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Miscellaneous - 428 WINTER STREET 4/30/2018 (2)
1 � L 6 Lot & Street Map/Parcel d - lv�% CONSTRUCTION APPROVAL Has plan review fee been paid: � ES NO Permit# Plan Approval: Date: Designer: Conditions: Water Supply: Town Well Well Permit: Driller: Approved by: Plan Date: Well Tests: Chemical Date Apprbvel Bacteria I Date Approve Bacteria II Date Approved Plumbing Sign -Off: Wiring Sign -off: Comments: Form "U„ Approval: Approval to Issue: Date Issued By:_ Conditions: Final Approval: YES NO All Permits Paid? E NO Well Construction Approval? YES NO Septic System Construction Approval? C;� NO Certification? ES NO Other? -"YES NO Any Variance Needed? <YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: • /1 SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed?YES NO Type of Construction: NEW_.FPA R New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: NO DWC Permit Paid?Y� NO DWC Permit # �a� Installer: Begin Inspection: Excavation Inspection: Needed: Passed: Construction Inspdction: Needed: As Built Plan Satisfactory: YES: M Approval of Backfill: Date: By: Final Grading Approval: Date: By: ./ YES NO Final Construction Approval: Date: By: Certificate of Compliance: Approval: WSJ_(/ _ Date: 7&7Z1 4AA TOWN 0&' SYSTEM PUMPING RECORD DATE: `U✓�� �~ L SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) 't' -+J 4 a Roo &c-- DATE OF PUMPING: QUANTITY PUMPED: l 5-2 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste - n•' •. �r.I n HivUVVEF h41 p/OYldod;hli loan !cr Sao +�, ;o^u1 o HEA LTFiDEPF�RTMENT 00 i-�ml(Iod 10 lllo loCll 8^erc: Cr ,'.oJlln pr AArO;In Y C �'„lnprlry A. Faclllty InforrTl�clon d m G � I I, PVmpinq 3. Typ9 41 sys(am; CDC699p001(9) YEM-vOnl Too FII(e prr, �;Co�dl�lon'P(;9yt�m '.'k . �(�..ill: .1, r1. 111 •,fit .,, ..I ;1����'�I. I rf•.1 �'^./ti vt/) Ir 1�J�' �'l• �[• ll' 1, I • S r :"Yji rti�j 1 r, 'p :�� ;�•;,;1'.. �;�{'.i)�li� (I'1'.rf�bd �' ♦�l, I''��Il�',�,`r,l�' . on.Who I ooOlenta'yrora d(ypossv ` , t/; • , , ,",r:' : �.. �.;;, , I 1, `d ,� „^,rr,;� •/••;,�ll;'�'�'' Sl�nikul olhJ�:�1y�.,;�„<,,. ,.t . ma,�,BoY/dop�lYsloi/epproYaJa/Iblorm�.n�m>71n9�acl Y 43 T771O11r 1,1 Orr POPOC T8n,, II_y0 aJ l; c 6anaoi 7 4— c i ,T T• _. oA ,Y (.''l,' :J•.!ll( ..l r, ., '; Owner,.;`"'.AA Till, �----- �;, ,.4 '�.Sya►am I'� �drµ� (114Vf�rinl rpm buUon) CQr'Ow;1 � I I, PVmpinq 3. Typ9 41 sys(am; CDC699p001(9) YEM-vOnl Too FII(e prr, �;Co�dl�lon'P(;9yt�m '.'k . �(�..ill: .1, r1. 111 •,fit .,, ..I ;1����'�I. I rf•.1 �'^./ti vt/) Ir 1�J�' �'l• �[• ll' 1, I • S r :"Yji rti�j 1 r, 'p :�� ;�•;,;1'.. �;�{'.i)�li� (I'1'.rf�bd �' ♦�l, I''��Il�',�,`r,l�' . on.Who I ooOlenta'yrora d(ypossv ` , t/; • , , ,",r:' : �.. �.;;, , I 1, `d ,� „^,rr,;� •/••;,�ll;'�'�'' Sl�nikul olhJ�:�1y�.,;�„<,,. ,.t . ma,�,BoY/dop�lYsloi/epproYaJa/Iblorm�.n�m>71n9�acl Y 43 T771O11r 1,1 Orr POPOC T8n,, II_y0 aJ l; c 6anaoi 7 4— c i ,T T• _. Commonwealth of Massachusetts W City/Town of NORTH ANDOVER, '?S System Pumping Record M SV y Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. renes SSACHITS-E S DEP has provided this form for use by local Boards of Health. The S stem Pumping Record must be submitted to the local Board of Health or other approving authori RECEIVED A. Facility Information 1. System Location: Address Am City/Town 2. System Owner: /��--,-,►�� Name ----� Address (if different from location) City/Town trumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State JUN - 5 2006 TOWN O,F NORTH ANDOVER H DEPARTMENT Zip Code Stat Z' Code Telephone Number Date 2. Quantity Pumped; Cesspool(s) Septic Tank l� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Syste Pumped By: Name Company 7. Location where contents were disposed: Civ & . 29ZcQD �5 , /ign2tur-- of uler http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect vehicle License Number Date ' t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 TOWN OF NORTH ANDOVER (BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 8/7/01 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X ) by Todd Bateson at 428 Winter Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: to -C) q.- (example: left front of house) DATE OF PUMPING: I- to '"QUANTITY PUMPED_(— GALLONS CESSPOOL: NO V/ YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE ZEMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: rar-, _ Commonwealth of Massachusetts = City/Town of North Andover System Pumping Record Form 4 DEP has provided this form for use by local Boards of Hi Other fo`,ms may be used, but the information must be substantially the same as that provided �hd.f6, rfoi'e'u9ir g 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. rE V c�fi4 $FIP A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key. L lEltyl/ 4 System Location: jt� Wi'nkK Address North Andover Ma 01886 City/Town System Owner: — AIM Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping Date State State Telephone Number 2. Quantity Pumped: 3. Type of system: ❑ Cesspool(s) 4 Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: yr l Zip Code Zip Code too d Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 �YA�- 01107'�5L AS -BUILT CHECKLIST i� LOT NUMBER, STREET NAME i/ ASSESSORS MAP & PARCEL NUMBER IZ LOT LINES & LOCATION OF DWELLINGS F/ 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 A / V ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM �ly LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX LI -11. ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED Town of North Andover Office of the Conservation Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street North Andover, Massachusetts 01845 Brian LaGrasse Interim Conservation Administrator November 16, 2000 To: Robert Nicetta, Building Commissioner Alison Lescarbeau, Chairman, Planning Board William Sullivan, Chairman, ZBA From: Brian LaGrasse, Interim Conservation Administrator 00,417: Telephone (978) 688-9530 Fax (978) 688-9542 At our Conservation Commission meeting held on November 15, 2000 the following decisions were approved: 242-1044 428 -Winter_ Sir t This NOI was for the construction of a replacement septic system and associated grading within the Buffer Zone of a BVW. The Order of Conditions was approved as drafted for this project. 242-1046 314 Rea Street This NOI was also for the construction of a replacement septic system and associated grading within the Buffer Zone of a BVW. The Order of Conditions was approved as drafted for this project. 242-1049 659 Forest Street The Order of Conditions was approved as drafted for this NOI which was for the construction of a septic system and associated grading within the Buffer Zone of a BVW. 242-1047 212 Haymeadow Road This NOI was for the construction of a replacement of a failing septic system and associated grading within the Buffer Zone of a BVW. The Order of Conditions was approved as drafted for this project. If you would like a copy of the Order of Conditions please contact the Conservation Department. CC: Scott Masse, Chairman, Conservation Commission ;Heidi Griffin, Town Planner andra Starr, Board of Health Administrator BOARD OF APPEALS 688-9541 BUILDING688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLA.NrNING 688-9535 i 1 SEPTIC PLAN SUBMITTAL FORM LOCATION: VZ l"fiil� NEW PLANS: $125.00/Plan tv/ REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORAMS INCLUDED: 6 NO DATE: DESIGN ENGINEER: DATE TO CONSULTANT: *If you want your plans expedited, please submit three plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL (978) 475-3555, 373-5721 • FAX (978) 475-1448 • E-MAIL: merreng@aol.com TO: North Andover Board of Health FROM: Bill Dufresne/Merrimack Engineering DATE: rv- 2 -<x� RE: el -Z-3- C.JI444-e� S Y71, -X " TM: '16� 4 TL: 6 Y OWNER (NAME & ADDRESS) Members of the Board: An upgrade sewage disposal system plan dated: �?—/7—c5x9 has been submitted for the above referenced site. Pursuant to Title 5, and the North Andover Board of Health Regulations, Local upgrade approval and/or variances are being sought from the following sections. 2) 3) Please consider these requests for approval on your earliest available meeting agenda. We respectfully request your consideration of these matters. fjo cd Very truly yours, MERRIMACK ENGINEERING SERVICES William Dufresne r n r}I Tit at—� e qq �Iay 01 • a7+Gr E s] s. --S— M €si. t Y • n w 4gG• G : t h d tE 'S � �q C� .. _ ]7 .�... 7. F4,,. Gi _�Y1t a,�]i,E •�crtf 3•�)` n r *Y ] '33 grt j7d { d k i7 t, rE+� en 4° J " 5t MR 4r E n# i [• i wit n IT ����. To .1 G ,".M s] 7d.yjj7. t y /I t R tI�S,'yvq�..� k 1 i y r G E U Uil '• " - .' 7 ' :+ ] �E� 7i { a � - `. tit E �. ' „� r ##E { a t n - � ^H'+ Y gt yp.. ` iG doh r !- E�iGa� �,1, � y a• (t S Y{ t 1 ! FFfHY. P 15 LIM Y - � yllr:le� 13K] � ��i' tr7 i —win f 4Ya r' { N T-17 0 E01 i VVI I NESE.. 0L=, i 10N i i - 1 �C, CIS , _,::C TiNIEA.i I _ jWIE. i _ Gid. L O 9 Town of North Andover, Massachusetts Form No. 1 of No DTH qA BOARD OF HEALTH®Q 'CS 6q 'YO �Q h� a 0 v 70 APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME Site Location Engineer Test/I nsr Fee 76 ZW 1-a� CHAT MAN, BOARD OF HEALTH Test No. 9:5-0 — S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH Q BOARD OF HEALTH .t.EO l� " • � 19 0 ,:i`._`�, _ter ld°jUk �tiQAo°�° Ewaa."APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME ADDRESS TELEPHONE Site Location {r �'� �• y %�-�'�� �� - �-� Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee_ ' CHAIRMAN, BOARD OF HEALTH Test No. - S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. DATE: -3' /- &---° BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540. APPLICATION FOR SOIL TESTS MAP & PARCEL: M 10 +A, LOCATION OF SOIL TESTS: 4.2'9 4)i4 -rep- _ S-fi t'.►�c. (,`- OWNERAV We W ��N t c j TEL. NO.: Co f � - '� .S—° Co ADDRESS: , t f W N -' R. 7 '_ �o. � N 7) o V 2 �a �o X e2 3 ENGINEER: 4trIAAAckl &TEL. NO.: L/7.!(- J CERTIFIED SOIL EVALUATOR: Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within twoweeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: APR - 6 e` DATE: -3' /— " BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR SOIL TESTS MAP & PARCEL: N 10 +A, P.•rc . (,4 - LOCATION `- LOCATION OF SOIL TESTS: qg f � J J A► T 6 R Sfi • OWNERAV DQE W zrJ�u t 4. IZI%u c � TEL. NO.: lD p — So Co ADDRESS: '16 �y E R Y7, 4N 1> oy£ 2 100 yje X a 3 ENGINEER: 01 gel AAA C. k/ �u , N E E iz N TEL. NO.: CERTIFIED SOIL EVALUATOR: R, Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing: ✓ Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No Cacti I'' rn 6 Q THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $275.00 per lot for new construction This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or uppIrades. GENERAL INFORMATION We ANDREW Oil .IRENE SOUCY 976t666-2606 i 78 666-2506. 428 WINTER ST. - P.O. BOX 223 �- NORTH. ANDOVER, MA 01845 Zto the erof D OeI.IH on Mck. RTN Federal Credit Union 600 Main Street WaMarn, MA 02452 For M+ 1: 211313644S1:00582573It20 OSI 0 HARLAHD Date Received: Check Amount: Check Date: CLASSIC Y plans. 'ptem disposal area. Iscretion of the titted to the Board IA Q 1 Z Z aa.�j t •t ss• t•yl a� t.,; 66 t•G� Q'4 jig. . E ■� ARGEO PAUL CELLUCCI Governor COMMONWPOITH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF EIMMNIGNTAL PROTECTION ONE QVIIV'I'ER STREET, BOSTON MA 02108 (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM BIISPECTION FORK! PART A CEI WATION Property Address: 428 Winter Street, North Andover i�- TRUDY CORE seaetm DAVID B. STRUHS Commissioner Name of Owner Andrew Soucy Address of Owner: 428 Winter Street, North Andover, MA. 01845 Date of Inspection: 4/1/2000 Name of Inspector: Neil J. Bateson I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Bateson Enterprises Inc. Mailing Address: 111 Argilla Road Andover, MA 01810 Telephone Number. ( 978 ) 475-4786 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority X_F Inspector's Signature: l' Date: 41112000 The System Inspector s91ft mit a ' of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspectiosyste 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS APR - 7 ;nno revised 9/2/98 Page I of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 411/2000 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or move system components as described in the'Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four 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 revised 912198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 428 Winter Street, North Andover Owner. Soucy Date of Inspection: 4/1/2000 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and sal absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and sal absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 4/1/2000 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: _Yes_I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool. _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _X_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X Any portion of a cesspool or privy is within a Zone I of a public well. X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _X Any portion of a cesspool or privy is less -than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS - You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 4//2000 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _X Pumping information was provided by the owner, occupant, or Board of Health. _X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _N/A_ As built plans have been obtained and examined. Note if they are not available with NIA. _X The facility or dwelling was inspected for signs of sewage back-up. _X The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. X_ All system components, excluding the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _N/A Existing information. For example, Plan at B.O.H. X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [I 5.302(3)(b)) _X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 4/1/2000 FLOW CONDITIONS RESIDENTIAL: Design flow _ N/A g.p.d./bedroom. Number of bedrooms (design):—N/A_ Number of bedrooms (actual-4— Total actual4_Total DESIGN flow _N/A Number of current residents: _2_ Garbage grinder (yes or no): Yes _ Laundry (separate system) (yes or no):_ Yes_ If yes, separate inspection required Laundry system inspected (yes or no) No. Goes to drywell & owner says in gets mushy over it. Needs to be tied back to septic tank. Seasonal use (yes or no):_ No_ Water meter readings. N/A Sump Pump (yes or no): Has sump but no pump _ Last date of occupancy: Current COMMERCIALIINDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow 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: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped 12 years ago, owner. System pumped as part of inspection: (yes or no)_ No_ If yes, volume pumped: _gallons Reason for pumping: TYPE OF SYSTEM _X 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: House approx. 20 years old, owner. Sewage odors detected when arriving at the site: (yes or no)— No- revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 411/2000 BUILDING SEWER: X (Locate on site plan) Depth below grade: 36" Material of construction: cast iron _X_ 40 PVC _ other (explain) Distance from private water supply well or suction line: Diameter :4" Comments: No leaks SEPTIC TANK:X (locate on site plan) Depth below grade: 24" Material of construction:_X concrete _metal _Fiberglass _Polyethylene _other (explain) If tank is metal, list age _Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 7'x V x 4' x 7.5 =1000 gallons. Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 4" How dimensions were determined: Subtract scum & sludge depths to baffle length. Comments: Inlet & Outlet baffles ok. Depth of liquid at outlet invert. No evidence of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 41112000 TIGHT OR HOLDING TANK: _None (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction: concrete —metal _Fiberglass Polyethylene _other(explain) Dimensions: Capacity:_allons Design flow:allons/day Alarm present Alarm level: Alarm in working order: Yes _ No Date of previous pumping: Comments: DISTRIBUTION BOX.:_X_ (locate on site plan) Depth of liquid level above outlet invert: 8" Comments: D -box level & distribution equal. Evidence of solid carryover. D -box full of water, 8" above all inverts of outlet pipes. Evidence of leakage. PUMP CHAMBER: _None, gravity system_ (locate on site plan) Pumps in working order. (Yes or No) Alarms in working order (Yes or No) Comments: Revised 912198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued)) Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 4/112000 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, K possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number. leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: 20'x 40' leach area. overflow cesspool, number: Alternative system: Name of Technology: Comments: Soil ok. Vegetation ok. No sign of ponding to surface. Sign of hydraulic failure, water 8" above inverts of pipes in d -box. CESSPOOLS: None (locate on site plan) Number and configuration: Depth4op of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 4/1/2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) AtoI=17' Ato2=21' A to D -Box = 30'5" B to 1 = 26'4" Bto2=21' B to D -box = 16'3" revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 4/112000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 1.5 to 3.5 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record _X Observed Site (Abutting property, observation hole, basement sump etc.) X Determined from local conditions —X—Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers —X—Used USGS Data Describe how you established the High Groundwater Elevation. Essex County soil map, Sheet # 30, Sutton soil, water 1.5 to 3.5 feet deep. revised 912198 Page 11 of 11 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 428 Winter Street, North Andover Owner: Soucy Date of Inspection: 4/1/2000 My report contained herein does not constitute a guarantee of future usage and the functionality.of the existing septic system Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. eel L:� qNil Bateson Enterprises, Inc. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab rerun Commonwealth of Massachusetts City/Town of No.Andover System Pumping Record Form 4 V D APR � r `x 11 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with 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. A. Facility Information 1. System Location: 428 Winter St Address No.Andover Ma 01845 City/Town State Zip Code 2. System Owner: Ford Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record i 2) 1. Date of PumpingDate ` ' ` 1 2. Quantity Pumped: 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: ac -r -A 02)17� 6. System Pumped By Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 '- -n Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 System Owner �cd Date of Pumping: tp L.g — O i Cesspool: No [ Yes [ ] System Pumped by: 64&44at Massachusetts RECEIVED Massachusetts NOV - 2 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT System Location Quantity Pumped: t 50-0 gallons Septic Tank: No [ ] License # Contents transferred to: Greater Lawrence Sanitary District Date: �. c)—"( � " C) T Inspector: Yes [ TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION TOWN OF R10RTHAj"6&.ZR__ BC_- L'- : ,=,LiH The u dersigned hereby certify that the Sewage Disposal System ( ) constructed; ( repaired:!,�� -- 2 2001 located at ��( l t -l -Ey G, ecce . was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # dated—'(— with an approved design flow ofdgallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bed inspection date: Engineer Representative Final inspection date: _ � 11-01— 0, 0 z ngineer Rep esentative Installer: Gp a� Lic.#: Date.- Design ate: Design Engineer: t /G�., Q 1)V , Date:. Z_2 -7 --wt AS -BUILT CHECKLIST V LOTNUMBER, STREET N:4ME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM, Ate> t v TIES TO LOT LINES & DWELLING a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS / ELEVATIONS OF DISPOSAL SYSTEM y TOP OF FDN ELEVATION V LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN ISO' 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 V LOCATION & ELEVATIONS OF BENCHMARK USED 0 ® z \ ) c 2 �. E w § LL . . \ . \ \ 2 m ��'N"/ a ®/ 3 o « km ^� k c 0 3 U 7 2 6 « Y oe / k c Z Co � � / o < ■ k /\ 0 2�`.� ] . § © O ƒ 06 kA ` `9 \ § £ sem. /� $ ƒ » u vi CL / '9zp `✓ INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO Initials A. Bottom of Bed 1. Excavation to proper depth ✓� f /� �/' �j l 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation, etc. �- Comments: B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8" per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90° change 10. 10' minimum offset to water line Comments: D. Septic Tank 1. Level ti 2. 1,500 gal minimum 3. Gas baffle present on outlet G" 4. Manhole to grade 5. Manholes over center and each tee f� j 6. 3-20" manholes ✓` 7. Inlet tee minimum 12" under invert / 8. Outlet tee minimum 14" under invert l/ 9. Outlet line cemented 10. Air space 3" above tees �- 11. 2" - 3" drop from inlet to outlet 12. Pipe set 13. Compact base with 6" of 1/4" crushed stone under tank 14. Tank is watertight Comments: Yes NO E. Pump Chamber 1. If separate from tan , ompact base with 6" of/4" stone underneath 2. Minimum 2" pipe to d- if gravity system 3. 20" access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d -box Comments: F. Distribution Box 1. D -box level 2. Minimum 0.1 T' (2") drop from inlet to outlet ✓ 3. Minimum 6" sump �G 4. Outlet pipes show equal distribution >�- 5. Compact base with 6" of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement ✓ 8. Schedule 40 pipe -sem Comments: G. Soil Absorption system 1. All stone double -washed -'/1' - 1 ''/z" - pea stone Bucket test done? 2. Minimum T'. of pea stone above distribution lines 3. Minimum 6" stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9" of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not, then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan - Minimum 2'; maximum - 4'. 4. Vent present if <50 feet or specified 5. Distance between trenches minimum 4' and maximum of 6' 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6" per 100' 8. Depth of trenches below outlet invert minimum of 6". ,51- /1 Y�1� - I/ Yes 9. Pipes set on stable base. Comments: NO 1. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6" per 100' —? 3. Separation between pipe 6' maximum 4. Pipes connected at end t/ 5. Separation between adjacent fields 10' minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: J. Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12" and 48" wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9" soil 3. Cover soil free of stones larger than 6" —�- 4. Grading slopes away from dwelling �L 5. No areas over system that may pond INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North An/dover licensed installer for the construction of the septic system for the y property at o2Y- Al,', Ju relative to the application of l d2AZ) dated for plans by/'M C and dated J' with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Under,54ne icensed Septic Installer Date: Jr` D Works Construction Permit # BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: S- Y_ D / CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALL'&: l c9LO aAYe S e SIGNATURE: CHECK ONE: REPAIR: V TELEPHONE# '/7�-- c7 NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Eoundation-As=`Built' T" Administrative Use Only Yes No Yes No —Fl66r"_P1a`ris`7_ Yeses No Approval =/� Date: ' Vii- ,?0� , �O- OF_ j a � AY ' 4 200E E- x c w 0 ) W C M O 7 v 0 ' A 3 rt D C. �r 7 avv o c m m 0 I rt 1 v 16 9v I m C o � � D rr I � 'o c D m v D C lD D rt 1 D 0 3 CL i c w 0 ) W Town of North .Andover Office of the Health Department Community Development and Services Division William J. Scott, Division Director 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director November 22, 2000 William Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 428 Winter Street Dear Bill: Telephone (978) 688-9540 Fax (978)688-9542 This is to notify you that variances have been granted to allow installation of a leach field not less than 58 feet from a wetland and to allow separation to groundwater to be 3 feet instead of 4 feet. This second variance prohibits the addition of more rooms until the house is tied into sewer. With these variances the plans dated 11/12/00 for the repair of the septic t are approved. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Health Director SS/smc cc: Soucy File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANTNING 688-9535 f pORTh 0 �t�•o i�,M 0. O t ,SSACHUSEt� Applican Site Location Town of North Andover, Massachusetts ROARrl OF HFAI TH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Reference Plans and Specs Test No.� Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD OF HEALTH Fee Site System Permit No. /%�� TOWN OF NORTH ANDOVER BOARD OF HEALTH 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 SANDRA STARR, R.S., C.H.O. Health Director November 1, 2000 Bill Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 428 Winter Street Dear Bill: Telephone (978) 688-9540 FAX (978) 688-9542 '7 k This is to inform you that the proposed plans for the site referenced above have been disapproved and have technical deficiencies as followed: The design plan submitted to Port Engineering actually contains to separate design options. The first option as defined by the Designer provides for a pump while the �. second option is a gravity flow system. Since 310 CMR 15.00 makes no provision q or a design plan that contains two options, it is recommended that the Designer either VQP,-/eliminate one of the options or provide two (2) sets of design plans in order to prevent any confusion that may arise during construction. 0)4--55 � I D(� Legal boundaries not defined as required by 310 CMR 15.220(4)(a). Easterly ell �boundary is omitted altogether. �G�Is CosS jSetback to wetland from the leachin facilit appears to be much less than the minimum requirement of�l0 PPt riperl� C 1 Local upgrade approval -,$J has not been requested on the plan. Distance to wetland not shown as required by NA 8.03 c. — VO 0 u n ti -ec-P c7hc w� j, S9' d S )Septic tank buoyancy calculations not shown for option #1 as required by 310 CMR 221(8). fMinimum cover of 9 inches over septic tank is not specified as required by 310 CMR 228(l). gt",--,rJ ". uoyancy calculations for pump chamber not provided as required by 310 CMR 221 (8)• &)b7— �?��c !ez.2 /?.f Pump design curves not provided as required by 310 CMR 220 (4)(r). , ou f qr& pel--�A - $/No inlet baffle provided in distribution box for option #1 as required by 310 CMR 15.232 (3)(a). lV.Soil compaction and six-inch stone base not specified for distribution box as required by 310 CMR 15.221 (2). Elevation of of perc test not provided as required by NA 8.02 n. JGLOIvi-j If you have any questions, please do not hesitate to call the Board of Health Office. Sincerely, s Sandra Starr, R.S., C.H.O. Health Director cc: Soucy file Page 1 of 5 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5,310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non -conforming system with a design flow of <10,000 gpd, where full compliance, as defined in 310,CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non -conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: y Name: ! a(racct 3c&, e Address: L/-2.3 wr c -c 4.e -r- S -/-7 r Phone #: 6 9 e- -Z 57�Ce , Address of facility: Y Z Y 2) Applicant (if different from above) Name: Z2" � Address: Phone #: 3) Type of Facility: esidential (Specify) Commercial. School Institutional Page 2 of 5 4) Type of Existing System: _privy cesspool(s) '� conventional system other(describe)p, 41�- t..3'y c�.<-K-���� Type of soil absorption system (trenches, chambers, pits, etc.) 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system tiez-o gpd Approved: _yes Approval date:yj,/,e-Af". no Why: b) Design flow of proposed upgraded system bpd Why c) Design flow of facility gpd 6) Proposed upgrade of existing system is: a) ✓Voluntary required by order, letter, etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: CAO -0G- v4�1 c) Which of the following are applicable to the proposed upgrade? 41A Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) /JA Percolation rate of 30-60 minutes per inch (state actual perc rate) el% Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) /j�j . Relocation of water supply well (identify well, describe relocation) ,,,/ Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) 6 �� R Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater feet As determined by: Evaluator's name: Evaluator's Signature: Date of evaluation: 7-—CPO 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Address Abutter Name Address Date notified Date notified Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. c) A shared system is not feasible. d) Connection to a sewer is not feasible. M "MA�I s� WT 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? yes ,,/no A -s Page 5 of 5 11) Certification 1, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." Facility Owner's Signature Date Print Name e? - Z-A=�M Name of Preparer IDate Telephone No. & Address of Preparer NOTE: Title 5,310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. a� ia�s �5126 u1 a NJcEs`�- �° on fy onsgr a�prarr,1. �e f b o c k 7Ln U$ S,� TOWN OF NORTH ANDOVER BOARD OF HEALTH 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 SANDRA STARR, R.S., C.H.O. Health Director November 1, 2000 Bill Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Re: 428 Winter Street Dear Bill: A3 Telephone (978) 688-9540 FAX (978) 688-9542 This is to inform you that the proposed plans for the site referenced above have been disapproved and have technical deficiencies as followed: 1. The design plan submitted to Port Engineering actually contains 0 separate design options. The first option as defined by the Designer provides for a pump while the second option is a gravity flow system. Since 310 CMR 15.00 makes no provision for a design plan that contains two options, it is recommended that the Designer either eliminate one of the options or provide two (2) sets of design plans in order to prevent any confusion that may arise during construction. 2. Legal boundaries not defined as required by 310 CMR 15.220(4)(a). Easterly boundary is omitted altogether. 3. Setback to wetland from the leaching facility appears to be much less than the minimum requirement of 100 feet as per 310 CMR 15.211. Local upgrade approval has not been requested on the plan. 4. Distance to wetland not shown as required by NA 8.03 c. 5. Septic tank buoyancy calculations not shown for option #1 as required by 310 CMR 221(8). 6. Minimum cover of 9 inches over septic tank is not specified as required by 310 CMR 228(l). 7. Buoyancy calculations for pump chamber not provided as required by 310 CMR 221 (8)• 8. Pump design curves not provided as required by 310 CMR 220 (4)(r). I- 9. No inlet baffle provided in distribution box for option #1 as required by 310 CMR 15.232 (3)(a). 10. Soil compaction and six-inch stone base not specified for distribution box as required by 310 CMR 15.221 (2). 11. Elevation of perc test not provided as required by NA 8.02 n. If you have any questions, please do not hesitate to call the Board of Health Office. Sincerely, Rnnrlrn Rtnrr R R C: N n_ Oct -10-00 01:59P Paul D. Turbide, PE/PLS 978-465-0313 P.03 Facsimile Cover Sheet To: SANDRA STARR Company: NORTH ANDOVER BOH Phone: 978-688-9540 Fax: 978-688-9542 From: Paul D. Turbide, P.E.IP.L.S., President Company: Port Engineering Associates, Inc. Phone: (978) 465-8594 Fax: (978) 465-0313 Date October 10, 2000 Pages Including This Cover Page: 2 Comments: Sandy, I have attached our review of the SDS upgrade at 428 Winter Street. Thanks, Pau! D. Turbide, P.EJP.L.S. PORT INGINERING Civil Engineers & Lend Surveyors One Harris Street Newburyport, MA 01950 (978)465-8594 Uct-10-00 01:58P Paul D. Turbide, PE/PLS PORT ENGINEERING, Civil Engineers & Land Surveyors October 10, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School Street North Andover, MA 01845 978-465-0313 P.02 RE: Title V review for SDS upgrade at 428 Winter Street Dear Sandra, Enclosed find our review of the "Checklist for North Andover Septic System Plans" for the septic system upgrade at the above-mentioned site. The following is a list of technical deficiencies that Port Engineering has found. ❑ The design plan submitted to Port Engineering actually contains two separate design options. The first option as defined by the Designer provides for a pump while the second option is a gravity flow system. Since 310 CMR 15.00 makes no provision for a design plan that contains two options,ecommend that the Designer either eliminate one of the options or provide two (2) sets fo design plans in or er to prevent any confusion that may arise during construction. o Legal boundaries not defined as required by 310 CMR 15.220(4)(a). Easterly boundary is omitted altogether. o Setback to wetland from the leaching facility appears to be much less than the minimum requirement of 100 feet as per 310 CMR 15.211. Local Upgrade Approval has not been requested on the plan. a Distance to wetland not shown as required by NA 8.03 c. a Septic tank buoyancy calculations not shown for option #1 as required by 310 CMR 221(g) ❑ Minimum cover of 9 inches over septic tank is not specified as required by 310 CMR 228 (1). ❑ Buoyancy calculations for pump chamber not provided as required by 310 CMR 221(g). a Pump design curves not provided as required by 310 CMR 220 (4xr). o No inlet baffle provided in distribution box for option #1 as required by 310 CMR 15.232 (3)(a). o Soil compaction and six-inch stone base not specified for distribution box as required by 310 CMR 15.221(2). o Elevation of perc test not provided as required by NA 8.02 n. If you have any questions or comments please feel free to contact me. One Harris Street Sincerely Newburyport, MA 01950 (978)465-8594 Paul D. Turbide, PE/PLS Merver MNABHtP288AWNTER STREET 428.DOC r � c �5