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HomeMy WebLinkAboutMiscellaneous - 394 BOSTON STREET 4/30/2018 (2)������ :�� ,� � 0 NOR7h 1 4102 OL i y 4q OS$ A[ HU`M'S PUBLIC HEALTH DEPARTMENT Community Development Division RECEIVE® MAY 3 0 2008 TOWN OF NORTH ANDOb`F!= —HEAL-TH-DE-PA+?T;;AE-il, � TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (JI/constructed; ( ) repaired; By: Td bD D16Ti;S�) (Print Name) Located at; � 4A Rj� Gj-j��� )T2� (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated o7 and last revised on "` with a design flow of 4- 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: t5 -1 -0g _170U,.. VUF12El'l )e, And - Print Name Final Construction Inspection Date: 911 L -L- 122 And - Print Name Installer:______/° ev I sy gVLADIMIR L. y NEMCHENOK Enginer: i! N o. FFG/STEp`�oc� ONA1. Engineer Representative (Signature) Engineer Representative (Signature) Date: C' And - Print Name Date: OSI2�4T1cvl q.41A.4 i1, /y &C41(ZNbK— And - Print Name 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com NOTE•* THIS PLAN & CERTIFICATION IS NOT A WARRANTY OF THE SUBSURFACE DISPOSAL SYSTEM. IT IS A RECORD OF THE LOCATION AND ELEVATION OF THE EXISTING SYSTEM COMPONENTS. I HEREBY CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM HAS BEEN INSTALLED RECEIVED IN ACCORDANCE WITH THE PROVISIONS OF 310 CMR. 15.00 (TITLE 5) AND THE MAY 3 0 2008 APPROVED DESIGNS PLANS. TOHEAOF NORTH LLTH DEPARTMENT E OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NORTH ANDOVER, MASS./394 BOSTON STREET AS PREPARED FOR JOYCE FEROCCHI TM 107D DATE: 5-12-08 TL 4 SCALE: 1"=40' 0 20 40 80 MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 f NOTE•o THIS PLAN & CERTIFICATION IS NOT A WARRANTY OF THE SUBSURFACE DISPOSAL SYSTEM. IT IS A RECORD OF THE LOCATION AND ELEVATION OF THE EXISTING SYSTEM COMPONENTS. I HEREBY CERTIFY THAT THE SEWAGE DISPOSAL SYSTEM HAS BEEN INSTALLED IN ACCORDANCE WITH THE PROVISIONS OF 310 CMR. 15.00 (TITLE 5) AND THE APPROVED DESIGNS PLANS. OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NORTH ANDOVER, AS PREPARED FOR JOYCE PEROCCHI RECEIVES DATE: 5-12-08 JUN 0 9 2008 SCALE: 1"=40 MASS. /394 BOSTON STREET TM 107D TL 4 0 20 40 80 E TOWN TARTMR ATMERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01610 �I Commonwealth of Massachusetts Map -Block -Lot Oq A+ b 107.D- 0004 - ----------------------- Board of Health Permit No North Andover - BHP -2008-00 - 13 ---- --------------- -- P.I. FEE F.I. $250.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd -Bate -son ---------------------- ------------------------------------------------------------------ to (Upgrade) an Individual Sewage Disposal System. atNo 394BOSTONSTREET -- - -------------------------------------------------------------------- --------------------- --------------------------------- as shown on the application for Disposal Works Construction PermitNo. �BHP-2_0087_001 --- Dated , --- March 10,2008 ------ --------- M -FILE ------------------------- Issued On: M ar- 1 0 200 8 Board of Health Commonwealth of Massachusetts Board of Health North Andover Certificate of Compliance ACINU THIS IS TO CERTIFY, That the Individual Sewage Disposal S by Todd Bateson ---------------------------------- Map-Block-Lot 107.D- 0004 - -------------------- atNo- -3-9-4- -BOSTON -STREET ------ - --- ----- --------- -- -------------------------------------------------------------------------------- has been installed in accordan"th-f� e ��Drovisions of TITLE 5 of the State Environmental Code as described in the application for Disposal—Worls Construction Permit No. - BHP -2_008700 I - Dated - - -March_ 1-0,2908 ------ _I>-*— --------------- ----------------------- Printed On: Mar -10-2008 Board of Health Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street r Property Address 1. Joyce Perocchi Owner's Name North Andover Cityrrown MA 01845 6/4/2015 State Zip Code Date of Inspection1, G� a'� 1 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. Important: A. General Information G When filling out RECEIVED forms on the computer, use 1. Inspector: - only the tab key 111 (� JUN 15 2015 to move your Neil J. Bateson �J cursor- do not Name of Inspector TOWN OF NOR! t use the return key. Bateson Enterprises Inc. HEALTH I UEr�rt I ftI`PJT Company Name 111 Argilla Road Company Address Andover MA 01810 Citylrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further E uation by the Local Approving Authority 6/4/2015 InspecOe"igkature 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 not 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street Property Address Joyce Perocchi Owner's Name North Andover Cityrrown B. Certification (cont.). MA 01845 State Zip Code 6/4/2015 Date of Inspection Inspection Summary: Check A,B,C,D or 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 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 ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Foran: Subsurface Sewage Disposal System • Page 2 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 394 Boston street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 6/4/2015 City/Town' 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 the system 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 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 or 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 394 Boston street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 6/4/2015 Cityrrown 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. ❑ 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 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 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: 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 1/ day flow t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage'Disposal System • Page 4 of 17 ❑ ® 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 following, in addition to the questions in Section D. 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. t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ., . •''� 394 Boston street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 6/4/2015 every page. Cityfrown 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 of cesspool 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 following, in addition to the questions in Section D. 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. t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 6/4/2015 every page. 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 3/13 Title 5 Official Inspection Form: 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 394 Boston street Property Address Joyce Perocchi Owner Owner's Name Information is required for North Andover MA 01845 6/4/2015 for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: well water for sprinkler Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 7 of 17 i Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street D. System Information (cont.) 01845 6/4/2015 Zip Code Date of Inspection Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Pumped 2014, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank. Reason for pumping: Inspect tank & tees 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 Property Address Joyce Perocchi Owner Owners Name information is required for North Andover MA every page. Citylrown State D. System Information (cont.) 01845 6/4/2015 Zip Code Date of Inspection Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Pumped 2014, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank. Reason for pumping: Inspect tank & tees 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street Property Address Joyce Perocchi Owner's Name North Andover City/Town MA 01845 6/4/2015 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 7 years old, 5/12/2008, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 3 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.): 4" cast iron through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 2" ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 gf-,\'. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,p 394 Boston street Owner information is required for every page. t5ins - 3/13 Property Address Joyce Perocchi Owner's Name North Andover MA 01845 6/4/2015 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 31" 211 91 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Inlet cover has riser 4" deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street Property Address Joyce Perocchi Owner . Owner's Name information is uired for North Andover MA 01845 6/4/2015 req 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: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? El Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 394 Boston street Property Address Joyce Perocchi Owner's Name North Andover Citylrown D. System Information (cont.) MA 01845 6/4/2015 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 9 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.): D -box level & distribution equal. No evidence of carryover. No evidence of leakage. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps 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): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 12 of 17 Commonwealth of Massachusetts I uTTithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 6/4/2015 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 40 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields 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.): Soil Ok. Vegetation ok. No sign of ponding to surface. 4 trenches of infiltrators 10 chambers per trench 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 ❑ No t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 - tNz Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 6/4/2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5in5 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 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 394 Boston street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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: 6/4/2015 ® hand -sketch in the area below ❑ drawing attached separately D`,uewan D— 9� ( {� Vo -tM_ Z� ae ` Q—ee�.A = tr S�s [! t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 394 Boston street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 6/4/2015 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 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: 12/05/2007Date ❑ 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: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston street State 01845 Zip Code 6/4/2015 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Property Address Joyce Perocchi Owner Owners Name information is required for North Andover every page. City/Town State 01845 Zip Code 6/4/2015 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 • Summary Record Card generated on 5/11/2015 9:41:29 AM by Maureen McAuley Page 1 Town of North Andover Tax Map # 210-107.D-0004-0000.0 Parcel Id 18503 394 BOSTON STREET PEROCCHI, PAUL & JOYCE G 394 BOSTON STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type. 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.56 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until PEROCCHI, PAUL & JOYCE G Payor 394 BOSTON STREET NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 24504.0 - 394 BOSTON STREET Last Billing Date 5/8/2015 1090565 01 Cycle 01 Active UB Services Maint. Account No. 1090565 Service Code Rate MISCFEE ADMIN FEE 1 1 WTR WATER 01 ALL METER SIZE UB Meter Maintenance Account No. 1090565 Serial No Status Location 34133294 a Active ERT HH Date Reading Code 4/27/2015 220 a Actual 1/30/2015 206 a Actual 10/24/2014 127 a Actual 7/25/2014 112 a Actual 4/24/2014 100 a Actual 1/27/2014 79 aActual 10/23/2013 54 a Actual 7/23/2013 40 a Actual 4/24/2013 21 a Actual 1/18/2013 0 n New Meter Charge Multiplier/Users 9.18 1/1 53.20 1/1 Brand Type Size YTD Cons b Badger w Water 1 1 220 Consumption Posted Date Variance 14 5/19/2015 -80% 79 2/20/2015 389% 15 11/14/2014 26% 12 8/13/2014 -46% 21 5/15/2014 -7% 25 2/14/2014 71% 14 11/18/2013 -28% 19 8/15/2013 -3% 21 5/20/2013 2/13/2013 Commonwealth of Massachusetts City/Town of . System Pumping. Record Form 4 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. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of house, Left / i hVsid;oqf hous ,Left/ Right side of building, Left / Right front of building, Left / Right rear of building, n er c Address �� [ City/Town State Zip Code 2. System Owner. Name' Address (if different from location) Citylrown ' B. Pumping Record 1. Date of Pumping 3. Type -of system: ❑ Stat 3 Telephone Number C, -L-k-c Date 2. Qu Pumped Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yeas 5. Condition of Syste� �OA 6.. System Pumped By: Neil. Bateson Name Bateson Enterprises Inc Company 7. Location re contents were disposed: _ Lowell Waste Water Gallons , ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number &-- C16---ft-- Date t5form4.doo- 06103 System Pumping Record •Page 1 of 1 ttORTFf O !C � 4 ��SSACHUS���y PUBLIC HEALTH DEPARTMENT Community Development Division CE127I�FICA�I'E OrF CO�L�1'LIA�VC'�E As of: June 13, 2008 This is to cert that the individual subsurface disposalsystem received a SA7ISEACT0RT13VS(ECqI0Yof the: Tuff Septic System Repair By. Todd (Bateson At: 394 Boston ,Street Wap 107.10; (Parcef4 North Andover, M q 01845 The Issuance of this certiftate shall not 6e construed as a guarantee that the system will function satisfactorily. z Susan Sawyer f' Public Yfealth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Application for Septic Disposal System (Construction Permit -TOWN OF ORTH ANDOVER. MA Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* N4epair or replace an existing on-site sewage disposal system* ❑ Repair or replace an existing system component — What? A. Facility Information :30/y �sf �� zi Address or Lot # City/Town 2.- *TYPE QFJSEPTIC SYSTEM*: ❑ Pump Gravity (choose one) *** pump system, attach copy of electrical permit to application*** onventional System (pipe and stone system) v�D TODAY'S DATE 250.00 — Full Repa 1 ponent F-1 Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Name Address (if different from above) Me ALP-- CitylTown 3. Installer `.Information ll Name ' Address - • Cityrrown 4. Designer Information Name Address Cityrrown State Zip Code & 3 -- Fs'�ify Telephone Number me of Company State Zip Code Telephone Number (Cell Phone # if possible please) ��'��.•e %,gym ".�.�-� % �ai � - .1��. Name of Comp �Aak • / - State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 NORTH APphcation Lor Ssposal System eptic Di ' �-Construction Permit —TOWN OF * c�'. .•' ORTH ANDOVER. MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: 5 esidential Dwelling or ❑Commercial B. Agreement 3 — �—d TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been iss by this Board of Health. Nam Date Applicati Approved Board of Health Representative) 3 -z 7 - z�:e N e Date ,Application Disapproved for the following reasons: For Office Use Only: Application for Disposal System Construction Permit • Page 2 of 2 L Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes 4,1 No 3. Pump Sys tem? If so, Attach copv ofElecuical Permit Yes 1)1d No 4. Foundation As -Built. (new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans? (new construction only). YesJ 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: (Address of septic system) Relative to the application of (Installer's name) Dated :3 �"�'�d 8' o ay s ate For laps by 1�/ I < ,--L4.- r-, �°v�J,,"�u�2.� P (Engineer) And dated 14; -'-la ^,zr 17 - (Original ate With revisions dated I understand the following obligations for management of this project: (Last revised date) 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 MY company a. Bottom of Bed — Generally, this is the first (V) 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: healthdeptnn,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 than simple 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 solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: �� ,/¢ fes�.� / (Today's Date) 3 (Name —Print) oll"' M. "� " �*_- Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - dip; not use the refum key. _Q 11/:V=:x Iml Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary AssesE 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover City/Town MA 01845 State Zip Code lr V )WN OF NORTH ANDOV!'R HEALTH DEPARTMEt4T 1/20/2012 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 1. Inspector: Neil James Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town . State Zip Code 978-475-4786 SI' 15 Telephone Number License Number B. Certification 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Need Further Evaluation by the Local Approving Authority 1 /20/2012 Inspect is ignatu 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 not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System •Page 1 of 17 Owner information is required for every page. J0. s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 1/20/2012 Citylrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 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 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 0 N ❑ ND (Explain below): t5ins - 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 2 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 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 State Zip Code 1/20/2012 Date of Inspection ❑ 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 the system 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 t5ins • 11/10 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 3 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 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 1/20/2012 Cityrrown 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. ❑ 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 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 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: 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 - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 ❑ ® 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 following, in addition to the questions in Section D. 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 II 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. t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r< 394 Boston Street Property Address Joyce Perocchi Owner Owners Name information is required for North Andover MA 01845 1/20/2012 every page. Cityrrown 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 of cesspool 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 following, in addition to the questions in Section D. 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 II 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. t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 5 of 17 =ail= Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 1/20/2012 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 11/10 Tftle 5 official Inspection Form: 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 y( 394 Boston Street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 every page. Citylrown State Zip Code 18 D. System Information Description: 1/20/2012 Date of Inspection Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): On well water Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 11/10 We 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 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 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 1/20/2012 City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Date Pumping Records: Source of information: Pumped last year, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 1500 gallons Measured tank tank & tees ® 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 • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 8 of 17 Owner information is required for every page. t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 1/20/2012 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 4 years old, 5/12/2008, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain): OR - 3 feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron thru wall. 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass 2 feet ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x5'x4' Sludge depth: 2" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston Street Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 1/20/2012 Date of Inspection 24" 1" 8" Distance from bottom of scum to bottom of outlet tee or baffle 20" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at invert. No evidence of leakage. Riser cover over inlet cover, 4" deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: t5ins • 11/10 feet ❑ polyethylene ❑ other (explain): Date 'rifle 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 10 of 17 Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 1/20/2012 Date of Inspection 24" 1" 8" Distance from bottom of scum to bottom of outlet tee or baffle 20" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at invert. No evidence of leakage. Riser cover over inlet cover, 4" deep. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: t5ins • 11/10 feet ❑ polyethylene ❑ other (explain): Date 'rifle 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston Street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 every page. CitylTown State Zip Code E 1/20/2012 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: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Desi n Flow' U gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 11/10 Idle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner . information is required for every page. 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 1/20/2012 City/Town D. System Information (cont.) State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Date of Inspection 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.): D -box level & distribution equal, has flow levelers. No evidence of leakage. Evidence of light carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Owner information is required for every page. t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 1/20/2012 Cityrrown 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 number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 4 trenches 40' long Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 4 trenches 40' long has 10 infiltrators per trench. Soil ok,Vegetation ok. No sign of ponding to surface. 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 ❑ 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 394 Boston Street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 1/20/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): IE 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.): t5ins • 11/10 Title 5 Official Inspection Form: 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 394 Boston Street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA- 01845 1/20/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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 -sketch in the area below ❑ drawing attached separately 2 S'eql oc- _ff IK O T I -r-O-kA >jS e- � �tl �7 g "e Detvewccy W -e11 7 tso t Q6Ld . sh t5ins -11110 Title 5 Official Inspection Foran: Subsurface Sewage Disposal System - Page 15 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 394 Boston Street Property Address Joyce Perocchi Owner's Name North Andover MA 01845 1/20/2012 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 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: 12/05/2007 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 394 Boston Street Property Address Joyce Perocchi Owner Owner's Name information is required for North Andover MA 01845 1/20/2012 every page. Citylrown 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 l5ins • 11110 Title 5 Ofridal Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record y Form 4 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. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Leftt side of house�Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address � i t4 pcs-�O"� I��Tv ku�- cityrrown State Zip Code 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): stated a 3 - Ilia Telephone Number I -Do-'-)o I Date 2. Quantity Pumped; Cesspool(s) e'ptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Cond' ion of System: oc,McLJI, 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locjjg hhere contents were disposed: / . Lowell Waste Water iule4 I Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 r TOWN OF NORTH ANDOVER f µoRtH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 ' "..«- ..�, • NORTH ANDOVER, MASSACHUSETTS 01845 4&SacHUSYt 978.688.9540 — Phone Susan Y. Sawyer, RENS/RS 978.688.8476— FAX Public Health Director E-MAIL: healthdept@townofnorthandover.com WEBSITE: http://www.townofnorthandover.com SEPTIC PLAN SUBMITTAL FORM Date of Submission: 1 Z - Z0 -07 Site Location: 4,7014 1 V7o4rT-Dj\) of ILEef'f Engineer: H lQft4 l M e E 1 12,rh New Plans? Check # '30 49 (includes 1't submission and one re- review only) Revised Plans?Yes $75/Plan Check # Site Evaluation Forms Included? Yes ✓ No Local Upgrade Form Included? P,A -Yes No RECEIVED PIAN 10 2008' Telephone #: 15 5;5;5 X- Z© Fax #: �Ifg 2 c/ I E-mail: 1J 1- f7L4 Fl2Eh6jE_ a9_"M C . r l✓ T OFFICE USE ONLY When the submission is complete (including check): ➢ Date stamp plans and letter ➢ i Complete and attach Receipt ➢ Copy File; Forward to Consultant ➢ L"I", Enter on Log Sheet and Database Locution: 7 Q O . 4�_rr Ounces blame If c, ;Map/Parcel: b Addmn:±14 2]2"./J{ Installer: Tel "New plso) _grpdr ✓ Date: Z'4i "Peilands >_Zone II Sall Srtnboi�So11 Rtrme G e-t� Soil Q ass Deep Observatijan Hole Logs Elmdon Depth Soil 14cizon Soil Tutt Soll Color Soil htottling % Gmwi. Stones, a to Obser-adon $ole9 Depth of Pett 0 . Stat Presoak o Time at n o • Time at 9" ; Time at 6" Ca ; Timc (9"-6"L_ -Rate hfinanA -. 1 k.L - r,r.wUtaterw. -`1L-L DepA��08edewk.2:_bbwugw~jkdwSdes �• Rss�tn=tnaiZ9tF.oe g µ 04 47 PattatMatetiat t L�`s a Bdtselc stat watet in alta Sties Wcepint ttwa llt Face_ _EMGWt lv P7 Date Obser-adon $ole9 Depth of Pett 0 . Stat Presoak o Time at n o • Time at 9" ; Time at 6" Ca ; Timc (9"-6"L_ -Rate hfinanA -. 1 Pe rotation Tests Performed By. c d3 5� Witaessed Br- �e i `["` � w 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. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. l Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.415. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. A. Facility Information 1. Facility Name and Address: Joyce Perocchi Residence Name 394 Boston Street Street Address North Andover City/ Town 2. Owner Name and Address (if different from above): Jovice Perocchi Name North Andover Citylrown 01845 Zip Code 3. Type of Facility (check all that apply): ® Residential ❑ Institutional 4. Describe Facility: 4 Bdrm. House 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) Ma 01845 ' State Zip Code 394 Boston Street Street Address Ma State (978) 683-8784 Telephone Number ❑ Commercial ❑ School ® Conventional ❑ Other (describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Seepage Pits t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval, Page 1 of 4 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): ME gpd 440 gpd 440 gpd ® Voluntary ❑ Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: date of inspection 2. Describe the proposed upgrade to the system: new 1500 Gal. Septic Tank, gravity flow to a 755 s.f. Leach Field with Infiltrator Chambers 3. Local Upgrade Approval is requested for (check all that apply): ❑ Reduction in setback(s) — describe reductions: ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. ❑ Reduction in separation between the SAS and high groundwater: Separation reduction Percolation rate Depth to groundwater ft. minAnch ft. % reduction t5formga.doc • rev. 7/06 Application for Local Upgrade Approval* Page 2 of 4 Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater ® Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test ❑ Other requirements of 310 CMR 15.000 that cannot be met— describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by: Randy Burley Evaluator's Name (type or print) C. Explanation Signature 12-5-07 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: System is designed in full compliance however only one deep hole is within the proposed leach field. The presence of the existing system components and other existing conditions prohibited two deep holes from being excavated in the proposed leach area 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: NA t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval* Page 3 of 4 Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval 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: NA 4. Connection to a public sewer is not feasible: None Available 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ❑ Application for Disposal System Construction Permit ® Complete plans and specifications ® Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2), ❑ Other (List): D. Certification "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." Owners Signature Jo a Perocchi Print Name Bill Dufresne/Merrimack Engineering Services Name of Preparer 66 Park Street Preparers address 01810 State/ZIP Code 12-26-07 Date 12-26-07 Date Andover City/Town (978) 475-3555 Telephone t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval* Page 4 of 4