HomeMy WebLinkAboutMiscellaneous - 45 LACY STREET 4/30/2018 45 LACY STREET I
210/105.D-0113-0000.0
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FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements. 1131301(-.5,CHYbc�4A
****************-Applicant fills out this section*******************
APPLICANT: ��-~�� f�/,[� s Phone
LOCATION: Assessor's Map Number IJ5 Parcel 7
Subdivision C Lot(s)
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Street `-�� L G r 7- St. Number _4_5L
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************************Official Use Only************************
RECO NDATIO OF TOWN AGENTS:
Date Approved
Co servati Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
Date Approved
is
�spec�tor-Ke -�th D-a/t�e Rejected
Commentsu
D✓ cam)i d cam.
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
E' D
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CONS R RA ION COM�►ISSEON
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4o,,-A7-EP AJ .4 t:+ I'L A I Al / 799 Turnpike Street
NORTH ANDOVER, MASSACHWSETTS 01815
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BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINA IO d
Permit NO: Date Received 4 5*
�9SSACHUSE��
Date Issued: 01
IMPORTANT: Applicant must complete all items on this page
LOCATION 46 LAc-q X31 t\) Ny0c- MA
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PROPERTY OWNER I�tLf-�fir — 4- �`a t ��Llc
Print
MAP NO: )(),S E�S PARCEL: l 12� ZONING DISTRICT: V,r Historic District yes Pno
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Machine Shop Village yes
TYPE OF IMPROVEMENT- PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
Addition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
'Demolition ❑ Other
❑ Septic ❑ Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
6eLIL )�J e-*T M U�V9Z_(� 6,,),se ,Z
Identification Please Type or Print Clearly)
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OWNER: Name: � � ��., �' ���- � t �,�� Phone:
Address: �-I`� 1_PN
CONTRACTOR Name: Phone:
ddress:
upervisor's Construction License: Exp. Date:
ome Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ -3-UO FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting;withft unre istered contr, ctors do not have access to the guaranty fund
Signature of Agent/Owner ignature of contractor
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Plans Submitted Ll Plans waived u uertiriea viol Tian u otarnpeU riaiis u
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,etc. Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVE
t.
/PLANNING & DEVELOPMENT ❑ ❑ i
COMENTS
CONSERVATION ❑ ❑ 11 1 �_ ^
COMMENTS
DATE REJECTED DATE APPROVED
EALTH ❑ Eru
COMMEN p 5 e
act d—
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Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature&Date Driveway Permit
Located at 384 Osgood Street
FIRE D PARTNI NT - Temp Du Aster on site yes no
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Located at 124 Main Street
Fire Department signature/date
COMMENTS
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GEOTECHNWAL CONSULTANTS
OF MASSACHUSETTS, MC.
79S Turn,�Ae St-est
NORTH ANCOVE'R, W-IkGSACMSEEM�W845
,per
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 45 Lacy Street za
North Andover,MA 01845
Owner's Name: Peter&Susan Chines Owner's Address: Same
ER ',
Date of Inspection: 05-13-2005
Name of Inspector:(please print)John Soucy
Company Name: Soucy Sewer Service,Inc.
Mailing Address: 830 Livingston Street
Tewksbury,MA 01876
Telephone Number: 978-851-8839
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: ;U--- Date: S —13- 61
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic
system.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
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ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
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 surface water
_Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
x _ Pumping information was provided by the owner,occupant,or Board of Health
x Were any of the system components pumped out in the previous two weeks?
x _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
n/a Were as built plans of the system obtained and examined?(if they were not available note as N/A)
x _ Was the facility or dwelling inspected for signs of sewage back up?
x _ Was the site inspected for signs of break out?
x _ Were all system components,excluding the SAS,located on site?
x _ 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?
x _ 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:
Yes No
x Existing information.For example,a plan at the Board of Health.
x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[3 10 CMR 15.302(3)(b))
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
FLOW CONDITIONS
RESIDENTIAL
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_
Number of current residents:_3
Does residence have a garbage grinder(yes or no):no
Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required]
Laundry system inspected(yes or no): no
Seasonal use:(yes or no): no
Water meter readings,if available(last 2 years usage(gpd)):Well water
Sump pump(yes or no): no
Last date of occupancy: recent
COMMERCIALANDUSTRIAL N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Home Owner
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: 1500 gallons--How was quantity pumped determined?Gage on truc
of inspk
Reason for pumping:Part ection and annual service.
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1984
Were sewage odors detected when arriving at the site(yes or no):No
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
BUILDING SEWER(locate on site plan)
Depth below grade: 28"
Materials of construction: X cast iron _40 PVC other(explain):
Distance from private water supply well or suction line: 75'
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: x (locate on site plan)
Depth below grade: 12"
Material of construction: X concrete_metal_fiberglass_polyethylene_other
(explain)
If tank is metal list age:_Is age confirmed by a Certificate of Compliance(yes or no):`(attach a copy of
certificate)
Dimensions: 6'x 11'
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 38"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: Tape&Sludge Tool
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan) N/A
Depth below grade:_
Material of construction: concrete metal fiberglass_polyethylene_other(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)N/A
Depth below grade:
Material of construction: concrete metal fiberglass___polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (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.): D-Box highly deteriorated,replaced D-box(see permit)
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):_
Alarms in working order(yes or no):_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
X leaching fields,number,dimensions: see sketch of sewage disposal system nage 10.
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 Sign of Hydraulic Failure.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)N/A
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)N/A
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 45 Lacy Street
North Andover,MA 01845
Owner's Name: Peter&Susan Chines
Date of Inspection: 05-13-2005
SITE EXAM
Slope
Surface water
Check cellar x
Shallow wells
Estimated depth to ground water b' from elevation of leach field plus.
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
X 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:
Dud Hole with Auger.
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Map-Block-Lot
Commonwealth of Massachusetts 105.0-0113-
04
ffi Board of Health PennitNo
S North Andover BHP-2005 0119
FEE
; �. .W.
P.I. _------ $125.00
-----
'�'�. tea":.ei qY•tr .�
s.��wssf F.I.
Disposal Works Construction Permit
rantedJohn Soucy -----=------------=-----------------------------------------
Permission is hereby g --------------- -----
to(Repair-D-BOX ONLY).an Individual Sewage Disposal System.
- ----------
-------------------------------------------------------------------------
atNo 45 LACY STR _______________________ __
--------------------- --- -
2005
as shown on the application for Disposal Works Construction Permit No. BHP-2005-011 Da ay 13,
--------
--------------------------- ----
-- ----------------------
Issued On:Ma 13-2005 _---------------------------
Boar f He
.....
........................................................ _
r§,
TOWN OF NORTH ANDOVER .►°erN
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET 41
NORTH ANDOVER, MASSACHUSETTS 01845 �,s•,„o""°�'
s�C&WOUst
978.688.9540—Phone
Susan Y.Sawyer,REHS/RS 978.688.9542—FAX
Public Health Director healthdeptgtownofnorthandover.com-e-mail
www.townofhorthandover.com-website
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: = `�,
LOCATION:
LICENSED INSTALLER NAME:
PLEASE PRINtf
SIGNATURE: u TELEPHONE# &
j
CHECK ONE.
FULL SYSTEM REPAIR: ($250)
OMPONENT REPAIR(indicate what parts): f � C�.P ($125)
* NEW CONSTRUCTION:
* If NE CONSTRUCTION, please attach the Foundation As-Built Plan.
$250.00 0 �iMFAttached? Yes No
Project Manager Obligation From Attached? Yes No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval of Health Agent4C416 ate: ��
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at a-/ Asa-c-, 4, relative to the application
ofl`, /� GOA- dated for plans by 6.eo -�e4and
dated t(—f`7� with revisions dated
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
manger, 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 Tile 5 and the Board of Health Regulations may
result in a$50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be
on site.
4. As the installer I understand that only I may perform the work(other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work by others unlicensed to install septic systems in
North Andover can constitute reasons for denial of the system, and/or revocation or
suspension of my license 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 of Health 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 . en d Septic Installer
U Date: v
Disposal W rks Construction Per t#
Py Town of North Andover,Mass .
ermit -"r - 73 Date V. $ i9-----
APPLICATION FOR WELL & PUMP PERMIT
Application is heteby made for permit to drill a well ( ) . Application is
made to install (_) a pump system'. _
Location: Address ACe/` - Lot
Owner / ,�1� 0/Il�i� 'vryPC'tA//Address-�_77 �/�,QOUe� - ------Tel . 6.96 3,63-C
t•Jell Contractor f - /� ���// � -
iC � ly_Ad d r e s s _L.?_ �, �I'lsiN� �T eZ 32
Pump Contractor o(C (,Je�( F ,2p Address �f - 2� ( j Tel Af40, 23,2 -
— -11�- - + - - - ---
WELL CONTRACTOR (To be completed at time of pump test )
Type of Well---- ---Well used for �� _ _------- -
Diameter of Well Size of Casing
Depth of Bed Rock_ 3 -_ Depth casing into Bed Rock ,_�,G -1
Was Seal Tested? Yes No (_) Date -of Testing
" Depth ofWell-! _ ��j — _ - - -Well Fnded in 14hat Mater_iafl-��
Depth to tti'ater_- -- l(9 — -Delivers _ Sf -Ga 1 s . Per Min . for 4 h _.urs
Drawdown_-3lQ- feet after pumping hours at s GPM
Date of Cornpletion tZ
Si »Lui Ile Contractor .
PUMP INSTALLER- (T6 be filled --in bef-ore - installation)
Size & Name- Pump---- iSD� 2 Pi :Iiia »e Used
11'ater Pump Delivers GPM _ Size of Tank li(J
Pipe Material Used in Well : -Cast Iron (-) Galvanized ( ) Plastic (�(j
Well Pit (_) or Pitless- Adapter
Was sleeve used to protect pipe?- Yes ( ) NO( Type or ',,'ell Seal
Date
r. n:i '.�:'i:i"r:SY'I�'iC iY ii aSY•rditi'rY it )�Sr2 A---A `iY ii . �t. -+ :1.:I. -.._ _�.� wc
: i>c:
Date t'Jater analysis report submitted to Board of lleal t.-h
Date release . gi_ven to owner of record & Bl c1g. Insp
- ---- 11e;iI t h Tnsppct or - - -
Pumps
• Submersible
WELL PUMP CO. • Jet
9� RT.28 WINDHAM, N.H.03087 • Centrifugal
V • Cellar
1IR qZ [603]898-4232 [617)887-5888 • Sewage
Tanks
Filters
• Softener
• Iron
• Charcoal
BrR CON-S-7 TEL.NO. • Neutralizer
477 ANDOVER ST 686-3653
NO ANDOVER MA 01 ;�` Cartridge
Water Testing
Pump Parts
LOT NUMBER OR SAMPLE LOCATION4 LOT #Z Motor Controls
Water Softener Salt
MATER TEST RESULTS 7 MAYS Resin Cleaner
HARDNESS 68.4 (0-50 REC STANDARD) Rust & Stain Remover
IRON .:,:.' (0--•K.3 REG STANDARD.) Potassium
MANGANESE 0 (0—,.0 ' REC STANDARD) Permanganate
HYDROGEN SULFIDE 0 (0—.01 REC STANDARD) Plastic Pipe & Fittings
Ph (ACIDIT`r') 7.5 (6.5-7b5 REC STANDARD) Lawn Watering
TURBIDITY 0 (0-20 REC STANDARD) Systems
CHLORIDES 10 (0-150 REC STANDARD.)
COLIFORM BACTERIA 0 (0 REQUIRED STANDARD) Water Heaters
�r�ek �eena �r �i�e • Solar
CHARGE FOR CHEMICAL & BACTERIA TEST ** $215.00 • Heat Pump
• {• • Electric
ABOVE TESTS MEET RE4WIRED STANDARDS. AND BASED ON THESE, • Energy Saving
Wells
MATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMPTION.
THERE ARE OTHER LESS COMMON MINERALS NHICH CAN AFFECT • Drilled
OUALITY OF 14ATER. • Driven
• Dug
• Gravel
Chemical Feeders
Tank Alarms &
Controls
Hoist Service
JU1�'r�tGS - tot Portable Pump Puller
Emergency Service
Goulds
Aermotor
Jacuzzi
Red Jacket
Fairbanks Morse
Wayne
Aquatron
Well-X-Trot
FORM U - VERIFICATION FORM
INS'T'RUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements. 6C7 3r3o1U;
bf-el CAY�a,,L
****************Applicant f' lls out this section******************
APPLICANT: /G /,C� Phone —
LOCATION:
hone -
II
LOCATION: Assessor's Map Number 16) Parcel /
Subdivision // ,^, 'r Lot(s)
ZA
Street � C 5 7� St. Number -�
************************Official Use Only************************
/ RECCOMMENDATIONS OF TOWN AGENTS:
v Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
Date Approved Z
fif'isSpector-He h /� �{-D-ate Rejected
Comments 41'122 F G , a 71re
lot
Public Works — sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
.,rth Andover, Mass. Street No Go9. 1.4x-%4 r Femme r-sT, Lot No
Loc/Subdiv. Pland Owner
Investigator 4tO. CONsI-or Observer 115 iZ.
SOIL PROFILE DATES
1,tlev 2.Elev 3.Elev 4.Elev
A �-- LD -� - ----
0 0 0 0
s
Ties P�s est
2 Tl S 2 TS 2 . 2
34 3 3 y
u 4 t-IF-r> 4. SAA P*-9
5 5 5 5
5 6 6 6 I
t REFu seal., 7 •Rtpv 7 a
M r
3 8 g 8
ttj '5- I
9 9 9
.3/u/i
== i
L 10 10 10
Benchmark Location
Elevation Datum
PERCOjrATION TESTS
DATES it Lti 03 i 'L\V2 o
Pit Number
Start Saturation
Soak-Minutes
Z
0'.�
starte
Drop of 3"-Time UO
-Drop of 6"-Time r
Mmms.lst 3" drop
Mdns.2nd " Drop__
Percolation
Board Of Health SEPTIC SISTER �iIAce _<T� i?s8a
North vera. �'� T
INSTALLATIClQ CHECK IS ,
4 i
C7VID DATE FXISAPM XAVATICH Ob FAIL
Reaffonst
I. Distance Tot
a. Wetlands
b. Drains
c.. Well
F
2. Water Line Location
3. No PPC Pipe .
U
�. Septic Tank =
a. -Tees -_Length & To Clean Out Covers.
b. Cement Pipe .to Tank - On Both Sides of Tank
Distribution Box
(/ a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
C. No Back Flow
6. . Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped Ends
i; d. Clean Double Washed Stone
7. Leach Pits
'
no Dimensions
` b. Stone Depth
j c. Splash Pads
d. Tees
e. Cement Pipe to Pit - Both Suedes
f. Clean Double Washed Stone
I'
f 8, No Garbage Disposal
i,
9. -Flnal Gradin; Inspection
10. Barricading Covered System
11. As Built Submited r
a. Lot Location
b. Dimensions of System
c. Location with Regard-to Perc Test
d. Elevations
e: Water Table
tk,ara of Eealth
N�r~�.r: :,ndover,?Saea
SffBSURFACE DISPOSAL DESIGI CHECK LIST
LOT .,.�. t f r •
DISAPPROVED DATE
APPROPID DATE ' Reasons:
e,
ivy
Title V FAIL
Reg 2.5 e �b`mi—t;e;d plan must show as n a n_i=t
} the lot to be served-area,dimensions lot #,abutters
„h " location and log deep observation holes-distance to ties
location and results percolation tests-distance to ties
le design calculations & calculations showing required leaching area
e location and dimensions of system-including reserve area
t existing and proposed contours
_ location any vot areas Athin 7001 of sel.ge disposal system or
sclaimer-check wetlands mapping
surface and subsurface drains within 10DI of se�rdge disposal
system or disclaimer
J) location any drainage easements thin 7001 of sewage disposal
system or diselair`.er-P1 anni"g Board files
C3)�kno= sources of �.ater simply jtitbin 2001 of se re disposal(J)
isposal a
system or disclainer
(0--�cati-on-of any proposed ,-ell to serve lot-100' from leaching facil
(1) location of mater lines on property-10' from leaching fa.cili yt�A
Location of benchmark
drive-.-ays
"(p') -garbage disposals
(p) no PVC to be used in construction
t(q) profile of -system-elevations of basem--mt, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Otter elevations
'ma.x4= m ground cater elevation in area se-„-age disposal system
s) plan must be prepared by a Professional Engineer or other
0
professional authorized by 1 :,w to prepare sucb plans
Peg 6 � S�tic Tz�ks
, ..inter table, tEes, depth of tees,
a) capacities-150%- of flog
access, pining
(b)- cleanout
(c) 101 from cellar � or inground s�-�-ng pal
d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
slope greater than 0.08
Reg 10.4 ( b)
Subsurface, Denim Check List Page 2
' FAIL Cg
Leaching Pits
Leaching pits are preferred where the installation is possible
Reg U.2 a) calculations of leaching area-rdni rm m 500 sq ft
114 b) spacing �
11.10 c) surface �e 2
11.11 d) cover erial
e) IIx2 I n splash pad
f) to at elbow
g) bends in pipe from d-box to pipe
chin Fields
Reg 15.1 no greater than 20 �ainutes/inch
-� 940 aq ft
15.4 construction of field
15.8 seirface drainage 2 %
3.7 e) 201 fpm cellar wall or inground svinrAng pool
Leachin Tranches
Reg 14.1 a) culations of leaching area-min 500 sq ft
14.3 b) spacing-4_.ft rdn 6 ft with reserve between
14.4 c) dimensions
14.6 d) construction
14.7 le) otsene
1.4.10 f) surface drainage 2%
Dounhill Slope
swop e y x = (t4 be show-n)
b) y/x X 150 -= (to be shown) _
Reg 9.1 a) Vsd_b7Val
9.6 b) power