HomeMy WebLinkAboutMiscellaneous - 448 BOXFORD STREET 4/30/2018 J 448STREET
J 210/105.C-005.0-0 044 8-0000.0 �
1
I
r
/+ 1
1
1
I
North Andover Board of Assessors Public Access Page 1 of 1
pORTM I��rfh �ndwer Board of Assessor:s
'lays wwr.o..�5,�9
S�cNuSE roperty Record Card
Parcel ID :210/105.C-0048-0000.0 FY:2012 Community:North Andover
SKETCH PHOTO
Click on Sketch to Enlarge Click on Photo to Enlarge
Y.
,A t
y
448 BOXFORD STREET
7
J
Location: 448 BOXFORD STREET
Owner Name: POLO,JAMES W.
POLO,HEATHER,M.
Owner Address: 448 BOXFORD STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5-5 Land Area: 1.00 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2019 sqft
Total Value: 386,700 386,700
Building Value: 189,300 189,300
Land Value: 197,400 197,400
Market Land Value: 197,400 �—
Chapter Land Value:
LATEST SALE
Sale Price: 405,000 Sale Date: 07/30/2009
Arms Length Sale Code: Y-YES-VALID Grantor: KEVIN SULLIVAN
Cert Doc: Book: 11713 Page: 0166
http://csc-ma.us/PROPAPP/display.do?linkld=1895127&town=NandoverPubAcc 4/26/2012
Residential Property Record Card
PARCEL ID:210/105.C-0048-0000.0 MAP:105.0 BLOCK:0048 LOT:0000.0 PARCEL ADDRESS:448 BOXFORD STREET FY:2012
PARCEL INFORMATION Use-Code: 101 Sale Price: 405,000 Book: 11713 Road Type: T Inspect Date: 12/09/2002
Tax Class: T Sale Date: 07/30/09 Page: 0166 Rd Condition: P Meas Date: 12/09/2002
Owner: Tot Fin Area: 2019 Sale Type: P Cert/Doc: Traffic: M Entrance: C
POLO,JAMES W. Tot Land Area: 1.00 Sale Valid: Y Water: Collect Id: RRC
POLO,HEATHER,M. Grantor: KEVIN SULLIVAN Sewer: Inspect Reas: C
Address:
448 BOXFORD STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/° Indust-B/L% / Open Sp-B/L% /
NORTH ANDOVER MA 01845
RESIDENCE INFORMATION LAND INFORMATION
Style: CL Tot Rooms: 8 Main Fn Area: 1161 Attic: NBHD CODE: 5 NBHD CLASS: 5 ZONE: R1
Story Height: 2.00 Bedrooms: 4 Up Fn Area: 858 Bsmt Area: 1161 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class
Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43569 1.000 197,367
Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: VALUATION INFORMATION
Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 2019 Current Total: 386,700 Bldg: 189,300 Land: 197,400 MktLnd: 197,400
Foundation: CN Bath Qual: T RCNLD: 189262
Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: Prior Total: 386,700 Bldg: 189,300 Land: 197,400 MktLnd: 197,400
Heat Type: HW Ext Kitch: Year Built: 1982 Sound Value:
Fuel Type: - O Grade: AG Cost Bldg: 189,300
Fireplace: 1 Bsmt Gar Cap: 2 Condition: A Aft Str Val1:
Central AC: N Bsmt Gar SF: Pct Complete: Aft Str Va12:
Aft Gar SF: %Good P/F/E/R: /100/100/88
Porch Type Porch Area Porch Grade Factor
W 130
SKETCH PHOTO
in
{,f
W
13130 Sq�Ft�
FM/B FU/FM/8
336 Sq.F 825 Sq.Ft
24 25 25
14 1 448 BOXFORD STREET
FUH
33 Sq.Ft
Parcel ID:210/105.C-0048-0000.0 as of 4/26/12 Page 1 of 1
Commonwealth of Massachusetts I
City/Town of
System Pumping Record
w Form 4G� ���
M
DEP has provided this form for use by local Boards of Heal _ Othe , but the
information must be,substantially the same as that provided h fo , check with your
local Board of Health tQ determine the form they use. The S eco r must be submitted to
the local Board of Health or�otber approving authority.
A. Facility Information
1. System Location: L idem a Right side of house, Left front of house, Right front of house,
Left rear of h e, Right rear of ho s . Left rear of building_ Right rear of building.
Address ""1 Lf CR., ,
City/rownState IV Zip Code
2. System Owner: pp
� lC�
Name
Address(if different from location)
City/Town Stat -Zip C
, « - �
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? i es ❑ No If yes, was it cleaned? U9-f6sEl No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ntents were disposed:
G.L.S.D Lowej#W to Water
lc:)
Signature of a r Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
r• � Y M 9! i
Commonwealth of Massachusetts F
F
City/Town of
System Pumping Record (�T
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Oth T � ' 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 front of house, right front of house, left side of house, right side of house, Left
rear of hous , rig rear of hous left side of building, right rear of building, under deck.
Ll
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stater Zip Cade
:7 ---&
Tel ane Number ���/�
B. Pumping Record
1. Date of Pumping
Date 2 Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? 9-Y-e-s-n No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Loca ' ere contents were disposed:
G.L.S.D. leqwqQ Waste ftter,
(f
Signature of 14aular Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
SUMMARY OF INVERTS BUILDING TIES
SEWER ® FDTN. PRE—EXIST. BLDG. CORNER A B C Nom. THIS PLAN & CERTIFICATION IS NOT
I
SEPTIC TANK IN 93.93 SEPTIC TANK IN 29.2 32.9 A WARRANTY OF THE SUBSURFACE DISPOSAL
SEPTIC TANK OUT 93.63 PUMP TANK OUT 45.0 41.2 SYSTEM. IT IS A RECORD OF THE LOCATION
PUMP TANK IN 93.57 DIST. BOX 99.0 82.0 AND ELEVATION OF THE EXISTING SYSTEM
DIST. BOX IN 95.05 COMPONENTS.
DIST. BOX OUT 94.88
INV. IN CHAM. 94.87
BOTT. CHAM. 94.2
I
i
LQLt4Y
43,569 S.F.
LEAM nuo
W/40 INFlURA101t
dIA11BERS
D-BOX
27*,y;
yhy lj+
9m. {"!
PORT r...i
1.000 GAL
PUMP TANK
r �
50't
S� 1,300 GAL
`+ SEPtIC TANK
2 0 54't
/f EX15T.
t I ai:i:i:. Q
I 1 �
d
F1'4147, a tDF:k
1 (' DWELLING ¢448
s BIT
1 L'RivE 1 1
4�4
I ? `
WELL �
150.w 1
j BOXFORD SmmT
i
0f Mgss,9
O� VLADIMIR L Oy
G
NEMCHENOK
o i
r, .�lll! cin
No.
.o9o�,pFC%
Ss�DIVAL
(
AS BUILT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH ANDOVER, MASS./448 BOXFORD STREET
AS PREPARED FOR
KIMBERLY GOC TM: 105C
RECEIVED DATE: 7-17-09 TL: 48
SCALE: 1"=40'
0 20 40 80
JUL 2 1 2009
TOWN OF NORTH ANDOVER MERRIMACK ENGINEERING SERVICES
HEALTH DEPARTMENT 66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
i
i '
'R
i
i
SUMMARY OF INVERTS BUILDING TIES
SEWER ® FDTN. PRE-EXIST. BLDG. CORNER A B C -NO THIS PLAN & CERTIFICATION IS NOT
SEPTIC TANK IN 93.93 SEPTIC TANK IN 29.2 32.9 A WARRANTY OF THE SUBSURFACE DISPOSAL
SEPTIC TANK OUT 93.63 PUMP TANK OUT 45.0 41.2 SYSTEM. IT IS A RECORD OF THE LOCATION
PUMP TANK IN 93.57 DIST. BOX 99.0 82.0 AND ELEVATION OF THE EXISTING SYSTEM
DIST. BOX IN 95.05 COMPONENTS.
DIST. BOX OUT 94.88
INV. IN CHAM.__+ 94.87 `
BOTT. CHAM. 94.2
I `
LQL IMA
43,569 S.F.
LEAW nMD
rM rrra
IIR
A16ERS
D-Bw
27'3
mv.
My
1.000 CAL.
PUMP TANK
50't
Z 1,300 0AL
2`+ o SEPVC TANK
i G:,'f,R'U"K j
pZO
i G
t
l � 1
' � 1
t t
S S )^
I i
3 y
i
I WE li.
i
15(LW
BOXFORG STREET
OV�OF
O VLADIMIR L. C\
NEMCHENOK
Offs
FSS�ONAL
AS BUILT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH ANDOVER, MASS./448 BOXFORD STREET
AS PREPARED FOR
KIMBERLY GOC TM: 105C
RECEIVED DATE: 7-17-09 TL: 48
SCALE: 1"=40'
JUL 2 1 2009 0 20 40 80
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT MERRIMACK ENGINEERING SERVICES
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
i
I
i !
I
I
i
i
I
I
I
I
I
I
i
I
i
I I
I
SUMMARY OF INVERTS BUILDING TIES A'nTc
SEWER 0 FDTN. PRE-EXIST. BLDG. CORNER A B C �l�.S� THIS PLAN & CERTIFICATION IS NOT
SEPTIC TANK IN 93.93 SEPTIC TANK IN 29.2 32.9 A WARRANTY OF THE SUBSURFACE DISPOSAL
SEPTIC TANK OUT 93.63 PUMP TANK OUT 45.0 41.2 SYSTEM. IT IS A RECORD OF THE LOCATION
PUMP TANK IN 93.57 DIST. BOX 99.0 82.0 AND ELEVATION OF THE EXISTING SYSTEM
DIST. BOX IN 95.05 COMPONENTS.
DIST. BOX OUT 94.88
INV. IN CHAM. 94.87
BOTT. CHAM. 94.2
L f 105A
43,569 S.F.
/EACH Flan
A16ERS
D—BOX
Y
' IKSP.
PaRT .,
1,000 CAL
PUUP TANG
50't
= 1,500"L
SEPTIC TANK
JA
0 L-3,!U'gG ;428
j t
j
3
I
t
t � !
150.W 1
80XFOR0 STREET
j�N00F
O� VLADIMIR L. �rG\
NEMCHEMOK m
s
cy NcAlI�l�t
STI
ss�NNAI.
AS BUILT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH ANDOVER, MASS./448 BOXFORD STREET
AS PREPARED FOR
KIMBERLY GOC TM: 105C
RECEIVED DATE: 7-17-09 TL: 48
SCALE: I"=40'
JUL 2 1 2009 0 20 40 80
TOWN OF NORTH ANDOVER MERRIMACK ENGINEERING SERVICES
HEALTH DEPARTMENT 66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
�i
I
I
�I
If >r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
trek 448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. General Information VtL)
on the computer, �
use only the tab 1. Inspector: �� `1 4 `NIZ
key to move your
cursor-do not
use the return Ralph Simard
key. Name of Inspector MEgLTH nfD. TMI+IT
Simard Construction
Company Name
PO Box 436
Company Address
North Reading Ma 01864
City/Town State Zip Code
508-958-2002 si13015
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:
19 Passes Conditionally Passes El Fails
❑ Needs Further Evaluation by the Local Approving Authority
In cto igrrgture Dater
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 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Pe 9 Y 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. Cityrrown 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:
19 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:
System is in good shape and working as designed
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
--_ Title 5 Official Inspection Form
° Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
-� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. 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
❑ 0 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. Citylrown 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
El ❑ 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 Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
qi Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
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
❑ to Were any of the system components pumped out in the previous two weeks?
1z ❑ 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?
ED ❑ 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:
JZ ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins•11/10 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owners Name
information is
required for every North Andover Ma 01845 05/08/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
complete system was in very good condition outlet filter needs to be cleaned at every pumping
system working as designed
Number of current residents: 4
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)}: na
Detail:
well water per new design
Sump pump? ❑ Yes [9 No
Last date of occupancy: currant
Date
Commercial/Industrial Flow Conditions:
I- 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
N - ?
on sanitary waste discharged to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
• II
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: currant
Date
Other(describe below):
system in very good shape working as designed all levels as designed
General Information
Pumping Records:
Source of information: BOH
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
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 cop of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
Cl Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y" 448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
June 25 2009
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade: 14
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 100++
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
all joints tight at this time no evidance of leackage at this time system vented as needed and
designed
Septic Tank(locate on site plan):
Depth below grade: 1 riser to grade
feet
Material of construction:
ED concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1500 gallon tank as designed on June 25 2009 pump chamber 1000 gallon and working as designed
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: standard 1500 and 1000 gal tanks
Sludge depth:
4"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is North Andover Ma 01845 05/08/12
required for every '
page. 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
28"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? rod with foot
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
outlet filter should be washed out at least upon pumping of tank all liquid levels as designed tank
structual sound and water tight as designed all inlet and outlet pipes as designed
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass El 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:
Date
t5ins-11110 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
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. City/Town 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.):
system in good shape at this time outlet filter to be washed out with yearly pumping all tees and
baffels as designed no sign of ponding or break out at this time
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
N 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? ❑ Yes ❑ No
t5ins-11110 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
-` W? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
I
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
dee box solid and level all liquid levels as designed per plans no sign of carry over at this time
Pump Chamber(locate on site plan):
Pumps in working order: Z Yes ❑ No
Alarms in working order: ® Yes [] No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
tank in good condition float levels as designed per plans tank all good at this time
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. 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:
5*45
❑ 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.).
no signes of hydrolic failure or ponding at this time all soils and vegetation good at this time
h,'✓1- 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s�- 448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. CityrFown 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.):
no ponding no hydrolic failure all good at this time
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
. " 448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. City/Town 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
a 0
rhos Ll yl
PUVA
I�vv
Pc
(
7
Prl u1
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is
required for every North Andover Ma 01845 05/08/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
0 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: 04/23/09 BOH test
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
test pits 04/23/09
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
plans at BOH 04/23/09
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 448 Boxford St
Property Address
James&Heather POLO
Owner Owner's Name
information is North Andover Ma 01845 05/08/12
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
inspection Summary: A R 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
tAORTF
O� tLED 16��
O
SAC HUS���y
PUBLIC HEALTH DEPARTMENT
Community Development Division
CE RTI FIC. I'E O F VI
CO� <1'.GI �
.ACE
As of:
Jufy 2 7, 2009
This is to cert that the individual su6surface disposal system received a
SAIISFACTORT INS(ECYZ'IOYof the:
4�fpair/WfpCacement of the complete
-)tT r BXposalSystem
By
Todd Bateson
At.
448 Bw ford Street
Kap — 105.0; Farrel-48
JVorth Andover, W,4 01845
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
,ISIsan T Sa er
! ft 6lu Yfealth Director
1600 Osgood Street,North Andover,Massachusetts 01845
I
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
F Hot�vk q �
Q 4,.Lb.a•tiQ
1 a A
RECEIVED
�SSACWUSE4
PUBLIC HEALTH DEPARTMENT JUL 2 1 2009
Community Development Division TOWN OF NORTH ANDOVER
I FSEAt-I n DEPARTMENT—
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( )constructed;(--j'repaired;
By: T120
(Print Name)
Located at: *10
12�t�iT
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
��/" and last revised on-. ��`?;O ,with a design flow of
d_+,22 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: —=!; ��/A_,,
Engineer Representative(Signature)
�i u-
And–Print Name
Final Construction Inspection Date: ,
Engineer Representative(Signature)
g1 tL- c7a eew iw
And–Print Name
Installer•
(Signature) Date:
D D F7A-TE o1J
D And–Print Name
Enginer: V401"Ke 4119'A(4YG(WAZ(Signature) Date:
VL'ev 1 i>'-t I I? Irl C H':�'qE t�a e_-
And–Print Name
1600 Osgood Street, North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web htt : www.townofnorthandover. m
I,
P// co
r
DelleChiaie, Pamela
From: Isaac Rowe[irowe@millriverconsulting.com]
Sent: Friday, July 17, 2009 9:23 AM
i
To: 'Daniel Ottenheimer'; Grant, Michele; irowe@millriverconsulting.com; 'Marianne Peters';
DelleChiaie, Pamela; 'Randy Burley'; Sawyer, Susan
Subject: 448 Boxford Street
Attachments: 448 Boxford Street-Final Construction Inspection 7-16-09.doc
Susan,
Please find attached the construction inspection form for the above referenced property.
I would recommend that the water softner for the well be removed from the building sewer line. This is not a requirement
but we have seen the water softner cause problems with septic systems and lead to premature failures. The discharge
line can be put outside to a pit of crushed stone or mini dry well.
Please let me know if you have any questions.
Thank you,
Isaac
Isaac M. Rowe,R.S.
Project Manager
Mill River Consulting
2 Blackburn Center
1
F
NORTH
s O <tLLC 06,q'`'p
OL
O to
O coc.uiiwu•�•
Air D
SAC HUS���y
PUBLIC HEALTH DEPARTMENT
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 448 Boxford Street MAP: 105C LOT: 48
INSTALLER: Todd Bateson
DESIGNER: Vladimir Nemchenok
PLAN DATE: 6/3/09
BOH APPROVAL DATE ON PLAN: 6/26/09
INSPECTIONS l l Q
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: 7/16/09
DATE OF FINAL GRADE INSPECTION: VIM
SITE CONDITIONS
® Contractor reports any changes to design plan
® Existing septic tank properly abandoned
® Internal plumbing all to one building sewer
® Topography not appreciably altered
Comments: Recommend new owner of property remove the water softner discharge
from the building sewer.
SEPTIC TANK
® Building sewer in continuous grade, on compacted
firm base
® 1500 gallon tank has been installed
H-10 loading mono construction
®
Watertightness of tank has been achieved by
Visual testing
® Inlet tee installed, centered under access port
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Inspection Form June 2008
i
pORTH
ir �'� -
O M
F- 70
T co—cArgiv
�iOO Pay
��SSAC HUS���y i
PUBLIC HEALTH DEPARTMENT
Community Development Division
® Outlet tee installed, centered under access port
(effluent filter)
® 24" inch cover to final grade installed over inlet and
outlet access ports
® Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
® 1000 gallon Pump Chamber installed
® H-10 loading monolithic construction)
® Inlet tee installed, centered under access port
® Pump(s) installed on stable base
® Alarm float working
® Pump On/Off floats working
® Separate on/off floats
® Drain hole in pressure line
® 24" cover at final grade installed over pump access
port
®
Watertightness of tank has been achieved by
Visual testing
® Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
® Alarm & Pump are on separate circuits
® Alarm sounds when float is tripped
® Location of controlpanel: boiler room in
basement
® Alarm signal located inside
Comments:
DISTRIBUTION-BOX
® Installed on stable stone base
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Inspection Form June 2008
NORTi4
41"10 16,
? t
o ti
� � ey �
,$A coctlt"'11-1
1
TED
��SSACHUS����
PUBLIC HEALTH DEPARTMENT
Community Development Division
® Inlet tee (if pumped or >0.08'/foot)
® Hydraulic cement around inlet & outlets
® Observed even distribution
Comments:
SOIL ABSORPTION SYSTEM (General)
Size of SAS excavated as per plan
® Title 5 sand installed, if specified on plan
® 40 Mil HDPE barrier installed
® Laterals installed and ends connected to header (and
vented if impervious material above)
® Elevations of laterals and chambers installed as on
approved plan
❑ Final cover as per plan
Comments:
SOIL ABSORPTION SYSTEM (Gravel-less Chambers)
® Brand and Model of Chamber: Standard Quick 4
Infiltrator Chambers
® Number of chambers per row: 10
® Number of rows (trenches): 4
Comments: 40 Chambers total
BM = 100.00
HR = 1.39
HI = 101.39
SYSTEM ELEVATIONS
ROD ELEVATION AS-BLT INVERT ELEV I DESIGN INVERT ELEV
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Inspection Form June 2008
pORTi4 q
• 0 ttLEO i6
7 tiO
OL
O ti Ar
o . lb
t.
[OCMIC lWKM V
SSACHUs���y
PUBLIC HEALTH DEPARTMENT
Community Development Division
Benchmark 1.39 100.00 100.00
Building Sewer OUT 94.9+/-
Septic Tank IN 7.12 93.92 93.50
Septic Tank OUT 7.40 93.64 93.25
Pump Chamber IN 7.48 93.56 93.20
Pump Chamber OUT --- ---
Distribution Box IN 2" 6.18 95.04 95.07
Distribution Box OUT 6.15 94.89 94.90
4"
Lateral 1 TOP 6.18
Lateral 1 INVERT 94.86 94.87
Lateral 2 TOP 6.18
Lateral 2 INVERT 94.86 94.87
Lateral 3 TOP 6.18
Lateral 3 INVERT 94.86 94.87
Lateral 4 TOP 6.18
Lateral 4 INVERT 94.86 94.87
Top Charnberl 6.18 95.21 95.20
BED BOTTOM ELEV. 7.18 94.21 94.20
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Inspection Form June 2008
NORTH q
O
.i' - - L
�yy� ey yyM
T °fA COCMK Mt wKw y7' T
�9SSAC HU`����y
PUBLIC HEALTH DEPARTMENT
Community Development Division
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Tank SAS Sewer
® Property line 10 10 --
® Cellar wall 10 20 --
® Inground pool 10 20 --
® Slab foundation 10 10 --
® Deck, on footings, etc 5 10 --
® Waterline 10 10 101
® Private drinking well 75 1002 50
® Irrigation well 75 100
® Surface Water 25 50
® Bordering Vegetated Wetland ,
Salt Marsh, Inland/Coastal Banka 75 100
® Wetlands bordering surface
water supply or trib. (in Watershed) 150 150
® Trib.to surface water supply 325 325
® Public well 400 400
® Interim Wellhead Prot.Area
® Reservoirs 400 400
® Drains(wat. supply/trib.) 50 100
® Drains(intercept g.w.) 25 50
® Drains(Other)Foundation 10(5) 20(10)
® Drywells 20 25
Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland
bylaws
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
Inspection Form June 2008
RECEIVED
JUL 2 2 2009 AS-BUILT CHECKLIST
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
LOT NUMBER, STREET NAME
i
ASSESSORS MAP&PARCEL NUMBER
LOT LINES &LOCATION OF DWELLINGS
LOCATIONS &DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
TIES TO LOT LINES &DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATION
TESTS
ELEVATIOI -
l TOP OF FDI 6-oz- . '
LOCATION C.=
/ WITHIN 15(
LOCATION
DISTANCE;
TANK&D-1
ORIGINAL STAMP& SIGNATURE
IMPERVIOUS AREAS -DRIVEWAYS, ETC.
NORTH ARROW .
LOCATION&ELEVATIONS OF BENCHMARK USED
z
RECEIVED
JUL 2 2 2009 AS-BUILT C CKLIST
TOWN OF NORTH ANDOVER ��/
HEALTH DEPARTMENT j]
LOT NUMBER, STREET NAME
ASSESSORS MAP& PARCEL NUMBER
LOT LINES &LOCATION OF DWELLINGS
LOCATIONS &DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
TIES TO LOT LINES &DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES&PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS DRAINS WATERCOURSES
/ WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS,ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK&D-BOX
ORIGINAL STAMP& SIGNATURE
IMPERVIOUS AREAS -
DRIVEWAYS, ETC.
NORTH ARROW .
LOCATION&ELEVATIONS OF BENCHMARK USED
,.oRTi, Commonwealth of Massachusetts Map-Block-Lot
aL 105.0-0048-
Board of Health Permit No
North Andover BHP-2009-0482
---------------- --
+ P.I. FEE
�S�wc+wus�"t F.I. $125.00
-----------------------
Disposal Works Construction Permit
Permission is hereby granted Todd-Bateson
to(Repair-D-Box)an Individual Sewage Disposal System.
at No 448 BOXFORD STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2009-048 Dated March-3-0,-2-009
=IL ------
Issued On:Mar-30-2009 o d f alt
+ "0a¢" + Commonwealth of Massachusetts Map-Block-Lot
°,•" . �tioot 105.C-0048-
�, _ a Board of Health -----------------------
North Andover
�°••;+p';..� Certificate of Complianc
CH
THIS IS TO CERTIFY,That the Individual Se isposal System (Repair-D-Box)
by Todd Bateson
Installer
at No 448 BOXFORD T
has been ins ed'm accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
ap n for Disposal Works Construction Permit No. BHP-2009-048 Dated March 30,2009
----------------------- --------------- - - - -----
--------
Printed On:Mar-30-2009 Board of Health
1
Commonwealth of Massachusetts Map-Block-Lot
°b b� a 105.00048
Board of Health Permit No
- ; BHP-2009-0619
a" z . North Andover _______________________
• .�. • , P.I. FEE
�S ,�cwus¢j F.I. $250.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted ---------------------
to(Construct)an Individual Sewa;
at No 448 BOXFORD STR
as shown on the application for Di; 51 Dated July 06,2009
�- ioPY-----------
Issued On:Jul-06-2009 5)
�I
p4pnaw Map-Block-Lot
105_C0048
O — 9
CEI ,� CE
Z WOO
THIS IS TOC md, �qY 02� (Construct)
by - - -
Installer
at No 448 BOXFORD STREET
----------------------------------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. -BHP-2009-06- - 1 - -------Dated July-06,2009
---- ---------- ----- ---------
-----------------------------------------------------------------
Printed On:Jul-06-2009 Board of Health
I
��/e �
���
������ ,
__
I
1
el
Commonwealth of Massachusetts Map-Block-Lot
105.00048
Board of Health Permit No
North Andover -----------------------
P.I. FEE
BHP-2009-0619
♦ i w
f�4 .... •
F.I. $250.00
�ss��w�ys4
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted
to(Construct)an Individual Sewage Disposal System.
at No 448 BOXFORD STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2009-061 Dated July-06,200-9
----------------
Commonwealth of Massachusetts -
- -- - - -- ----- -------------
Issued On:Jul-06-2009 f P
----------
�ts�ry Map-Block-Lot
1o5.cooa8
s4 �p Board of Health - -
• North Andover
CERTIFICATE OF COMPLIANCE
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Construct)
by --------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at No 448 BOXFORD STREET
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-2009-061 Dated July-06,2009
----------------------- - ---------
----------------------------------------- -------------
Printed On:Jul-06-2009 Board of Health
y
ofd° T; Ayl.51i�ation for Septic Disposal System rj-� -cs q ►
Construction Permit - TOWN OF TODAYS DATE
ORTH ANDOVER, MA 01845 $250.00—Full Repair
S^ Nos $125.00-Component
Important: Application is hereby made for a permit to:
When filling out
forms on the ❑ Construct a new on-site sewage disposal system*
computer,use epair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component—What?
cursor-do not
use the return
key. A. Facility Information
s4
ICI Address or Lot#
City/Town Q-
2.-*TYPE OF SEPTIC SYSTEM*:
215"ump ❑ Gravity(choose one)
***If pump system,attach copy of electrical permit to application***
❑ Conventional System(pipe and stone system)
nfiltrator 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)
F AIS
Cityrrown State Zip Code
�0 �Qo
Telephone Number
3. Installer Information
Name Name of Company QJ
Address
Cityrrown State Zip Code
g��'
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name ` Name of Company —�
Address 8
City,'Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
r
:�. r+ �� . .`�
� .. .
,�
v..
i
a
�Application for Septic Disposal System
•-•_ -• • TODAY'S DATE
' =Construction Permit — TOWN OF
$250.00-Full Repair
ORTH ANDOVER, MA 01845 $125.00-Component
PAGE 2 OF 2
A. Facility.Information continued....
5. Type of Building: esidential Dwelling or[]Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
North Andover,and not to place the system in operation until a Certificate of Compliance has
been issued is Board of Health.
Name Date
Application pproved By: rd of Health Representative)
Na Date
Application Disapproved f the following reasons:
For Office Use Only: /
I Fee Attached. Yes No
2. Project Manager Obligation Form Attached. Yes No
3. Pump Sotem? Ifso,Attach cea ofElectand Permit Yes No
—/
4. Foundation As Built.;(new construction ronly). Yes No
(Same scale as approved plan)
.5 Floor Plans?(new construction only). Yes No
Application for Disposal System Construction Perms 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:
q //-V J
(Address of septic system) x For plans by
„`_n n (Engineer)
Relative to the application of
(Installer's name) And dated
riguia ate
Dated ;L-0 7
(today's ate With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer,I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer,I must call for any and all inspections. If homeowner, contractor,project manager, or any
other person not associated with my company schedules an inspection and the system is not ready,then
item three shall be applicable.
3." As the installer,I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally,this is the first(1s)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: healthdel2t(@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: (Today's Date)
ame—Print) igne
Date a........ ..
,40RTP#
TOWN OF NORTH ANDOVER
0
41 PERMIT FOR WIRING
C14us
This certifies that ... ......
.... ......
has Permission to perform .............................
wiring in//the building of...
at...X . ....e"
.................................. North Andover,Mass.
Fee.... ........... Lic. .............................................::�
ELECTRICAL INSPECTOR
Check //
%AORTH
OL
O
O cocwi�Hiwrt. 1•
'Q
SSAC MUSS
PUBLIC HEALTH DEPARTMENT
Community Development Division
June 26, 2009
Kimberly Goc
448 Boxford Street
North Andover, MA 01845
RE: Septic System Design,448 Boxford Street,North Andover, Map 105C, Lot 48
Dear Ms. Goc,
The North Andover Board of Health has completed the review of the septic system design plans,
for the above referenced property, submitted on your behalf by Merrimack Engineering Services,
dated June 3, 2009, final revision date June 23,2009. This plan has been approved. The approval
includes a Local Upgrade Approval as found attached. This plan is valid for two years from the
date of this approval.
The design has been approved for use in the construction of an onsite septic system for a 4-
bedroom house(maximum 9-room). During this time, a licensed septic system installer must
obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the
installer, designer and the Town of North Andover. In the event an imminent health problem
such as sewage backup into the dwelling is occurring,the North Andover Board of Health may
reduce the time period for which this plan is valid.
This approval includes the following:
Local Upgrade Approval
Use of only one deep hole in proposed disposal area
This approval is subject to the following conditions:
1. The owner shall keep the attached form 9b for their records
2. If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation,the originally issued Disposal System Construction
Permit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit(3 10 CMR 15.020(1)).
3. It is the responsibility of the applicant and/or the applicant's designer, installer or
other representative to ensure that all other state and municipal requirements are met.
These may include review by the Conservation Commission, Zoning Board, Planning
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
i
• ' Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The
issuance of a Disposal System Construction Permit shall not construe and/or imply
compliance with any of the aforementioned requirements.
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health Department may be reached at 978-688-9540 with any questions you
may have.'
;Sinceresan Y. Sawyer, REH S
Public Health Direct
Encl: list of licensed septic system installers
Form 9B for owner records
Cc: Merrimack Engineering Services
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Commonwealth of Massachusetts
City/Town of
: o Local Upgrade Approval
r`
Form 913
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address
on the computer,
use only the tab Kimberly GOC
key to move your Name
cursor-do not 448 Boxford Street
use the return
key. Street Address
North Andover MA 01845
Q City/Town State Zip Code
2. Owner Name and Address (if different from above):
Name Street Address
City/Town State
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15.203: 440
gpd
5. System Designer: Vladimar Nemchenok
Name ® PE ❑ RS
66 Park Street Andover 01810
Address City/Town State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction In setback(s)—specify:
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
448 Boxford Street 9b 6.26.09•rev.7/06 Local Upgrade Approval* Page 1 of 2
Y '
,. Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction
ft.
Percolation rate min./inch
Depth to groundwater ft
❑ 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
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
North Andover Health Department
Approving Authority
Susan SawyerJune 26, 2009
Print or Type Name and Title ignature Date
448 Boxford Street 9b 6.26.09•rev.7/06 Local Upgrade Approval* Page 2 of 2
i
,per /� ggjj Official Use Only
�-\ C,oirunarcaea[Ih•a�
c� Permit No.�4
eUeparfinenEa��ire�¢rviced
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] aeave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL.WORK
All work to be performed in accordance with.ihe Massachusetts Electrical Code(MEC),527 CMR 1200
(PLEASE PRINT.IN INK OR TYPEALL MFORMA TIM Date: ?-/ -09
Cityor Town of: K),4'K.Zs %j 4e.4e_ To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) Lf 9 �o
Owner or Tenant u.iV*^47-JL_ t a O C_ Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / volts Overhead❑ Undgrd❑ No.of Meters
Undgrd❑ No.of Meters
Date .. ...�.. .. . . ....
in table m be waived b the Ins ector o Brines.
kORT"
o�,t,,.o •�"o TOWN OF NORTH ANDOVER 6.of.__ Total
a? , --• o� �.- i j :'! Transformers KVA
S , p PERMIT
-FOR WIRING_ Generators KVA.
o.o Emergency g
0 Batte Units
,SSACMUs� - ,fi _ FIRE ALARMS No.of Zones
o
of Detection an
This certifies that ...... �, \\
Initiating Devices
_ .c- :,:.... i ........ No.of Alerting Devices
has permission toperform �'" �` o.o e - ontam
1 - ..... ;
/ Detection/Alertin Devices
wiring in the building of...f. !�.:..�. .... „ i \ Locat❑ C uncipa ❑ Other
�, s/�"` . ,North Andover,Mass. Systems.
at. .t�..1•� `��`. � ecurity ysteutse
� �� \No_of Devices or uivalent
Fee...`' • ' ... Lic.No. .... C •..ELEJ�-
1ntsPEc�oR Data Wiring.
" No.of Devices or uivalent
J _ elecommunicationsir-ing-:
Check 9 No.of Devices or Equivalent
QQ desired or as required by the Inspea 2r of Wires.
C3 CI
_ y-cnuntcipal policy.)
Work to Start: -7 8 Inspections to be requested in accordance with MEC Rule 10,and upon completk n.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
I certify,under the pin¢fid penalties o p�jjury,that the inform aon on this application is true and complete.
FIRM NAME: �a. (C� ��l ,C.t.ta•o E - LIC.NO.: _
Licensee: /" Signature. LIC.N0.:�7L�7 2 4t
(Ifapplicable,enter"ere t"in the license er tin ) Bus.Tel.No.;292 Y?f OT r—
Address: 7-0a Alt.Tet.No.:4a 7 7 P 9 4,/1'f
*Per hiG.L.c.141,9.57-61,s ty work requires Dep ent of Public Safety"S" nse: Lic.No.
OWNER'S INSURANCE WAI VER: I am aware that.the Licensee does not have the liability insurance coverage normally
required by law.. By my signator,below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's a ent
Owner/Agent [PERMIT FEE. S
Signature Telephone No.
i
r1ORTH
O ,Le D ,
t 6
O L
o coc �
'tsgSSgC
PUBLIC HEALTH DEPARTMENT
Community Development Division
June 26,2009
Kimberly Goc
448 Boxford Street
North Andover, MA 01845
RE: Septic System Design, 448 Boxford Street,North Andover, Map 105C, Lot 48
Dear Ms. Goc,
The North Andover Board of Health has completed the review of the septic system design plans,
for the above referenced property, submitted on your behalf by Merrimack Engineering Services,
dated June 3, 2009, final revision date June 23,2009. This plan has been approved. The approval
includes a Local Upgrade Approval as found attached. This plan is valid for two years from the
date of this approval.
The design has been approved for use in the construction of an onsite septic system for a 4-
bedroom house (maximum 9-room). During this time, a licensed septic system installer must
obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the
installer, designer and the Town of North Andover. In the event an imminent health problem
such as sewage backup into the dwelling is occurring,the North Andover Board of Health may
reduce the time period for which this plan is valid.
This approval includes the following:
Local Up ade Approval
Use of only one deep hole in proposed disposal area
This approval is subject to the following conditions:
1. The owner shall keep the attached form 9b for their records
2. If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation,the originally issued Disposal System Construction
Permit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit(3 10 CMR 15.020(1)).
3. It is the responsibility of the applicant and/or the applicant's designer, installer or
other representative to ensure that all other state and municipal requirements are met.
These may include review by the Conservation Commission,Zoning Board, Planning
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The
issuance of a Disposal System Construction Permit shall not construe and/or imply
compliance with any of the aforementioned requirements.
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health Department may be reached at 978-688-9540 with any questions you
may have.
Sincere ,
ZS/
usan Y. Sawyer, REH S
Public Health Direct
Encl: list of licensed septic system installers
Form 9B for owner records
Cc: Merrimack Engineering Services
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
Commonwealth of Massachusetts
City/Town of
: o Local Upgrade Approval
Form 913
DEP has provided this form for use by local Boards of Health if they choose to do so.
The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided
to the system owner.
A. Facility Information
Important:When
filling out forms 1. Facility Name and Address
on the computer,
use only the tab Kimberly Goc
key to move your Name
cursor-do not 448 Boxford Street
use the return
key. Street Address
North Andover MA 01845
City/Town State Zip Code
2. Owner Name and Address(if different from above):
Name Street Address
City/Town State
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Design flow per 310 CMR 15.203: 440
gpd
5. System Designer: Vladimar Nemchenok ® PE ❑ RS
Name
66 Park Street Andover 01810
Address City/Town State,ZIP
B. Approval
1. Local Upgrade Approval is granted for:
❑ Reduction in setback(s)—specify:
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
448 Boxford Street 9b 6.26.09•rev.7/06 Local Upgrade Approval*Page 1 of 2
Commonwealth of Massachusetts
City/Town of
Local Upgrade Approval
Form 9B
B. Approval (continued)
❑ Reduction in separation between the SAS and high groundwater:
Separation reduction .
Percolation rate
min./inch
Depthto groundwater
❑ 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
List local variances granted not requiring DEP approval per 310 CMR 15.412(4):
List variances granted requiring DEP approval:
North Andover Health Department
Approving Authority
Susan SawyerJune 26, 2009
Print or Type Name and Title ignature Date
448 Boxford Street 9b 6.26.09•rev.7/06 Local Upgrade Approval*Page 2 of 2
Commonwealth of Massachusetts
City/Town of North Andover
Form 9A - Application for Local Upgrade Approval
M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR
15.404(1), is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full
Y
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
Important:
When filling out 1. Facility Name and Address:
forms on the
computer,use Kimberly Goc Residence
only the tab key Name
to move your 448 Boxford Street
cursor-do not Street Address
use the return
key. North Andover Ma 01845
Citylrown State Zip Code
tab
2. Owner Name and Address(if different from above):
Kimberly Goc 448 Boxford Street
Name Street Address
North Andover Ma
Cityrrown State
01845 (978)688-1494
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
4 Bdrm. House
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below):
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Field
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: 600
gpd
Design flow of proposed upgraded system 440
gpd
Design flow of facility: 440
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is(check one):
❑ 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:
Complete replacement (see plan )
3. Local Upgrade Approval is requested for(check all that apply):
❑ Reduction in setback(s)—describe reductions:
❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction
® Reduction in separation between the SAS and high groundwater:
Separation reduction 1.0
ft.
Percolation rate 2
min./inch
Depth to groundwater 4.0
ft.
t5fo►m9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 2 of 4
Commonwealth of Massachusetts
Cityrrown of North Andover
Form 9A - Application for Local Upgrade Approval
M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
B. Proposed Upgrade of System (continued)
❑ Relocation of water supply well (explain):
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
® Use of only one deep hole in proposed disposal area
❑ Use of a sieve analysis as a substitute for a perc test
❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Isaac Rowe 6-3-09
Evaluator's Name(type or print) Signature Date of evaluation
C. Explanation
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:
Full compliance would result in raising the system even higher than designed which would potentially
cause drainage issues resulting in ponding on this property and adjacent properties.
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
M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
C. Explanation (continued)
3. A shared system is not feasible:
NA
4. Connection to a public sewer is not feasible:
NA
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."
h s Si azure Date
Kimberly Goc
Print Name
Bill Dufresne/Merrimack Engineering Services 6 7-el
Name of Preparer Date
66 Park Street Andover
Preparer's address City/Town
Ma/01810 (978)475-3555
State/ZIP Code Telephone
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval*Page 4 of 4
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 9 LAND SURVEYORS PLANNERS
66 PARK STREET•ANDOVER,MA 01810•(978)475-3555,373-5721 • FAX(978)475-1448• E-MAIL Info@merrimackengineedng.com
June 22, 2009
Susan Sawyer RECEIV/ FD
Public Health Director ��w/�- "
1600 Osgood Street, Suite 2-36 JUN 2 5 2009
North Andover, MA 01845 &/a
TOWN Or NORTH ANDOVER
RE: 448 Boxford Street HEALTH DEPARTMENT
Dear Ms. Sawyer,
We are in receipt of your review letter dated 6-16-09 for the above referenced site.
We have revised the design plan with regard to items 1,4,5,6,8 and 10 of your letter.
With regard to items 2,3,7 and 9,this information is all specified on the plan and was
missed by the reviewer.
Enclosed herewith are 3 copies of the revised plan. We feel that all your concerns have
been adequately addressed and that the plans are in compliance with Title 5 and the N.A.
Board of Health Regulations.
The property is currently under contract and time is of the essence, as such, we
respectfully request that the plans be approved as re-submitted so that our client may
move forward with construction as soon as possible.
We appreciate your prompt attention to this matter.
Very truly yours,
M��ERRIMACK ENGINEERING SERICES, INC.
William Dufresne
Project Manager
NORTil q
,bt +O
Z.
0 ~ (�
yy _
Tyy�
cocwi<
�9SSAC NUS����
FILE �Xnd PY
PUBLIC HEALTH DEPARTMENT
Community Development Division
June 16,2009
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover,MA 01810
Be:Subsurface Sewage Disposal System Plan for 448 Boxford Street Man I05C Lot 48
Dear Mr.Nemchenok:
The proposed wastewater system design plan for the above site dated June 3,2009 and received on June 9,2009 has
been reviewed. Unfortunately,the plan cannot be approved until the following items are corrected. The specific
section in Title 5:310 CMR 15.000,or North Andover regulation that is not met by this design follows each item.
1. Please indicate on the design Plan that a Local Upgrade Approval for only having one test pit
in the soil
absorption system area is being requested.
2. Please indicate that all the outlet pipes of the distribution box will be the same elevation(3 10 CMR
15.232(3)(b)).
3. Please indicate that all the outlet pipes of the distribution box shall be laid level for the first two feet(3 10
CMR 15.232(3)(c)).
4. Please indicate the flow back volume in the pump calculations(310 CMR 15.231(2)).
5. Please provide a pump performance curve for the proposed(3 10 CMR 15.220(4)(r)).
6. The total dynamic head was not provided in the pump calculations. Please indicate the total dynamic head
(3 10 CMR 15.220(4)(r)).
7. Please indicate that a manual operating switch will be provided(NA 12.01).
8. Please indicate the access cover above the outlet of the pump chamber will located at finish grade(3 10
CMR 15.231(5)).
9. Please indicate that the pump chamber shall be made watertight(3 10 CMR 15.221(1)).
10. Please depict the proposed impervious barrier on the site plan.
Please feel free to contact the office with any questions you may have. We look forward to working with you to
obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure
protection of public health and the environment of North Andover.
Sincer ,
'f S an Y. Sawy ,:REHSV
ublic Health Dirr
cc: Kimberly Goc
File
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
d u� �`�
y w J
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Tuesday, June 09, 2009 1:30 PM
To: 'Daniel Ottenheimer; 'Isaac Rowe'; Marianne Peters; 'Randy Burley'
Cc: Sawyer, Susan; Grant, Michele
Subject: FW: Septic- Plan Review-448 Boxford Street-Please Expedite
Attachments: SKMBT_60009060913120.pdf
Hello,
A little history on this property-Ben Osgood was initially hired to be the engineer. There were personal business
circumstances on Ben's end where he did not follow-up on getting the soil testing/plans done,etc. in a timely manner.
Therefore,the homeowner, Kimberly Goc, hired Bill Dufresne to conduct same.
The situation is this: homeowner has an offer on the property. The Purchase and Sale is being signed tomorrow,
6/10/09. The closing date is set for 7/30/09. If there is any possible way to speed the review process of this system so
that it can be reviewed,approved and installed well before closing date,the homeowner would be very appreciative.
Anything you can do to make the process go more quickly is appreciated.
Sending the plan in the mail to you today. Thank you for your assistance.
PameQa Z)e&e
Pamela DelleChiaie
Health Department Assistant
TOWN OF NORTH ANDOVER
Health Department
1600 Osgood Street
Building 20;Suite 2-36
North Andover,MA 01845
978.688.9540-Phone
978.688.8476-Fax
pdellechiaie@townofnorthandover.com-E-mail
http://www.townofnorthandover.com-Website
Notes:
If copied to BOH Members-Reference Copy Only-no response requested at this time
From: nore I townofnorthandover.com mailto:nore I townofnorthandov r. m
p y@ [ p y@ eco ]
Sent: Tuesday, June 09, 2009 2:13 PM
To: DelleChiaie, Pamela
Subject: Septic - Plan Review - 448 Boxford Street- Please Expedite
Tracking:
1
Recipient Delivery
'Daniel Ottenheimer'
'Isaac Rowe'
Marianne Peters
'Randy Burley'
Sawyer,Susan Delivered:6/9/2009 1:29 PM
Grant,Michele Delivered:6/9/2009 1:29 PM
i
I
2
TOWN OF NORTH ANDOVER E pOR7
Office of COMIMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT p
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 .rg►
NORTH ANDOVER,MASSACHUSETTS 01845 �qs q�NUS S'
Susan Y.Sawyer,REHS/RS 978.688.9540—Phone97$.688.8476—FAX
Public Health Director E-MAIL:healthdept(a townofnorthandover.com
WEBSITE:httD://www.townofnorthandover.com
SEPTIC PLAN SUBWnAL FORM
Date of Submission: �
Site Location:_-- �492 �e{y.w }?
Engineer: tj� 12d1✓I � 3(��f(fit! jr _
New Plans? Yes ��
,�$225/Plan Check# (includes 1 submission and one re-
review only)
Revised Plans?Yes $75/Plan Check`#
Site Evaluation Forms Included? Yeses/ No
Local Upgrade Form Included? Yes : No
Telephone 9-7 Fax
E-mail: 1
Homeowner
Name: �/-=TLfx'�
OIFFICE USE ONLY
When the submission is complete(including cheek):
Date stamp plans and letter -
➢ Complete and attach Receipt
�Copy File;Forward to Consultant
Enter on Log Sheet and Database
Y
Commonwealth of Massachusetts
CitylTown of North Andover
- Form 9A — Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use.
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
septic system with a design flow of less than 10,000 gpd,where full compliance, as defined in 310 CMR
15.404(1), is not feasible.
System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full
compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410
through 15.415.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
a new design flow to a cesspool or privy,or the addition of a new design flow above the existing approved
capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000.
A. Facility Information
Important
When filling out 1. Facility Name and Address:
forms on the
computer,use _Kimberly Goc Residence
only the tab key Name
to move your 448 Boxford Street
cursor-do not Street
use the return
Address
key. North Andover Ma _ 01845
City/Town state Zip Code
ad
2. Owner Name and Address(if different from above):
Kimberly Goc 448 Boxford Street
Name Street Address
North Andover Ma
CftyfTown state
01845 (978)688-1494
Zip Code Telephone Number
3. Type of Facility(check all that apply):
® Residential ❑ Institutional ❑ Commercial ❑ School
4. Describe Facility:
4 Bdrm. House
5. Type of Existing System:
❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below):
6. Type of soil absorption system(trenches,chambers,leach field, pits,etc):
Field
t5formga.doc•rev.7106 Application for Local Upgrade Approval*Page 1 of 4
Commonwealth of Massachusetts
Cityfrown of North Andover
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use.
A. Facility Information (continued)
7. Design Flow per 310 CMR 15.203:
600
Design flow of existing system: gpd
9pd i
Design flow of proposed upgraded system 440
gpd
Design flow of facility: 440
9pd
B. Proposed Upgrade of System
1. Proposed upgrade is(check one):
❑ 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:
Complete replacement (see plan )
3. Local Upgrade Approval is requested for(check all that apply):
Reduction in setback(s)—describe reductions:
❑ ( ) s
❑ Reduction in SAS area of up to 25%: sas size,sq.ft. °r6 reduction
® Reduction in separation between the SAS and
high groundwater:
Separation reduction 1.0
tt.
Percolation rate 2
minfinch
Depth to groundwater 4.0
ft.
t5forrn9a.doc°rev.7/06 Application for Local Upgrade Approval•Page 2 of 4
I
i
1
. 4 4 • V
Commonwealth of Massachusetts
Cityfrown 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 soft evaluator must be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Isaac Rowe 6-3-09
Evaluator's Name(type or print) Signature Date of evaluation
C. Explanation
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:
Full compliance would result in raising the system even higher than designed which would potentially
cause drainage issues resulting in ponding on this property and adjacent properties.
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.208 is not feasible:
NA
t5form8a.doc•rev.7/06
Application for local Upgrade Approval*Page 3 of 4
i
e
c
Commonwealth of Massachusetts
CitylTown 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:
NA
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
® Completelans and specifications
P P
® 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
"l, 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.'
9,.,1Y/L-41-
s S ature Date
Kimberly Goc
Print Name
Bill Dufresne/Menimack Engineering Services
Name of Preparer Date
66 Park Street Andover
Preparees address City/Town
Ma/01810 (878)475-3555
State23P Code Telephone
t5fom39a.doc•rev.7/06 Application for Local Upgrade Approval*Page 4 of 4
I
Lacutlon: Owner':Name
Mplp�a-txL• It rJ Ad �1. ''
` v
Instaiter: TeT �.i _' N
DatesX0-'3— °� Wedsmds Zone-II ---Soit 5�na�boi�5oIl Rhe d 505 Qur �✓
DCT.Obswvxdpn SoleUgs
Eterxtloa . Depth -%q fl c on Sail TWRM Soft Gator Soft, %t vd,Stoa�r,ete
V, ter t,�Jlr
LA so�
t
(at
LLM p,�
toy
V. Fri
Z 3 -F16*4
Par+atll�edaT__"� �_L.�p��+�*dL����dtutttt�tertae6a�8rter,��ttta�la=hswt?kF��Ye J .
--- l3amlRtlon TCS
: Obs�uuSioA Holo u ;— - •
• Dcpt$of Pow 7
Start Pfo o << .
Tim at 30 40
Time at 9".
Time at S"
Time(9"
•Rnte Mtollud,- .
Performed B.��.PJ.QU Cl ,-
s
• V v •
l
Filename: Document4
Directory:
Template: C:\Documents and Settings\pdellech\Application
Data\Microsoft\Tem plates\Normal.dotm
Title:
Subject:
Author: pdellech
Keywords:
Comments:
Creation Date: 6/9/2009 2:00:00 PM
Change Number: 1
Last Saved On:
Last Saved By:
Total Editing Time: 0 Minutes
Last Printed On: 6/9/2009 2:03:00 PM
As of Last Complete Printing
Number of Pages: 1
Number of Words: 80(approx.)
Number of Characters: 462 (approx.)
T C,Vv`[ OF !'TORTE; ANDOVER QypRTHof
�b
�:l��V�l i_C3: L I'\ 1 A I L7E R V/ L;E S S�? L
4 0� A
's�.. ,� ;-,;^r- c: G Ems` c ; ; ,l N' 2,. S ;i_�r •' g
600 C) ) :T c _i ; B i L:, . SIT .._ _
Noi-:TH A N`:�._;:,ER. rill A S S ,CH U'S'PET-I S 7-18a5 4 SACH�9
Nil's=1f1 mai\':`)':=f. ,=i-' r:? 9 868'8.9540
`u,bhcHeNl I� i. 'kil pf 191
-8,688,84--6% .f FAX
h�-A.It 1. oPN.noir1.:1i h,3,)dr,Dvtf Coli`
APPL I CATION FOR SOIL TESTS
DATE: MAP& PARCEL:
LOCATION OF SOIL TESTS: H q CE, $axjr'DfLp STj?,e t
OWNER: LL,►w% 8 Mt;1 �s-DG Contact#. cj 7.8
APPLICANT:_1�:►rvV• , (SoG Contact#.
ADDRESS-- AJ/��� C)(LIC AJ-2 00 e`'
ENGINEER:ex✓` 0s5ooy `T2_ Contact -5-29 32 L.h33
CERTIFIED SOIL EVALUATOR: nn G/� (�s o.�SL ZFti—
Intended Use of Land: Residential Subdivision Sin le Family Home CommercialLTOWN
IVEfl
IsThis: Repair Testing: X Undeveloped Lot Testing: Upgradefor Addition: 2 2009
1 n the Lake Cochichewid<Watershed? Yes No TH ANDOVERARTMENT
THE FOLLOWING MUST BE INCLUDED WITH THISFORM
➢ Proof of land ownership(Tax bill,or letter from owner permitting test)
➢ 8.5_x 11_Plot plan & Location of Testinq(please i ndicatetest pit siteson the plan)
➢ Fee of$425.00 per lot for new construction. This coversthe minimum two deep holesand
two percolation tests required for each disposal area. Fee of$360.0 per lot for repairs or upgrades.
GENERAL INFORMATION
➢ ON y Certi f i ed Soi I Eval uators may perf orm deep hol e i nspecti ons.
y Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
➢ At I east two deep hol es and two percol ati on tests are requi red for each septi c system disposal area
Repairs require at least two deep holes and at least one percolation test, at the di scret i on of the BOH
representative.
r Full paymentwili berequired for all additional tests within two weeks of testing.
Within 45 days of testing, a scat ed plan(no smd l er than 1=100)shall be submitted to the Board of Health
showi ng the I ocati on of al I tests(i nd udi ng aborted tests).
➢ Within 60 days of testing soil evaluation for ms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval Date:
Signatureof Conservation Agent:
Date back to Health Department: (starnp in):
i
i
/ Gni J7 C ( �' � ��,
I
I
�('��'�Q
�s��l-�
.� ��
��'11-ia is mss.
„ < r:�
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Tuesday, April 28, 2009 1:36 PM
To: 'Daniel Ottenheimer; 'Isaac Rowe; Marianne Peters; 'Randy Burley'
Cc: Sawyer, Susan
Subject: Task Status Report: Septic-448 Boxford Street-Soil Test Application
-----Original Task-----
Subject: Septic - 448 Boxford Street- Soil Test Application
Priority: Normal
Start date: Thu 4/23/2009
Due date: Wed 4/29/2009
Status: In Progress
0/6 Complete: 50%
Actual work: 0 hours
Requested by: DelleChiaie, Pamela
Septic-448 Boxford
Street-...
4/28/09—Site checked by Jennifer Hughes in Conservation. There is no wetland within 100 Feet. You can go ahead and
setup an appt.for soil testing.
1
DelleChiaie, Pamela
From: Isaac Rowe[irowe@millriverconsulting.com]
Sent: Wednesday, June 03, 2009 12:40 PM
To: 'Daniel Ottenheimer'; Grant, Michele; irowe@millriverconsulting.com; 'Marianne Peters';
DelleChiaie, Pamela; 'Randy Burley'; Sawyer, Susan
Subject: 448 Boxford Street
Attachments: Soil Testing Results-448 Boxford Street 6-3-09.pdf
Susan,
Please find attached the soil testing results for the above referenced property. There are no visible wetlands on site but
there are wells in the area that Bill should show on his design plan.
Please let me know if you have any questions.
Thank you,
Isaac
Isaac M. Rowe,R.S.
Project Manager
Mill River Consulting
2 Blackburn Center
1 i
i
1
B'loucester,*01930-2268
Phone: (978)282-0014
Fax: (978)282-0012
irowe()-millriverconsulting.com
www.millriverconsulting.com
2 '
_ ._. . Uq,Z' QST p
-
b�,,(s•Z
q-
,�
E _
Location! Owner's Name
MaplParcclAd . �'�
Installer. Tel f New Msk.Rcpgr
Date: (o-3-25 Wcdnnds__ZoaeII Sall Sart ibou�2 Soli mme C Sop A.. Jj.7
DeV Observation HoleLogs
Elevation Depth Son 14rlZon Soil Teanre Son Calor, %Grnvel,Stone;ear
i
61 vi
LA
�'ehat i►iatgiiri- \ 1...1�. q "" WitesM lbeH�ies � R fima?M F� ��,
U, 4;r LL
�►'►x..55 t�.:-
VIP te,_j
���Depehg8�6tuCI��Ysteriaa�eH�la,�Neepia=[�aatttFi«�X/ �CtY�
Dote 3-a percolation Tests
: ObscrcatioaEolc� ";'� -
Depth of Perr 2
Stut Pia.Sosl;
Time at 121f
Time at 9"'
Time at 6"
Time
-Rate hu U& .
PcrEormed 51. e
_Witnessed B�-_�.� ..�±�:57.• __
Commonwealth of Massachusetts ECIVE® .
Title 5. Official Inspection Form AP 2 3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
WWN OF NE R ANDD R
M
448 Boxford Street _T', P TME
Property Address
Kimberly Goc
Owner Owners Name
information is
required for North Andover MA 01845 4/7/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information
forms on the
computer, use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover Ma 01810
'B01' Cityfrown State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
1 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:
�I
❑ Passes ❑ Conditionally Passes ® Fails
❑ )Needs Further Evaluation by the Local Approving Authority
4/7/2009
I sp ct rs Signa6 re 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 samer
o different conditions of use.
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts RECEIVED
r . J Title 5 Official Inspection Form APR 2 3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
TOWN OF NOR'TR`ANDOVER
448 Boxford Street HEALTH,,DEPARYMENT
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. Cityrrown 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:
❑ 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•09/08
Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17
t Commonwealth of Massachusetts RECEIVED
} . Title 5 Official Inspection Form APR 2 3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
TOWN.OF NORTH ANDOVER
y 448 Boxford Street HEALTH DEPARTMENT
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
' Commonwealth of Massachusetts RECEIVED
a Title 5 Official Inspection Form APR 2 3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessmen
TOWN.OF NORTH ANDOVER
448 Boxford Street HEALTH
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. 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 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:
i
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
® El clogged
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 11 or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
' Commonwealth of Massachusetts EHWEALTHDE
D
Title 5 Official Inspection Form 9
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
TOWN OFOVER
M
448 Boxford Street NT
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
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-
1 0,000g pd.
® ❑ 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
e
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 or 17
i
Commonwealth of Massachusetts RECEIVED
Title 5 Official Inspection Form
APR 2 3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
TOWN OF NORTH ANDOVER
M yr•`•y 448 Boxford Street HEALTH DEPARTMENT
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. Cityrrown 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
E ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
r
Commonwealth of Massachusetts RECIVEp
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments APR 2 3 2009
448 Boxford Street TOWN -F NORTH Eft
M Property Address ARTMENT
Kimberly Goc
Owner Owner's Name
information is North Andover MA 01845 4/7/2009
required for '
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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 ears usage On well water
9 ( Y 9 (gpd))�
Detail:
Sump pump? ® Yes ❑ No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
flow
Design based on 310 CMR 15.203
i g ( ) Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
i
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts RECEIVED
Title 5 Official Inspection Form APR 2 3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
TOWN OF NORTH ANDOVER �
M 448 Boxford Street HEALTH DEPARTMENT
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped 2005, owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
i
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
I
❑ Overflow cesspool
I
i
❑ 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
RECEIVED
Title 5 Official Inspection Form APR 2 3 2009
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
448 Boxford Street
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
27 years old,12/10/1982, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.4
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.):
3" PVC in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
Years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'x 5'x 4'
de
Sludge the 4
p
t5ins-09/08 Title 5 ficial Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts RECEIVED
Title 5 Official Inspection Form APR 2 3 2009
Subsurface Sewage Disposal System Form-Not for voluntary Assessments TOWN'OF NORTH ANDOVER
HEALTH DEPARTMENT
lu
448 Boxford Street
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. City/Town 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
23"
Scum thickness
4"
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
17"
Tape Measure
How were dimensions determined? Ta p
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert evidence of leakage, etc.):
q ,
9 )
Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage.
Grease Trap locate on site plan):
Depth below grade: feet
Material ofn r
co st uction:
❑ 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:
Date
t5ins•09/08 Title 5 Official Inspection forth:Subsurface Sewage Disposal 9e
System•Pa 10 of 17
Y
Commonwealth of Massachusetts R
ECEIVED k
Title 5 Official Inspection Form 2009
Subsurface Sewage Disposal System Form-Not for Voluntary AssessmentsH ANDOVER
448 Boxford StreetRTfNENT
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
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? ❑ Yes ❑ No
t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
RECEIVED
Commonwealth of Massachusetts
Title 5 Official Inspection Form APR 2 3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments TOHEAOTH D PARTM LATER
L
M 448 Boxford Street
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
2"
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.):
Liquid level above all pipes 2". 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.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
r RECEIVED
Commonwealth of Massachusetts
Title 5 Official Inspection Form APR 2 3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments TOWN'OF NORTH ANDOVER
HEALTH DEPARTMENT
448 Boxford Street
Property Address
Kimberly Goc
Owner Owners Name
information is
required for North Andover MA 01845 4/7/2009
every page. 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: 1 field 20' x 45'
❑ 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. Liquid above all pipes in leach field.
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•09/08 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 13 of 17
I
Commonwealth of Massachusetts
APR 2 3 2009
Title 5 Official Inspection Form
LRECEVED
N OAF tMTH AABS MER
Subsurface Sewage Disposal System Form-Not for Voluntary AssessmentsEALTH�ARB7At�Ut
448 Boxford Street
Property Address
Kimberly Goc
Owner Owner's Name
information is wired for
required North Andover MA 01845 4/7/2009
every page. City/Town State Zip Code Qate 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.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official lnaectlon Foy
Subsurface Sewage Disposal System Form-Not for Voluntary Assessmentsm a
448 Boxford Street
Property Address
Kimberly Goc
Owner Owner's Name
information isCV
required for North Andover MA 09845
every page. Citylrown State Tip Code Date of Inspedion
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
A
-Av � = 4s
P-)
c, =S9 +9 "
D�
I
e5ins•agrots Tilt 5 Official lnspee ion FomK Simsurface Sewage Disposal system•Pap 15 of 17
i~tECEIVED
Commonwealth of Massachusetts
Title 5 Official Inspection Form APR 2 *312009009
3 2009
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments TOWN OF NORTH ANDOVER
HEALTH APARTMENT
448 Boxford Street
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. City/Town 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: 5/24/1978
Date
❑ 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:
Design plan test pit data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts APR 2 3 2009
Title 5 Official Inspection Form T®w4V OF NORTH VlE1R
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments H 'ARTUBiff
448 Boxford Street
Property Address
Kimberly Goc
Owner Owner's Name
information is
required for North Andover MA 01845 4/7/2009
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System••Page 17 of 17
i --
AA
_.LA/4�.4 z
if-wt 44.r.. 9 Z..�
.s
r o -,•.c
_. ------ _ 'o vAL
�k
XI
f
��X1aFl�1G'r( i
,r s
LS00. (SA) _ SEPTIC 7-,4"A< j
9aa �•F• L•3ED
g
t
I
pY
1
1
fox FOR,D