Loading...
HomeMy WebLinkAboutMiscellaneous - 383 SALEM STREET 4/30/2018 (2)a .- -rX7 . .� s �a o ! }Lot & Street Map/farce! CONSTRUCTION APPROVAL - r Has plan revieW fee been paid: ES NO Permit# d - Plan A roVaj Date: ` - �.Pp i 'Approved .FDes gper. _ ­. Plans Date. _ — - _ iWater Supply ow a - Well Fy : s V�Je11Permit =s- Dnller:' f- I a 1 ' 1NellTests'Chemical _ ...Date Approved.. - } - Nr Date Approved ria 4a6fena li ateAp roved Plumbirig�SignOff F iring Sign off 4 .a -wti."�.r A x may_ 31 S r Form #U�Approval rApprova! to Issuer YES W NO Da'ued - By Conditions - _. • spm ,ice--° 17*65 Approval z AI! Perniits Paitl� .F -YES NO WellkConstruct�onlApproval? - YES = NO } $epticxSystem ConstructionxApproval� YES Certification�c -YES; NO Other, YES ,NO t- Any VarianceNeeded? YES. hN0 =FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTICYSTEM INSTALLATION CONDITIONS. s Js the installer kec n* 6d� .k 'YE 'Type -of Construction Y r �.x NEW REPAIR- New Consruction Certified Plot'Plan oReview AYESK N Conditoons of A val from Form U - YES NO : ``Issuance of DWC perrr�t xt pp` E 0.' \ _ DWG Permit Paid?` f _ S NO ., DWC` Permit —t _ - T - c : 4. Begin Inspectjo-'- _ T NO Excavation lnspection� -� .� - _ � � _ Neededr �� - m �Q -�I7I� 27'er _�//li"u.�.s!'�a...f✓—�_ !"'. l'7.%�T�^'"4'i��.%e__�f� f '- :I g v c P. Passed 4 - By Cons#ruction Inspection ° y = 4 { ry Needed. `" zr -.: P�. S: Built Ian Satisfactory " k YES:, .: ;F Y 'a" +y '�,m E-`—,1 '. k 4 � A ' S � R .�Ad � f 4 I•a" Et -: 1 ��� L e W* t .Approval of'Backfill Date By Final`Grading Approval Date. y `" \ B , _ _ Final Construction, Approval: Date: By Certificate of Compliance: Approval: Date: -----------_- Commonwealth of Massachusetts City/Town of 1 RECEIVE ::� System Pumping Record Form 4 AUG 11 2006 wY TOWN OF NOF2TH ANUC}VE DEP has provided this form for use by local Boards of Health. The Syste"TPTPuriapSngrRe.iord must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: formster computer,-u.use' ona tab key Address mo to move your cursor - do riot Qi !Town use the return tY State Zip Code key. . 2. System Owner:- Name Address (if different from location) City/Town State ^o Telephone Number B Pumping Record - 1: Date of Pumping�� Date Quantity Pumped: Gallons .3. Type of system: ❑ Cesspool(s) ff.Septic Tank- TightTank: ❑ other (describe): 4. Effluent Tee Filter present? ❑ Yes L-i'No If es, was it cleaned? Yes Y ❑ ❑ No 5: Condition of System: & System urn ed 4_7S Name Vehicle License Number company -- . 7. Locatio re contents Isp e Signa t e o ter Date http://www.mass.gov/dep/wa er/ provals/t5formshtm#inspect t5forrn4.doc- 06/03 System:Pumping Record • Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECT in APR 2 22003 TITLE 5' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTAVYA ESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:-? 7? S ozl f'/2f 57-r ,/y %4,1,1,o o V­eY Owner's Name: 7-6 A4 /<//I -S Owner's Addresi• Date of Inspection: 41-115 -0-3 Name of Inspector: (please print) �j tin �3 U sa Company Name: 'S T e to 3 yr � .p ya �- � C_ Mailing Address:y So M, t S; Telephone Number: / - ) 3'7 Z -:741 / CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: JSPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ti. rq 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 '\\_ _,Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: GJ /� �i r %Y 1 01-1lo Q a r !- Owner: To n,, i,-, iii s Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: V-1" 1" SI have not found any information which indicates that any of the failure criteria described in 310 CMR 4 5.303 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. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)'are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed - ND explain: s, Page 3 of I 1 OFFICIAL. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �3 2 '�,) Ino S 1 — Owner: I�zj /-( S Date of Inspection: 0 3 C. Further Evaluation is Required by the Board of Health: / f �'^( C. / onditions exist which require further evaluation by the Board of Health in order to determine if the syst m is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy bf the analysis must be attached to this forth. , - 3. Other: ., Page 4 of 11 OFFICIAL INSPECTION FORD — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 %-? fc l/!r, 5 /- /-/ . /-/. 6d/-/DOvrV� Owner: To tri ,4 , A-1 s Date of Inspection: c/ 5`^G .3 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: ! 7 Yes N0 N. A ' ✓� 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 '/z day flow _ _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number —/Of times pumped . _ Any portion of the SAS, cesspool or privy is below high ground water elevation. °-'Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. l 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. t4A, 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) 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: l- • /4 To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either "yes" or "no" to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone. 11 of a public water supply well; If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 .Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J ,/ fP/ic, ,S I Owner: l f� 114' (i•r S Date of Inspection: 7 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 ? r _ 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 facilityor 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 Kaintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Y/no a Existing information. For example, a plan at the Board of Health. 'r Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 / R, ) �/k/l/ s% ilC)nU -tom Owner: T -U M Date of Inspection: Ir/- / C) 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): c Number of bedrooms (actual): 'j DESIGN DESIGN flow based on 310 C 15.203 (for example: 110 gpd x # of bedrooms): - 1-.0 Number of current residents: a, Does residence have a garbage grinder (yes or no): /` U Is laundry on a separate sewage system (yes or no):)& Uf yes separate inspection required] Laundry system inspected (yes or no): -Y-f 5 C'r P vd U Seasonal use: (yes or no): _Ll Water meter readings, if available (last 2 years usage (gpd)): , Sump pump (yes or no): Last date of occupancy: 6 r c r COMMERCIAL/INDUSTRIAL k/ Type of establishment: Design flow (based on 310 CMR 15.203): gnd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: V -S Was system pumped as part of4he inspection (yes or no):!°°S If yes, volume pumped: J4 -O gallons -- How was quantity pumped determined? %-2v C/4- Reason for pumping: TYPE -OF SYSTEM e _L-"'S'eptic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): —4/0 6 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 7 5f- ) /P4 S r / -�- iti Vv P/ Owner: r—O 0%a01C„-,s Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction:�ast iron _40 PVC _other (explain): Distance from private water supply well or suction line: v cv/y Comments (on condition of joints, venting, evidence of leakage, etc.): JQP/rs 9 aan C6a-"/uo�- C .r SEPTIC TANK -.y (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: l� �, L �., t)z' /Q yr J) Sludge depth: rr Distance from top of sludge to bottom of outlet tee or baffle: /7 Scum thickness: -,,, ' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 6 J-� S1 f� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ,,n/a G Jft5 013S&v t-cl GREASE TRAP: _(locate on site plan) Depth below grade: 14 � R Material of construction: _concrete ` metal _fiberglass polyethylene _othei (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . , . Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32? o 1,1, -IL Owner:5 Date of Inspection: � / _/ S�.- U 3 TIGHT or HOLDING TANK: /(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): r Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX:` P 6 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): RO X den PUMP CHAMBER: /"� `(1'ocate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): P4ge 9 of 11 n OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32,f- -5-c-Z/ f,,w 51— / -/. c -- Owner: T6 h-1 1 1, S Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):/(locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _' P leaching chambers, number: leaching galleries, number: leaching trenches, number, length: f leaching fields, number, dimensions: 'P -1— 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.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 ,age 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM 'INFORMATION (continued) Property Address: Owner: "]'�G ffA !�, / s Date of Inspection: (� -q SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. .,v A si .1, f � ro 10 0 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7? _ Ahi��v V Owner: / � i t? S Date of Inspection:— / U 3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 4 'feet Please indicate (check) all methods used to determine the high ground water elevation: /Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: 11 %i'v i ioFL, r, J /l`f3� aC�" .4iZo�n %G11 �/- ��0U1-ifs 11 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 4/14/00 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X ) by John Soucy at 383 Salem Street has been installed in accordance with the provisions of Title V of the State Sanitary Code anq. with the North Andover Board of Health regulations. Tl}y,Q issuance of this certificate shall not be construed as a guarantee that the system will T n satisfactorily. Board of Health Inspector TOWN OF NORTH :ANDOVER SEWAGE DISPOSAL SYSTE\,[ I\,STALLATION CERTIFICATION The unders]�Med here -v certuv that the SewaL-e Disposal Svster-1 r corst,-.ir.t i, (,�() re^aired! V— - ©N{ /V . _cam t9 C �3 — located at�� was installed in corlfermance with the North Andover Board of Health a:proves' plan, Svstem Design Pe. -Mat _ 1105 dated it �y �g _ with an arcroved des,"211 flow or I/ /�2ea;lons per day The materiais use% were in conformar.ce .vith Mose speculed oh the approved plan; the system, was installed in accordance ,%-iih the i revisions of 310 C'v-lR- l 000, Title 5 and local re�ilations, and the final grading agrees substantially with the approved plan. .-til work ;s accurately_ represented the As -built which has been submitted to the Board e- Health. Bed inspection -date );a / Final inspect, 7e A Installer: Cesium EnQireer: Engineer Eagir.eer Represer:tat.,v �..:c.T: Date: Date Tc rr 102r.. .11 3'73 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, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: /1� /'?I CURRENT INSTALLER'S LICENSE# LOCATION: 0 LICENSED INSTALLER: �, C LA SIGNATURE:.. TEL HONEn-Z /"A, CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only X75.00 Fee Attached? Yes l/ No Foundation As -Built? Yes No Floor Plans? Yes No ApprovalDate: r 1999 t�� M:® Elm c Q O .,o Q = 0 J Q N W ro _ LL O t ter•,., win Q c O — m c o z Z Q N ro = a > o L a o Q 00 U L � N H +.-t c O O U o c 0 � s N c ro ro o`o E 0 U - - - t U - - - ter•,., win - H H O _ i': fYN C ro O 0 v Y: MEW ENGLAND ENG�I�NEERING SERVICES October 13, 1999 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 383 Salem Street, North Andover septic system design Dear Sandra: Please accept this letter as a request to have the following local variances considered for approval at the next Board of Health meeting. Local Variance Required: 1 Allow a septic system installation without a pretreatment unit in the watershed district. 2 Allow the use of a 20 mill poly barrier in lieu of a concrete wall for slope reduction. If you have any questions or need additional information please do not hesitate to contact this office. I will attend your next Board of Health meeting to discuss this matter. Sincerely, 6—e Benjamin C. e?/'Jr-'EIT President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 NEW ENGLAND ENGINEERING SERVICES INC October 13, 1999 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 383 Salem Street, North Andover, Septic system design Dear Sandra: Enclosed you will find five copies of a septic system design for the above referenced property. These plans are being submitted for approval. The following additional items are also being submitted. 1. Soil evaluator sheets. 2. Application form. 3. Check to cover the fee. 4. Request to have the local variances and upgrade approvals considered at the next Board of Health meeting. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood, Jr., EIT or 3 19q� President — - - P.S. Please note that our new address is 60 Beechwood Drive, North Andover. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 Site Location Reference Plans and Specs. ENGINEER DESI Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee —' CHAIRMAN, BOARD OF HEALTH Site System Permit No. /les—� Town of North Andover, Massachusetts Form No. 2 NORT1y, BOARD OF HEALTH O� '4llD ,D. hrO 19 o P � s ;,r;p,,' DESIGN APPROVAL FOR ss"CHU SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Site Location Reference Plans and Specs. ENGINEER DESI Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee —' CHAIRMAN, BOARD OF HEALTH Site System Permit No. /les—� Oct -15-99 08:19A Paul D. Tut -bide, PE/PLS 508-465-0313 P.04 I October 15, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for 383 Salem Street Dear Sandra, I find that the design plans dated Sept 15, 1999 adequately address the regulations. Note that this upgrade design requires local variances for use of 20 -mil poly barrier in place of concrete wall and for not installing a pretreatment unit within a watershed district. If you have any questions or comments please feel free to contact me. Sincerely Carlton A. Brown, PE/PLS Salem 383. doc POitDi ENGINEIRIE Civil Engineers & Land Surveyors One Harris Street Newburyport, MA 01950 (978)465-8594 sr 9 —�+ F [ 11 a) �T�� pEaSA. a" d y Y L _ FORM 11 - SOIL EVALUATOR DORM ` Page I of 3 Date: No Commonwealth of Massachusetts Massachusetts Soil Suitability Assessment for On-site Sewage Diosal n - By:n�n�- (/sG,uvv _ .. Date: = j� Performed Witnessed By: Wc�iion Address a g 83 / Sa/em S?� o.,rcr� wme, C /ZT /?C, ' Address. and SAL �/17 -< %/- Tckphore / /�i �Z T7 r-12Gj t ) t- I` ' ew Construction ❑ Repair M 978- 685'! 9936 Office Review Published Soil Survey Available: No ❑ Yes Dd Unit Rip Soil Ma - Year Published / %f%/ Publication Scale / /s�yo.... p Drainage Class ��o ' / �' "^`° Soil Limitations Surficial Geologic Report Available: No ® Yes ❑ Year Published Publication Scale .......-................ Geologic Material (Map Unit) _._........_......_ ............................... . ._....._........_.................._ ...... . ...... __.. Landform ...................... _ ..... ...... .......... ................ ......... ....... ........_...................._........................_. Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes p 6 Within 500 year flood boundary No ❑Yes 1t Within 100 year flood boundary No El Yes ❑ !' n-- I 1 3199` Wetland Area: t National Wetland Inventory Map (map unit) ............ , Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Normal ❑Normal MBelc-/ Normal El Other References Reviewed: iaDEF APPROVED FORM - 12107/95 FORM 11 - SOIL EVALUATOR FORM' Page 2of3 -11 I vert Location Address or Lot No. 383 Sf1eEM SI C-- / , /V till v On-site Review Deep Hole Number77;j// Date: 9//c/`/ Time: /v -,JJ Weather Location (identify on site plan) /-,v-,T. n! h hr ` _ Land Use 1-.6w AJ Slope M / `'L� Surface Stones ti' �',�t Vegetation Cx cFss Landform Position on landscape (sketch on the back) S<<. t2<44-/% Distances from: Open Water Body > Zo., feet Drainage way 7 feet Possible Wet Area '> /vo feet Property Line o70 feet Drinking Water Well 7 .)oz� . feet Other DEEP OBSERVATION HOLE LU(i Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, G ulledl'rs, Consistency, % Depth from Surface (Inches) G� •" �i3 F. 1 � M E r� n yr2s%�? -/03 G G''�,s. sS Parent Material (geologic) _h�ti fiy^ T I Depth to Groundwater: Standing Water in the Hole: — Estimated Seasonal High Ground Water: —3- -, kiDEPAPPROVED FORM - 12/07/95 DepthtoBedrock: Weeping from Pit Face: FORM 11 - SOIL EIVALUATOR FORM Page 2of3 Location Address or Lot No. 3 b 3 ScrLL M ST -leer N A't''Dooce- On-site Review ' / / Deep Hole Number 7---P 0Z Date: �1 ! Q f Time: /D; Location (identify on site plan) Land Use Slope M Surface Stones Vegetation 6,sS Landform /K-0 Position on landscape (sketch on the back) Distances from: Open Water Body > 2,.% c, feet Drainage way '.1100 feet Possible Wet Area I /00 feet Property Line 3c) feet Drinking Water Well feet Other - Weather 7So DEEP OBSERVATION HOLE LOG" Depth from Soil Horizon Soil Texture Soil color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Parent Material (geologic) ghr &AI ! •,tL Depth to Groundwater: Standing Water in the Hole: _ Estimated Seasonal High Ground Water: rid kiUEP APPKOVED FO"t - 12/07/95 S017/3 nitro DepthtoBedrock: Weeping from Pit Face: -- TCIfilly OF pelt?(it'd -F;/ `...P OCT 11)3 1999 FORM II - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. 383 -'Sct lem C -r—, A) • �.�vo�e,2 Determination for Seasonal Him Water Table Method Used: ❑ Depth observed standing in observation hole ...... inches ❑ Depth weeping from side of. observation hole.. inches T, Depth to soil mottlesTPz5,6" inches ❑ Ground water adjustment ............. feet Index Well Number ....... ..... Reading Date .............. Index well level ... Adjustment factor ......... Adjusted ground water level ...... ...... .... ................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �� s If not, what is the depth of naturally occurring pervious material? Certification I certify that on Vou i49s (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date .71E 1,7 DEP APPROVED FORM - 12/07/95 Town of North Andover, Massachusetts Form No. 1 oRT1y qo BOARD OF HEALTH `ED rb 46ti 9<9 L 19 rir cr � :w 70 \A...... Ewoa, APPLICATION FOR SITE TESTING/INSPECTION Applicant--Z86Z� B�1464 NAME ADDRESS TELEPHONE Site Location $c3 5PL,6'0) �+-� `5600,b -le Engineer NAME �A DRRRESSC� TELEPHONE Test/Inspection Date and Time AOARD OF HE HOF HE H Fee Test No. 9411'' S.S. Permit No. ���� D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts 0RTli _ BOARD OF HEALTH \Ao°° FwoP. APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 V �SACHUS° r Applicant NAME ADDRESS TELEPHONE _ C ` Site Location Engineer Test/Inspection Date and Time fe 7�Fee ' AUUKtNN 77`-- C CHAIRMAN, BOARD OF HEALTH _ Test No. S.S. Permit No. ` = D.W.C. No. C.C. Date Plbg. Permit No. May -27-99 12:45P North Andover Com_ Dev_ 508 688 9542 P_01 SEPTIC PLAN SUBMITTAL FORM LOCATION: 3&37f NEW — — -- NEW PLANS: YLS $125.0041lan_1 j REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE:_. DESIGN ENGINEER: („ DATE TO CONSLtL.TANT: *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. kv# 'OL ll-4641211 LOS -14 Yi vi 'R IIIIIIIIIIIIN In��l�1 R���1111111 iilllilllllllll � '� 1' P-IN91N111� ► z. 11111�•�--.INS �NI-I�J�11 i '1,91E r° k . ,..� 11N nn � - 11111111111111 _ �� �$� n n�lNlmn �� r, l 44-1 v Y r 1ti14JI U3 lu 4C al 2 Z Z �� � 43�►,)s b Qo' --i NN ��-`•-o® �J U j, ZY J i i N 7 aC 1ti14JI U3 lu 4C al 2 Z Z �� � 43�►,)s b Qo' --i NN ��-`•-o® �J U j, ZY J i i ■.. 4-U ti 461 Li it 1 Q1 Board of Health - North__ An4b_V erZNaae. r A DI SU COVED eaffvnsi Erd-fIC SISTER INSTA.LLATICK CHECK, LIST 1 z LOT ). AVA _ CN OK FAIL 1. Distance To s�l `��'IC�' (� 1 a. Wetlands LL_ b. Drains C.. Well 2. Water Line Location 3. No PPC Pipe1��%i"� 4. Septic Tank a. ..Tees -_Length k To Clean Out Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flo i-Ang Equal Amounts C. No Back Flov 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Inds d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit Both Sides ' f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System jcxyal. As Built Submitted a. Lot Location b. Dime<isions of System c. Location with Regard -to Perc Test d. Elevations e. Water Table q TddV uvo. -jdaa XUMOTH s)laoM o-rTqnj 'jqTuaH10 PluOg pavoq ZUTUUuTd :01 IuDs saTdoD 986T 9 aunf- uo Uaz,qTo •V•N aMl ui aouo una OWN i uVulal-140 D-3-rA suu,)TA -9 :Ag -luawluToddu Aq pue -w-d 00:Z of uoou OO:ZT woag XL-psz)nj..uo Ivp Ixz)AopuV,tl:lxoN lz-)z).x:jS u-rVW ON '2uTPTTnq umol 'DOTJJO UOTSSTUIIn) UOTIVAaDSUOD ZLIJ IV ajqvjTVAU aaU SUPjj •401 uo poupua�jnddp pup s2uipTTnq -j o uoiqonajsuoo p—a a-Li'tjTin.XPMaATap A-.')j1i)ZaaWa PeOa ZU-L 1-su-C go sasodand xog V P120H- O-eS;DPTT-LD PU-e � -40-1 -4E PULT ZEDITv 0 .s;DIL-IDOSSV V-11 go qualuj go -.;�-UO Vy '.Z.BAOPUV, 11 42ON aaals UTU14 OZI 'Woou SUTID014 2u-1pjTnq umol auk' a ON'd 00:8 Tv �8586'T'ZT au'llf, uo 2UTaPDH OTTqnj aip u@do-aa --tT4U.-UQzzsTu'LuOO uO-r-4vA,'z)suO0 ;[Z)AOPUV 'ql-ION gill 'MVj AQ UOTIODIOIJ PUVIIDM S,aDAOPUV 111aON 90 umOl a4q Puu 'PaPuDwu su '0'7 UOTTZ)OS 'TCT aalduLID smul jvaauaD sqqasnLjopssujq dqOV UOTIODqOa.T snuvIlDM D'qq 90 AqTxoLjlnv aLp oq luvnsanj I" SOIL -C99 3NOHd3'131 NOISSIWWOD NO11VAM3SN00 S113-3 IHOVSSVW 'H3AOC1MV HIMON JO NMO-L ILPPROM DATE 'I . - LM -'F-5 Providedt SUBSURFACE DISPOSAL DESIGN CHECK LIST DISAPPROVED , DATE Reasons: A3 A&�v � P ?,.. V . I . j LOT # 0 5ALAA4.5T ritle v Reg 2.5 FAIL The submitted plan must show as a minimums 'a) the lot to be served-ariawdimenaionslot # abutters b location and log deep observation gies-1stance to ties clocation and results percolation tests-ct.stance to ties d design calculations & calculations shovi, g required leaching area (e) location and dimensions of system -int; ucLag veserve area f), existing and proposed contours (g) location any wet areas Athin 1001 of sews.63 disposal system or. . disclaimer -check wetlands mapping (h) surface and subsurface drains within 100, of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board files (J) known sources of water supply within 2001 of sewage disposal system or disclaimer (k) location of any proposed well to serve lot -1001 from leaching facility' (1) location of water lines on property -101 from leaching facility (m) location of benchmark driveways (o) garbage disposals (p) no PVC to be used in construction, (q) profile of system -elevations of basement, plumb., pipe., septic tank, distribution box inlets and outlets, dis•ribution field piping and other elevations (r) maximum ground water elevation in area sewage disposal system plan must be prepared by a Professional 'aglneer or other professional authorized by law to prepar, such plans '(n) —(s) Reg 6 Septic Tanks 0 . (a) capacities -150% of flow., water table. 'be, j., depth of tees., access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 251 from subsurface drains teg 10.2 Distribution Boxes (a) s ope greater than 0.08' teg 10.4 :Yb) sump 0 04. 11�.,�_1 Ilk BOARD OF HEALTH 146 MAIN STREET" NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS ° DATE: l �-7 I Ig LOCATION OF SOIL TESTS:',��G, Assessor's map & parcel number: M.A-p 3? �� ��,,�,� j �A OWNER: Ro�oc.tz-r . j; (Zv4G-H TEL. NO..- q73 — 68S—'Fq3? ADDRESS: 3 2- ENGINEER: ENGINEER: 6ze,a ,e 5 Tnc- TEL. NO.: q 7.9 7 6 9 e-� 0S��o CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial 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 $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showingthe location of all tests includin F d � -��L" / aborted tests). ('� _ [AUG271999 9ARDer`ALTH 7. Within 60 days of testing soil evaluation forms shall be submitted. 1 1. _. LOT' I SALcl✓1 SPI K$ IN 5(D" OAK *4fl m N ST2E E TOWN OF NORTH ANDOVER SYSTEM ]PIMPING RECORD DATE: SY r Y rc DATE OF PUMPING: 12 y a� SYSTEM LOCATION ____ (example: left front of house) lyu�r p�i� 7- QUANTITY QUANTITY PtTMPED, 1�rf o GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE �--- EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE FULL TO COVER ROOTS BAFFLES IN PLACE EXCESSIVE SOLIDS LEACHFIELD RUNBACK SOLIDS CARRYOVER FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY:J6,4 p A N y 7� / � d►�. A COMMENTS: CONTENTS TRANSFERRED TO: e J Commonwealth of Massachusetts LRECOVED City/Town of North Andover System Pumping Record UG 2 0 2009 Form 4 OFNORGt 4, SME ANI)OVERALTHPAF2DEP has provided this form for use by local Boards of Health. Otherused, 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. MA State 01845 Zip Code Citylrown State Zip Code 978-884-6147 Telephone Number B. Pumping Record 1. Date of Pumping 7/11/09 2. Quantity Pumped: 1,500 Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ® No 5. Condition of System: Good working condition 6. System Pumped By: Jason Elliott L90-471 Name Vehicle License Number Jason Elliott Septic Pumping Company 7. Location where contents were disposed: &9/20/09 Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms on the computer, use 383 Salem Street only the tab key Address to move your North Andover cursor - do not City/Town use the return key. 2 System Owner: David Grey Name 1�1 Address (if different from location) MA State 01845 Zip Code Citylrown State Zip Code 978-884-6147 Telephone Number B. Pumping Record 1. Date of Pumping 7/11/09 2. Quantity Pumped: 1,500 Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ® No 5. Condition of System: Good working condition 6. System Pumped By: Jason Elliott L90-471 Name Vehicle License Number Jason Elliott Septic Pumping Company 7. Location where contents were disposed: &9/20/09 Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1