c, 2 , with a design flow of
i q,3 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: 16
'�J� �•� a >� -� C� o � s> �7L
And — Print Name
Final Construction Inspection Date:
And — Print Name
Installer:w(Signature)
Engineer: (Signature)
Engineer Representative (Signature)
Engineer Representatve (Signature)
And — Print Name
Date:
And — Print Name
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.northandoverma.gov
Commonwealth of Massachusetts RECEIVED
v City/Town of NORTH ANDOVER
Certificate of Compliance SEP 13 2016
wM sForm 3 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On -Site Sewage Disposal System
Important: When
filling out forms
❑ Construction of a new system
on the computer,
® Repair or replacement of an existing system
use only the tab
❑ Repair or replacement of an existing system component
key to move your
cursor - do not
use the return
Has been done in accordance with Title 5 and the Disposal System Construction Permit (DSCP):
key.
DSCP Number DSCP Date
JOE AND JOANNE WESCOTT
Facility Owner
37 OLYMPIC LANE
Street Address or Lot #
NORTH ANDOVER MA 01845
Citylrown State Zip Code
Designer Information:
BENJAMIN C. OSGOOD, JR., PE None
Name Name of Company
SEPTEMBER 6, 2016
Signature Date
Installer Information:
PETER BREEN
NO Name of Company
G
nature Date
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Approving Authority
Signature Date
t5form3.doc• 06/03
Certificate of Compliance • Page 1 of 1
9/12/2016 Town of North Andover Mail - RE: 37 Olympic
NOR1' ' A DOVER
Massachusetts Lisa Hadge <Ihadge@northandoverma.gov>
RE: 37 Olympic
1 message
Isaac Rowe <irowe@millriverconsulting.com> Mon, Sep 12, 2016 at 8:01 AM
To: Lisa Hadge <Ihadge@northandoverma.gov>, Pam Lally<plally@millriverconsulting.com>
Cc: Brian LaGrasse <blagrasse@northandoverma.gov>, Isaac Rowe <irowe@millriverconsulting.com>
Brian/Lisa,
Attached is the final construction report for the above referenced property. Everything looked good. When the final
grade inspection is conducted please confirm the septic tank was abandoned. That was the only outstanding item.
Please let me know if you have any questions.
Thanks,
Isaac M. Rowe, R.S.
Project Manager
Mill River Consulting
6 Sargent Street
Gloucester, MA 01930-2719
Phone: 978-282-0014 ext.804
Fax: 978-282-1318
irowe millriverconsulting.com
www.millriverconsulting.com
From: Lisa Hadge [ma iIto: Ihadge@northandoverma.gov]
Sent: Thursday, September 08, 2016 10:01 AM
To: Dan Ottenheimer; Isaac Rowe; Pam Lally
Cc: Brian LaGrasse
Subject: 37 Olympic
Good Morning,
https://mail.google.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&th=1571 e4632602al c6&siml=1571 e4632602a 1 c6 1/2
9/12/2016
Town of North Andover Mail - RE: 37 Olympic
Peter Breen was wondering when you might be able to go out for final inspection at 37 Olympic Lane. I just got back
today and he said that Michele was supposed to reach out to you yesterday. Thanks.
Lisa Hadge
Health Department
Town of North Andover
1600 Osgood Street, Suite 2035
North Andover, MA 01845
Phone
978-688-9540
Fax
978-688-8476
Email
Ihadge@northandoverma.gov
Web
www.northandoverma.gov
Please note: As of January 11, 2016, all Town Hall offices, except Assessor and Veterans Services, will be
temporarily moving to 1600 Osgood Street, Suite 2043.
All email messages and attached content sent from and to this email account are public records unless qualified as an exemption under the Massachusetts
Public Records Law.
Visit us online at www.northandoverma.gov.
37 Olympic Lane - final inspection report.doc
388K
https://mail.google.com/mail/ca/u/0/?ui=2&ik=46857787dO&view=pt&search=inbox&th=1571 e4632602a 1 c6&siml=1571 e4632602a 1 c6 2/2
North Andover Health Department
Community and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 37 Olympic Lane MAP: 106.13 LOT: 0142
INSTALLER: Peter Breen
DESIGNER: Benjamin Osgood, Jr.
PLAN DATE: 7/26/16, rev. 8/5/16
BOH APPROVAL DATE ON PLAN: 8/17/16
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION: 8/29/16
DATE OF FINAL CONSTRUCTION INSPECTION: 9/9/16
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
N/A Contractor reports any changes to design plan
El Existing septic tank properly abandoned
® Internal plumbing all to one building sewer
® Topography not appreciably altered
Comments: 9/9/16 - Septic tank still needs to be abandoned ... IR
SEPTIC TANK
® Building sewer in continuous grade, on
compacted firm base
N/A Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
® Weep hole plugged
® 1500 gallon tank has been installed
H-10 loading
® Monolithic tank construction
® Water tightness of tank has been achieved by
visual testing
® Inlet tee installed, centered under access port
® Outlet tee installed, centered under access port
(gas baffle)
® 24" inch cover to within 6" of finish grade
installed over one access port
® Neoprene boots around inlet & outlet
Comments:
DISTRIBUTION -BOX
® Installed on stable stone base
® H-20 D -Box
N/A Inlet tee (if pumped or >0.08'/foot)
® Hydraulic cement around inlet & outlets
® Observed even distribution
® Speed levelers provided (not required)
® Schedule 40 PVC Pipe
Comments:
SOIL ABSORPTION SYSTEM (General)
X Bottom of SAS excavated down to C soil layer,
as provided on plan
X 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
N/A Retaining wall (boulder / concrete / timber/ block)
❑ Final cover as per plan
Comments: No sand on site. System with overdig is 30w x 554". Michele asked
Peter lengthen by 3' more to meet the designers septic size.
SOIL ABSORPTION SYSTEM (Gravel -less Chambers)
® Brand and Model of Chamber: Standard Quick
4 Infiltrator Chambers
® Number of chambers per row: 12
® Number of rows (trenches): 6
Comments: Total Chambers = 72
BM = 101.28
HR = 3.25
HI = 104.53
SYSTEM ELEVATIONS
ROD
ELEVATION
AS -BLT INVERT
ELEV
DESIGN INVERT
ELEV
Benchmark
Building Sewer OUT
1.64
102.54
102.00
Septic Tank IN
2.40
101.78
101.62
Septic Tank OUT
2.78
101.40
101.37
Distribution Box IN
2.90
101.28
101.27
Distribution Box OUT
3.05
101.13
101.10
Lateral 1 TOP
3.19
Lateral 1 INVERT
100.99
101.00
Lateral 2 TOP
3.19
Lateral 2 INVERT
100.99
101.00
Lateral 3 TOP
3.19
Lateral 3 INVERT
100.99
101.00
Lateral 4 TOP
3.19
Lateral 4 INVERT
100.99
101.00
Lateral 5 TOP
3.19
Lateral 5 INVERT
100.99
101.00
Lateral 6 TOP
3.19
Lateral 6 INVERT
100.99
101.00
Top of Chamber
Bottom of Bed/Chamber
100.33
100.34
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
1 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
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 Bank3
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
1 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
FINAL GRADE
C7 Loamed
Seeded
❑ Cover per plan
Comments:
DOCUMENTS NEEDED
❑ Certification of Installation Form submitted
By engineer and signed and dated by
Engineer and installer
❑ As -Built Plan
Town of North Andover — Sevtic Svstem - AS -BUILT
1) d All changes to the design plan have been reflected and noted on the as -built plan
2) v As -built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans)
3) 4/ Street Address, Assessor's Map and Lot Number
4) Lot Lines and Location of Dwellings served by the system
5) cations, Elevations and Dimensions of As -built system components, including reserve (if applicable)
6) Ties to all tank openings, d -box, and leach area from dwelling or Permanent Structure
Setback distances are shown on the as -built plan from system components to:
/Subsurface, interceptor & foundation drains
atch basins
Property lines
::3�Dwellings or other structures
-Private water supply or irrigation wells
�atercourses or wetlands
8) Locations of Wells, Drains, Wetland esource Areaswit in 150 feet of system
9) ✓ cation of water, gas, e ectri 1 s, cable, control panel (if applicable)
10) cation of Structures within 6 Inches of Finished Grade
11) Original Stamp & Signature
12) Location and holder of any easements which could impact the system
13) Impervious Areas; Driveways, etc
14) v orth Arrow
15)ation &Elevation of Benchmark used
16) STATEMENT ON PLAN (NA 5.3)
a. "I certify the locations, elevations, ties, cover material; exposed component covers etc.,
shown on this as -built substantially agree with the approved plan and have determined that the
break out elevations, if applicable, have been met."
Signature of Designer
Date
b. "If a STUCTURAL WALL IS PRESENT (NA 4.9) a Letter or statement on the as -built indicating
the wall - was, or was not, constructed in accordance with the intended design and any
manufacturer's specifications. "
Signature of Designer
Revised 3/17/15
Date
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
INA
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-�a-aL R 15.000.
A. Facility Information
1. Facility Name and Address:
Joe and Joanne Wescott
Name
37 Olympic Lane
Street Address
North Andover
CitylTown
2. Owner Name and Address (if different from above):
same
Name
City/Town
Zip Code
3. Type of Facility (check all that apply):
® Residential ❑ Institutional
4. Describe Facility:
existinq 4 br hom
5. Type of Existing System:
❑ Privy ❑ Cesspool(s)
AUG 0 12016
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
MA
State
Street Address
State
Telephone Number
❑ Commercial ❑ School
01845
Zip Code
® Conventional ❑ Other (describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
leach field
t5form9a • rev. 7/06
Application for Local Upgrade Approval, Page 1 of 4
Ej
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.
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility:
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
440
gpd
440
gpd
440
gpd
❑ voluntary ❑ Required by order, letter, etc. (attach copy)
® Required following inspection pursuant to 310 CMR 15.301: May 2016
date of inspection
2. Describe the proposed upgrade to the system:
Install new 1500 gallon septic tank and infiltrator leach field
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 1
ft.
>5 (sieve analysis)
Percolation rate min./inch
Depth to groundwater 3
ft.
t5form9a • rev. 7/06
Application for Local Upgrade Approval* Page 2 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.
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:
Evaluator's Name (type or print) Signature
C. Explanation
Date of evaluation
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:
The increased elevation will make grading the area difficult without the use of walls
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
Cost prohibative
t5form9a • 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:
no area on adjacent properties
4. Connection to a public sewer is not feasible:
sewer is too far
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
® Application for Disposal System Construction Permit
® Complete plans and specifications
® Site evaluation forms
❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other (List):
D. Certification
"I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for submitting false information, including, but not limited to, penalties or fine and/or
imprisonment for deliberate violations."
C v "2 Aug 1, 2016
racility Owner's Signature Date
Benjamin C. Osgood, Jr., Agent
Print Name
Benjamin C. Osgood, Jr., PE Aug 1, 2016
Name of Preparer Date
157 Bluff Street
Preparer's address
NH 03079
State/ZIP Code
Salem
City/Town
978-435-1324
Telephone
t5form9a • rev. 7/06 Application for Local Upgrade Approval, Page 4 of 4
uUMass
J Extension
Particle Size Analysis - Basic
Prepared For:
Benjamin Osgood Jr.
157 Bluff St
N Andover, MA 01845
bosgoodpe@gmail.com
978-435-1324
Soil and Plant Nutrient Testing Laboratory
203 Paige Laboratory
161 Holdsworth Way
University of Massachusetts
Amherst, MA 01003
Phone: (413) 545-2311
e-mail: soiltest@umass.edu
website: soiltest.umass.edu
Sample Information:
Sample ID: TP -2
Order Number:
24031
Lab Number:
X160718-110
Received:
7/18/2016
Reported:
7/21/2016
USDA Size Fraction
Main Fractions
Size m
Percent
Sand
0.05-2.0
65.6
Silt
0.002-0.05
33.9
Clay
<0.002
0.5
USDA Textural Class: sandy loam
MA Title V Textural Class II
1 of 1 Sample ID: TP -2 Lab Number X160718-110
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r 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.
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.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
A. Facility Information
1. Facility Name and Address:
Joe and Joanne Wescott
Name
37 Olympic Lane
RECEIVED
AUG 01 2016
Vo OF NORTH ANDOVER
HEALTH
key.
Street Address
North Andover
MA
01845
r�
City(rown
State
Zip Code
2. Owner Name and Address (if different from above):
same
Name
Street Address
Cityfrown
State
Zip Code
Telephone Number
3. Type of Facility (check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑
School
4. Describe Facility:
4 br home
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other (describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
leach field
t5form9a • rev. 7106 Application for Local Upgrade Approval* Page 1 of 4
Commonwealth of Massachusetts
City/Town of North Andover
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility:
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
440
gpd
440
gpd
440
gpd
❑ Voluntary ❑ Required by order, letter, etc. (attach copy)
® Required following inspection pursuant to 310 CMR 15.301
2. Describe the proposed upgrade to the system:
Install new 1500 gallon septic tank and infiltrator leach field
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 in separation between the SAS and high groundwater:
Separation reduction
1'
Percolation rate
Depth to groundwater
t5form9a • rev. 7/06
ft.
>5 (sieve analysis)
min./inch
3
ft.
May 2016
date of inspection
% reduction
Application for Local Upgrade Approval- Page 2 of 4
r 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.
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:
Evaluator's Name (type or print) Signature
C. Explanation
Date of evaluation
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:
The increased elevation will make grading the area difficult without the use of walls
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
Cost prohibative
t5form9a • rev. 7/06
Application for Local Upgrade Approval* Page 3 of 4
L\ Commonwealth of Massachusetts
City/Town of North Andover
u Form 9A - Application for Local Upgrade Approval
a
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:
no area on adjacent properties
4. Connection to a public sewer is not feasible:
sewer is too far
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
® Application for Disposal System Construction Permit
® Complete plans and specifications
® Site evaluation forms
❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
❑ Other (List):
D. Certification
"I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for submitting false information, including, but not limited to, penalties or fine and/or
imprisonment for deliberate violations."
J C Aug 1, 2016
Facility per's Signat Date
Benjamin C. Osgood, Jr., Agent
Print Name
Benjamin C. Osgood, Jr., PE
Name of Preparer
157 Bluff Street
Preparer's address
NH 03079
State/ZIP Code
Aug 1, 2016
Date
Salem
City/Town
978-435-1324
Telephone
t5form9a • rev. 7/06 Application for Local Upgrade Approval* Page 4 of 4
uUMass
J Extension
Particle Size Analysis - Basic
Prepared For:
Benjamin Osgood Jr.
157 Bluff St
N Andover, MA 01845
bosgoodpe@gmail.com
978-435-1324
Soil and Plant Nutrient Testing Laboratory
203 Paige Laboratory
161 Holdsworth Way
University of Massachusetts
Amherst, MA 01003
Phone: (413)545-2311
e-mail: soiltest@umass.edu
website: soiltest.0mass. edu
Sample Information:
Sample ID: TP -2
Order Number:
24031
Lab Number:
X160718-110
Received:
7/18/2016
Reported:
7/21/2016
USDA Size Fraction
Main Fractions
Size mm
Percent
Sand
0.05-2.0
65.6
Silt
0.002-0.05
33.9
Clay
<0.002
0.5
USDA Textural Class: sandy loam
MA Title V Textural Class II
1 of 1 Sample ID: TP -2 Lab Number X160718-110
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Owner
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every page.
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1C�I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Olympic Lane
Property Address
Wescott
Owner's Name
North Andover
City/Town
MA June 7, 2016
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
RECEIVED—
JUN 14 2016
Inspector:
TOWN OF NORTH ANDOVER
Dean G. Luscomb II HEALTH DEPARTMENT
Name of Inspector
Dean G. Luscomb II & Sons
Company Name
P.O. Box 135
Company Address
Middleton
City/Town
978-774-4065
Telephone Number
B. Certification
MA
State
S1848
License Number
01949
Zip Code
I certify that I have personally inspected ithe sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
vV . June 7, 2016
Inspectori Signature Date
The system inspector shall submit a, copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does root address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 37 Olympic Lane
Property Address
Wescott
Owner
informat;on is
required for
every page.
Owner's Name
North Andover
Cityfrown
B Certification t
MA June 7, 2016
State Zip Code Date of Inspection
Inspection Summary: Check A,B, Cor E / always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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.
Check the box for "yes", "no" or "not! determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
/l )� will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ NU(Explain below):
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is
required for North Andover MA June 7, 2016
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes!(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
/ ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
U the system is failing to protect public health, safety or the environment.
V 1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is
required for North Andover MA June 7, 2016
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. ,System will fail unless the;Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
11
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
V supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that ino other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
5 Yes
No
/ ®
❑
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
®
❑
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
t5ins • 3/13
TRIe 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is
required for North Andover MA June 7, 2016
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion oflcesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of'a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of.a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that! no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
® The system is `a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the followin , in addition to the
questions i ction D.
Yes No
❑ ❑ the system is wi ' 400 feet of a s ce drinking water supply
❑ ❑ the system is within 200 fe o 'bud tary to a surface drinking water supply
❑ ❑ the system is locat n a nitrogen sensiti ea (Interim Wellhead Protection
Area — IWPA) mapped Zone II of a public wa supply well
If you have answered "yes" ny question in Section E the system is considered -a significant threat,
or answered "yes" in Se i n D above the large system has failed. The owner or operator of any large
system considered ignificant threat under Section E or failed under Section D shall upgrade the
system in acc ance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Olympic Lane
Property Address
Wescott
Owners Name
North Andover MA June 7, 2016
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑
Pumping information was provided by the owner, occupant, or Board of Health
❑ ®
Were any of the system components pumped out in the previous two weeks?
® ❑
Has the system' received normal flows in the previous two week period?
❑ ®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 gpd
t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is
required for North Andover MA June 7 2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
owner and town
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
ozs , g C,F. x -7 _ 1431 s qal p el-
Sump pump?
Last date of occupancy:
Type of 661 lishment:
Design flow (based o
Basis of design flow (si
Grease trap present?
Industrial waste holding
Flow Conditions:
0 CMR 15.203):
ft., etc.):
Non -sanitary waste -discharged to the Title 5 system?
Wate eter readings, if available:
day (gpd)
K
❑
Yes ® No
❑
Yes ® No
❑
Yes ® No
❑
Yes 0 No
—�❑
❑ Yes ® No
current
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage DispoftLS,ystem - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 37 Olympic Lane
Owner
information is
required for
every page.
Property Address
Wescott
Owner's Name
North Andover MA June 7, 2016
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupa
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
Pumped 2007, 2011 & 2015.
❑ Yes ® No
Zero
gallons
Pumping can be done when repairs are made.
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
w v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M '< 37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is
required for North Andover MA June 7, 2016
every page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components; date installed (if known) and source of information:
System is from 1979 - 37 years old..
Were sewage odors detected when 'arriving at the site?
Building Sewer (locate on site plan):
18"
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other (explain): —
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
❑ Yes ® No
Septic Tank (locate on site plan):
6"
SDepth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
Precast rectangular concrete -1000 gallons
tS i 1) Gavc� cc V) 011, 10'1
confirmed by a Certificate of Compliance? (attach a copy
Dimensions:
Sludge depth:
t5ins • 3/13
years
5'x5'x8'-1000aallons
1"
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�., 37 Olympic Lane
Property Address
Wescott
Owner
information is
required for
every page.
f/
t5ins • 3113
Owner's Name
North Andover MA June 7, 2016
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
34"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? by measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank and baffle are in very good shape. The solids are light and do not require pumping at this
time.
Grease Trap (locate on site plan):
Depth below grade
Material of construction
❑ concrete ❑ metal
Dimensions:
Scum thickness
Distance from top of
Distance from betto'm
Date of last pumping:
❑ fiberglass
curd -t6 top of outlet tee or baffle
of scum to bottom of outlet tee or baffle
feet
❑ other (explain):
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Sumurface Sewage Disposal System Form.- Not for Voluntary Assessments
,M 37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is North Andover MA June 7 2016
required for ,
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels -as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
V ❑ concrete metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
Comments (condition of a
,gallons per day
❑ s ❑ No
Alarm in wor ' q order:
X Date
and float switches, etc.):
❑ Yes ❑ No
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is
required for North Andover MA June 7, 2016
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Zero
/ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d -box is 20" x 20" and is 24" below grade. The d -box is full to cover and is in hydraulic failure.
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
Comments (note condition of pump
❑ Yes
❑ No*
of pupp9-and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
SIf SAS not located, explain why:
SAS was located by asbuilt dray
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
a Subsurface
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS is in hvdraulic failure at this time.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
v Depth — top of liquid"
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of
Indication of groundwater inflow
t5ins • 3/13
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Sewage Disposal System Form - Not for Voluntary
Assessments
37 Olympic Lane
Property Address
Wescott
Owner
Owner's Name
information is
required for
North Andover MA
June 7 2016
every page.
City/Town State
Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits
number:
/
❑ leaching chambers
number:
❑ leaching galleries
number:
❑ leaching trenches
number, length:
® leaching fields
45'x 20'
number, dimensions:
❑ overflow cesspool
number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS is in hvdraulic failure at this time.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
v Depth — top of liquid"
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of
Indication of groundwater inflow
t5ins • 3/13
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Olympic Lane
Property Address
Wescott
Owner
information is
required for
every page.
Owner's Name
North Andover MA June 7, 2016
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, conditi
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions.
.—.,Depth of solids
Comments (note condition of
etc.): /
vegetation,
sigrapf hydraulic failure, level of ponding, condition of vegetation,
t5ins • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is
required for North Andover MA June 7 2016
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a ew of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketc in the are below
El drawing att hed sep ately
-mr—Wal
F,oN} o7 Aokst,
37 010" p %c L4,.w,
A AholovLr
4-
Pocc, ILA
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RATS „
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t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
..<LCommonwealth
of Massachusetts
.
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
37 Olympic Lane
Property Address
Wescott
Owner
Owners Name
information is
required for
North Andover MA June 7 2016
,
every page.
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water AJo v% -C
® Check cellar r�
® Shallow wells IIJo'tic.
Estimated depth to high ground water: 5.5'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Jan. 15, 1979
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Proposed, asbuilt and pumping records on file.
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Test hole # 1 showed ground water at 66". Test hole # 2 showed ground water at 5' 6". Test hole #
3 showed groundwater at 7'6". Basement is 5' below grade with no sump pump
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 37 Olympic Lane
Property Address
Wescott
Owner Owner's Name
information is
required for North Andover MA June 7, 2016
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth*to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
w
FILE # N A nd 671
TITLE V INSPECTION
Dean G. Luscomb H & Sons
P.O. Box 135
Middleton, MA 01949
978-774-4065
Licensed Plumber # 20285
RECEIVED
JUN 14 2016
TOWN OF NORTH ANDOVER
HEALTH DEPARFri
4 r)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PROPERTY OWNERS NAME. n �Oa n , CC��"�"
PROPERTY ADDRESS -�r7 (Iy or IJ i c LQ I J e.
N. Andover MA
DATE OF INSPECTION _J LL n e r7 O 1 (o
NAME OF INSPECTOR -D e-0 r> �� . L Lt-'!:-, C n rnh :1E
QUALITY IS NUMBER ONE TO US
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• $f Application for Septic Disposal System
toConstruction Permit - TOWN OF
NORTH ANDOVER, MA 01845
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
seam
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
❑ Repair or replace an existing system component — What?
A. Facility Information
3 9 al °7 /n /'I
Address or Lot #
TODAY'S D TE
$350.0 Full Repair
0 - Component
City/Town RECEIVED
2.- *TYPE OF SEPTIC SYSTEM*:
➢ E]Pump Gravity (choose one) AUG ? 2 201645qi
4
***If pump system, attach copy of electrical permit to application***
➢ ❑ Conventional System (pipe and stone system) TOWN OF NORTH ANDOVER
➢ [TInfiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certificatitMT ARRA of system.)
➢ ❑ Pressure Distribution S.A.S. (No D -Box)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before D WC issuance)
What is the Make?
2. Owner Information
TOz l,�s e 5 c o
Name
Address (if different from above)
City/Town
Email address
Installer Information
What is the Model.
State Zip Code
Telephone Number
Pc—, d3 r cne— r,,, (L f e—' arm ,i F )Lcet vn_, I v► G T ,-r
Name & Name of Company
Address
City/Town State Zip Code
Telephone Number (Cell Phone # if possible please)
a. Designer Information
j& _,,y0 S Cicao�
Name
Address
City/Town
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
• Application for Septic Disposal System
Construction Permit -TOWN OF TODAY'S DATE
NORTH ANDOVER, MA 01845 $ -Full Repair
$1775.5.00 00 -Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: eKesidential 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. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approved.
7-� �l 6
Name Date
Appli i n App v y: ( and of Health Representative) I
2Z
Na a Date
Ap natio isapproved for the following reasons:
For Office Use Only: /
1. Fee Attached? Yes v No
2. Project Manager Obligation Form Attached.? Yes No
3. Pump -Sys tem? If so, Attach copy of Electrical Permit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout?
4. Reviewed a rovalletter all a erwork received? Yes �/
pp p p No
5. Foundation As -Built? (new construction only): Yes No
(Same scale as approved plan)
6. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit • Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
a o %`,7Pt c 1,,e--&-, O S boot
(Address of septic system) For plans by
i
(Engineer)
Relative to the application of 'L T 'e-( � •%E'-�
(Installer's name) And dated
ngina date)
Dated � c? l6
o ay 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 obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. 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 Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
M company
a. Bottom of Bed - Generally, this is the first (1 s� inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection - Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdept&townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a 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. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other thanimple 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 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 to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. 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 ofHealth staff or consultant.
d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solerresponsible for the installation of the system as per the
approved plans. No instructions_bv the homeowner, general contractor, or anv other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: /--y� �� � v l_._ (Today's Date) a- i G
c(cS (Z- tee ✓&i2z
7 ame - Print -Tame - igne
North Andover Health Department
Community and Economic Development Division
August 17, 2016
Joe and Joanne Wescott
37 Olympic Lane
North Andover, MA 01845
Re: Subsurface Sewage Disposal System Plan for 37 Olympic Lane (Map 106B, Lot 142)
Dear Mr. and Mrs. Wescott:
The proposed wastewater system design plan for the above site dated July 26, 2016 with a final
revision date of August 5, 2016 and received on August 9, 2016 has been approved.
The design plan has been approved for use in the construction of a new on-site septic system for
a 4 -bedroom (max 9 -room) home utilizing a Quick 4 Standard LP Infiltrator Chamber system.
This design plan approval is valid until August 17, 2018.
During this time, a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer, designer and the Town of North
Andover. In the event an imminent health problem, such as sewage backup into the dwelling is
occurring, the North Andover Board of Health may reduce the time period for which this plan is
valid.
This approval is also subject to the following conditions:
1. 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 (3 10 CMR 15.020(1))
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,
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
37 Olympic Lane
August 17, 2016
Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical
Inspector. The issuance of a Disposal System Construction Permit shall not construe
and/or imply compliance with any of the aforementioned requirements.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Sincerely,
lor
Z///? (4, t
rian J. LaGrasse, CEHT
Director of Public Health
Encl. Installers list
cc: Benjamin C. Osgood, Jr. PE
File
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
Benjamin c. Osgood. Jr. P E.
157 Bluff Street
Salem, NH 03079
Tel: 978-435-1324
August 5, 2016
Brian J. LaGrasse, CEHT
Director of Public Health
North Andover Board of Health
Building 20 Suite 2035
1600 Osgood Street
North Andover, MA 01845
Re: 37 Olympic Lane, North Andover
Dear Brian:
RECEIVED
AUG 0 5 2016
TOWN OF NORTH
ER
HEALTH DEPARTMENT
Enclosed are three (3) copies of revised subsurface sewage disposal which have been revised as
follows.
1. The scale has been corrected on the plan to F' = 20'
2. The distance from the house to the tank has been corrected in the profile view
3. The tank indicates 9" min of fill over the top and the grade line has been adjusted to
reflect this minimum requirement. The tank dimension has been corrected so that it is
drawn to the proper size.
4. The distribution box inverts have been corrected in the profile view.
5. The reserve area has been shown with an area equal to a pipe in stone area
requirement. This reserve area overlaps the proposed system area.
6. An additional designer certification has been added.
7. A letter from the owner certifying that they agree with the standard approval
conditions for the IA system is attached.
These plans are being submitted for approval by the Board of Health.
If you have any questions you may contact me at 978-435-1324.
Sincerely,
Benjamin C. Osgoo
CERTIFICATION
RECEIVED
AUG 0 5 2018
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
We Joseph and Joanne Wescott as property owner of 37 Olympic Lane, North Andover,
MA hereby certify to the following:
1. I have been provided a copy of the Title 5 VA technology Approval, the Owner's
Manual, and the Operation and Maintenance Manual, and agree to comply with all
terms and conditions.
2. I agree to fulfill my responsibility to provide written notification of the Approval to
any new Owner, as required by 310 CMR 15.287(5)
4. I understand that the design does not provide for the use of garbage grinders, the
restriction is understood and accepted.
5. Whether or not covered by a warranty, -1 understand the requirement to repair, replace,
modify or take any other action as required by the Department or the Local
Approving Authority (LAA), if the Department or the LAA determines the System to
be failing to protect public health and safety and the environment, as defined in 310
CMR 15.303.
Signed this 5`s day of August, 2016
�� ojlazf�,�
sep Wescott
Qwk� I &)WA' -z ...... .. ......... .... .. .. .... ..........................
&nne Wescott
North Andover Health Department
Community and Economic Development Division
August 2, 2016
Benjamin Osgood, P.E.
157 Bluff Street
Salem, NH 03079
Re: 37 Olympic Lane (Map 10613, Lot 142)
Dear Mr. Osgood:
The proposed wastewater system design plan for the above site dated July 26, 2016 and received
on August 1, 2016 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. The site plan scale appears to be 1" = 20' instead 1" = 30' as noted on the design plan
(3 10 CMR 15.220(4)).
2. In the profile view, the distance from the house to the septic is different than the site plan
view.
3. In the profile view, the septic tank only has 6" of proposed cover material and the tank
does not appear to be drawn to scale.
4. In the profile view, the distribution box inlet and outlet elevations need to be switched.
5. Since the Infiltrator Chamber system is proposed as an alternative soil absorption system
the "Standard Conditions for Alternative Soil Absorption Systems with General Use
Certification and/or Approved for Remedial Use" will apply. Please provide the
following as required by the approval conditions
Section II(7):
e) The record drawings, approved by the LAA, must clearly indicate an area for
the best feasible replacement system that could be installed in the event that the
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
proposed Alternative Soil Absorption System fails or it is determined that it is not
capable of providing equivalent environmental protection;
Section II(18):
a) proof that the Designer has satisfactorily completed any required training by
the Company for the design and installation of the Technology;
c) certification by the Designer that the design conforms to the Approval, any
Company Design Guidance, and 310 CMR 15. 000; and
d) a certification, signed by the Owner of record for the property to be served by
the Technology, stating that the property Owner:
1. has been provided a copy of the Title S IIA technology Approval,
the Owner's Manual, and the Operation and Maintenance Manual,
and the Owner agrees to comply with all terms and conditions:
iii if the design does not provide for the use of garbage grinders, the
restriction is understood and accepted; and
iv whether or not covered by a warranty, the System Owner
understands the requirement to repair, replace, modem or take any
other action as required by the Department or the LAA, if the
Department or the LAA determines the System to be failing to
protect public health and safety and the environment, as defined in
310 CMR 15.303.
Please feel free to contact the office or Mill River Consulting at 978-282-0014 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,
X.
h
Tian J. aGrasse, CEHT
Director of Public Health
cc: Joe & Joanne Wescott
File
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
TOWN OF NORTH ANDOVER
NORTH ANDOVER, MASSACHUSETTS 01845
µORTyp
O�ggVO �6 �'bO
� A
Ssacaug�
Permit Number
Date Issued (0 1 � ?h (A
Expiration Bate
Jackie's Law — Permit Application
RECEIVED
JUN 23 2016
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Pursuant to G.L. c. 82A §1 and 520 C1MR. 7.00 et seq.(as amended)
THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION
Name of Applicant 94,6-17 B PV^A EX G AV AI (N 6
Phone Cell
Street Address ? ? 0 OCO S'T
City/Town
MA
I ZIP
%Van, LkgAl
0 I bq5
Name of Excavator (if different from applicant)
/ %Cell
Phone r/o I
V
Street Address
it
"� tt�� Vi
ll
/
i? o �C{.v oQ f7 tv19 AAA
City/Town
MA
ZIP
Name of Owner(s) of Property To d
Phone q19 Cell
Street Address3
5 13 a [ -I
City/Town
MA
ZIP
Permit Fee Received No Yes
Other Contact
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.
pt, a, G T'S
Insurance Certificate #:
Name and Contact Information of Insurrer::
LANCE
(3b-�A-:; l v\5o lLl�VvC
Policy Expiration Date: I i
Dig Safe #: ) i ( -; SO ( j
Name of Competent Person (as defined by S20 Cl.02):
Y' Q,
t l vxk o 2 L,
Massachusetts Hoisting License # H G11
License Grade: K e °' -A
Expiration Date: 8/11 ;A Q C
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 GOVERING 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 ITS 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 S GNATURE
DATE W
EXCAVATOR SIGNATURE (IF DIFFERENT)
DATE
OWNER'S SIGNATURE (IF DIFFERENT)
DATE:
2 1 P a g e
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:
In
M
iv.
V1.
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,
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".
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;
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.
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 www.mass.g_ov/dps
3 1 P a g e
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
W �c
ORTN AND ��
QW�I pF NpEPARiM�
HEALTH DEPARTMENT
1600 OSGOOD STREET; SUITE 2035
NORTH ANDOVER, MASSACHUSETTS 01845
APPLICATION FOR SOIL TESTS
978.688.9540 - Phone
978.688.8476 - FAX
healthdept@northandovenna.gov
www.northandoverma.gov RECEIVED
JUN 21 2016
DATE: 6,-17-16 MAP & PARCEL: /D6 �✓- s Al2- TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
LOCATION OF SOIL TESTS: 3 7 VK -P/C " I
Wi
OWNER: , - C- i JZ:` 0,V NE U9 E SCo Contact #: -.5-OB - Z (=,�- cjq$Z
APPLICANT: t5, -e? a1 C, Contact #:
ADDRESS: 32 0 / v, -i 14" p v ✓ et -
ENGINEER: Rjt �� ��rq r, ,� 2 Contact #: 7
CERTIFIED SOIL EVALUATOR:
Intended Use of Land: Residential Subdivision ' g_ le Family Hom Commercial
Is This: Repair Testing: Undeveloped Lot Testing: Upgrade for Addition:
In the Lake Cochichewick Watershed? Yes
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
No
➢ Proof of land ownership (Tax bill, or letter from owner permitting test)
➢ 8.5"x H" Plot plan & Location of Testing (please indicate test nit sites on the plan)
➢ Fee of $585.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $440.00 per lot for repairs or upgrades.
GENERAL INFORMATION
➢ Only Certified Soil Evaluators may perform deep hole inspections.
➢ Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
➢ At least two deep holes and two percolation tests are required for each septic system disposal area.
➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH
representative.
➢ Full payment will be required for all additional tests within two weeks of testing.
➢ Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health
showing the location of all tests (including aborted tests).
➢ Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval /Dame: ('0 z A [ i0
Signature of Conservation Agent: 1
Date back to Health Department: (stamp in):
-C-'\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record \J
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authors
A. Facility Information
Important:
When filling out
1.
System Location:
forms on the
C
computer, use
only the tab key
Addres
to move your
cursor - do not
Cityrro wY
use the return
key.
�i
2
S Owner:
m
Name �/�
a
�
Address (if different from to atic
City/Town
B. Pumping Record
1.
Date of Pumping
3.
Type of system: ❑
SEP 1 1 2007
TOWN OF NORTH AN VER
i
i
State Zip Code
State— ^ _ � � 3"i Co
Telephone/) Number
Date 2. Quantity Pumped
Cesspool(s) W
Septic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ YeKO No
5. Condition of System:
�-
?-:2)
1allons
E] Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
6. Systw Pumped By:
Nam Vehicle Lice a Number
ign ze�
Company
7. Location
posed:
5lgnatuVf Hauler v
hftp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
W City/Town of North Andover
System Pumping Record
Form 4
'M
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
� rab
reran
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
RECEiv�r�
A. Facility Information
1. System Location:
37 Olymipic Lane
Address
North Andover
Ma
JUN -7 `1011
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
01845
City/Town State Zip Code
2. System Owner:
Westcott
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
5/5/11
Date
❑ Cesspool(s)
2. Quantity Pumped:
® Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
Xsolids
6. System Pumped By:
Bruce Merrill
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant. 20 So. Mill Bradfol
of
Signature of
1000
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Ma 01835
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
rt`�
(A
1 Yy a 7�r t'N i
LA D 'f
iI+
L.E\/AT (,oAjw C:
)UT OF NSE _
J TO TAN V a -�-
UT-OF D! r,NJ < 1 _
box I o2 . (73
5 �UlL ;.
5_v �_ TS -u I2. t7l!!"�F- D,
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-
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01; -- c.TES ¢
� St AN D�v�'� �T � �'• A•N C��/E.
I
I
I IE
t TL OK t
Di siance To:
'.:'etl ends
Dr;.-ns
Well
?. 1:'a -ter Line Location
�. No P -VC Pipe
u. Septic Tank
Tees - Length & To Clean Out Covers
Cement Pipe to Tank - On Both Sides of Tank
Distribution Box
Cover x Box - No Crac,s
All Lines Flo°:•ring Equal Amounts
No Back Floe
Leech Field or Trench
�> �siors
Caprled Ends
Clean Double ?;.asked Slone
%. Lea, -,h
Di, o, ? sions
Stone D
Spla Pay's
m sJ
er,ent Pipe to Pit - 13 o'. Sides
i Clel�n Double t:'ashed. S ,one
,_.,o Ga ?, -e Di spcsal
R _nal ncd . n Inr pec' i.on
in.
11. As - Built i, ',,mi'L ved
Lot LOCaiG'_On
Dimensions of
I,oon i.i:h ,,rind o r s
EI e v a' i c,iis
','aLer Table
DISPOSAL SISTEMI CHD.K L16T
NORTH Ali
DOVER BOARD OF HEALTHd�
'D DkTE PROVIDED DISAPPROVED DATE TIME REASON
Title 5
Reg. 2.5
Reg. 6
Fail OK The submitted plan must show as a minumum:
(a) the lot to be served (area,dimensions,lot //,abutters)
((Planning Board files)
b . location and log of deep observation holes -distance
to ties
�-'(c) location and results of percolation tests -distance
to ties
d) design calculations & calculations showing required
/ leaching area
(e) location and dimensions sf system (including reserve
area)
f existing and proposed contours
g location of any wet areas within 100' of the sewage
/ disposal system ordisclaimer (check wetlands mappin
(h-) surface and subsurface drains within 100' of sewage
disposal system of disclaimer
L4/�M location of any drainage easements within 100' of
set -age disposal system or disclaimer (planning boar
files)
(j ) known.- sources: --of _-water supply- within- 200'--- of sewage!
disposal system or disclaimer ' ,
(k) location of any proposed well to serve the lot (10G
from leaching facility)
-(F1) location of water lines on property (10' from. leac!
facilities)
�/(m) location of benchmark
{(n) driveways
-o) garbage disposers
i p) no PVC is to be used in construction
q) a profile of the system (elevations of basement,!
pipe septic tank, distribution box inlets and out
distribution field piping and any other elevation
'�(r) maximum ground water elevation in area of sewagel
f system
i / (s) plan must be prepared by a Professional Engineer
other professional authorized by law to prepare
plans
.6 tic Tanks
(a) Capacities - 150% of flow, water table, tees, c"
of tees, access, pumping,
Lod, b Cleanout
(C 10' from cellar wall or inground swimming pool
�(d 25' from subsurface drains
`d over Subsurface disposal system check list - Page 2
�a-11
,O.2
/'I0.4
C
Reg.11 .2
Reg.11 .4
Reg.11 .1C
Reg.11 .11
Reg.15.1
Reg. 15.1
Reg. 15.4
Reg. 15.8
Reg. 3.7
Reg.14.1
Reg. 14.3
Reg, 14. 4
- 14-5
Reg.14.6-
Reg.14.7
Reg.'14.1
Reg. 9.1
Reg. 9.6
Distribution Boxes
a Slope greater than 9.08
b Sump
Leaching Pits
Leaching pits are preferred where the installation is
possible
a Calculations of leaching area (minimum 500 S.F.)
b Spa i-h�g
C) Sace drainage 2%
d.--'C9ver material
e -aching Fields
,) ?',Greater than 20 minutes/inch
'b Area(minimum_-900 S.F. )
c Construction of field
d Surface drainage 2%
e 20' from cellar wall or inground swimming pool
Leaching Trenches
(a Calculations of leaching area (min. 500 S.F.
(b Spacing (4 ft. min. 6 ft. with reserve between)
(c Dimensions -
Ne
Construction -_:-=
Stone
(f) Surface drainage 2%
Downhill Slope
(a) Slope y/x _ (to be shown
b/x X'150 to be shown)
Pump a
(a Approval
(b� Shand -by power