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Miscellaneous - 459 SALEM STREET 4/30/2018
0'0000-5900-0'8Eo/%,7 - J ARDS W31VS 69V Commonwealth of MassachusettsRECEW® City/Town of W' System Pumping Record JUIL 2.2 2013 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for us&by local Boards of Health. Other AMS HSA P 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 Locatio Le ightjront of Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) City/Town StateZip Code (p?, _I ? Telephone Number B. Pumping Record 46 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? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No ' S. Condition of 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location re contents were disposed: GLS. Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ^r Commonwealth of Massachusetts RE` "KEYED City/Town of System Pumping Record hIAR L 4 2014 •�~ Form 4 OWN OF NG.2YH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location:Rightont of house Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Rig t front of building, Left/Right rear of building, Under deck Address t v o Y-- lk 0 ' City/Town State Zip Code 2. System Owner. Name Address('d different from location) Citylrown ' State; ��� ,�,� Zip Code Telephone Number ✓`S i i B. Pumping Record 1. Date of Pumping pate 'Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? es ❑ No if yes, was ft cleaned? es ❑ No: 5. Condition of Sys m: t " 6. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location re contents were disposed: o Lowell Waste Water t 3 Sign Haul Date t5fbrm4.doc-06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping-Record Form 4 DEP has provided this form for usesby local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Locatio a RightCont=houQLeft/Right rear of house, Left/right side of house, Left/ Right side of buil Ing, Left/Right front of building, Left/Right rear of building, Under deck Address �/' • �� � A w - Cityfrown State Zip Code 2. System Owner. Job l cj\ '-4 Name Address(K different from location) Citylrown State Zip Code f Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? 'Yes L J No If yes,was it cleaned? es ❑ No: 5. Condition of System: 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. o ere contents-were disposed: 7z S. Lowell Waste Water -3-4 Sign Haut Date t5form4.doe-06/03 System Pumping Record•Page 1 of 1 ` �5��ED j��' • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF. COMPLIANCE As of: 8/26/13 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair and Construction of an On-Site Sewage Disposal System By: Todd Bateson At: 459 Salem Street Map 38 Lot 55 North Andover, MA 01845 e ssuance of thierti � shall n t be construed as a guarantee that the system will function satisfactorily. ichele Grant FILE COPY Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com � w s�xcnc. North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 459 Salem St. MAP: 38 LOT: 55 INSTALLER: Todd Bateson DESIGNER: Merrimack Engineering PLAN DATE: 4/16/13 BOH APPROVAL DATE ON PLAN: 6/5/13 INSPECTIONS TANK INSPECTION: 7/16/13 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: 7/19/13 DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS N/A Contractor reports any changes to design plan ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SEPTIC TANK X Building sewer in continuous grade, on compacted firm base N/A Cleanouts per plan X Bottom of tank hole has 6" stone base X Weep hole plugged X 1500 gallon tank has been installed H-10 loading X Monolithic tank construction ® Watertightness of tank has been achieved by visual testing ® Inlet tee installed, centered under access port 44 ® Outlet tee installed, centered under access port (effluent filter) ® 24" inch cover to within 6" of finish grade installed over one access port ® Neoprene boots around inlet & outlet Comments: 43' from house DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box N/A Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM (General) X Bottom of SAS excavated down to C soil layer, as provided on plan X Size of SAS excavated as per plan X 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 ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: 55'L x 23" W, 57" from the house SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ® Brand and Model of Chamber: Standard Quick 4 Low Profile Infiltrator Chambers ® Number of chambers per row:11 ® Number of rows (trenches): 4 Comments: Total Chambers = 44 FINAL GRADE Loamed Seeded Cover per plan Comments: Ga�, l DOCUMENTS NEEDED Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer [/ As-Built Plan I BM = 100.00 HR = 3.60 HI = 103.60 SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT 11.51 91.94 91.7 Septic Tank IN 11.88 91.37 91.25 Septic Tank OUT 12.12 91.13 91.00 Distribution Box IN 12.46 90.79 90.80 Distribution Box OUT 12.56 90.69 90.63 Lateral 1 TOP 12.60 Lateral 1 INVERT 91.00 90.58 Lateral 2 TOP 12.60 Lateral 2 INVERT 91.00 90.58 Lateral 3 TOP 12.60 Lateral 3 INVERT 91.00 90.58 Lateral 4 TOP 12.60 Lateral 4 INVERT 91.00 90.58 Top of Chamber 90.93 90.97 Bottom of Bed/Chamber 13.34 90.26 90.30 f 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 1.0' ® Private drinking well 75 100' 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) z 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 a y @cY°wmsS �^ North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 459 Salem St. MAP: 38 LOT: 55 INSTALLER: Todd Bateson DESIGNER: Merrimack Engineering PLAN DATE: 4/16/13 BOH APPROVAL DATE ON PLAN: 6/5/13 INSPECTIONS TANK INSPECTION: 7/16/13 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: 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: SEPTIC TANK Building sewer in continuous grade, on Vmpacted firm base eanouts per plan ttom of tank hole has 6" stone base eep hole plugged 00 gallon tank has been installed H- / onolithic to or`sfr�ction ❑ a er ig tness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port s ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank 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 ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base ❑ H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEnA (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan [� 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) I ❑ Elevations of laterals and chambers installed as on f approved plan Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: i w4"� SOIL ABSORPTION SYSTEM Gravel-les C ambers ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE [�Loamed [Ceeded over per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN Jr• A f . 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 75 100' 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Mar 3 Marsh, Inland/Coastal Bank 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 I I .00Rr Wf 29 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT �as�crn>s� PUBLIC HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( constructed;( )repaired; By: 1-y 02 (Print Name) Located at: o- ►�i-7A [�-/( 42 �f � (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan,originally dated -jig '12 and last revised on '" with a design flow of 440 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: -2-i"( - � Engineer Representative(Signature) P�i�� - And-Print Name Final Construction Inspection Date:F) (21J Engineer Representative(Signature) And-Print Name Installer: �~ (Signature) Date: � 2�I� �� A And-Print Name Enginer: [�[� ltyl,C �c / T��°a ar IQ _(Signature) Date:"' V1_A01 t-I10__ kiFI�I�-}i'i And-Print Name 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com [ SUMMARY OF INVERTS BUILDING TIES SEWER ® FDTN. PRE—EXIST. BLDG. CORNER A B C D � THIS PLAN & CERTIFICATION IS NOT SEPTIC TANK IN 91.27 SEPTIC TANK OUT 57.5 54.0 — _ WARRANTY OF THE SUBSURFACE DISPOSAL SEPTIC TANK OUT 91.00 SYSTEM. IT /S A RECORD OF THE LOCATION DIST. BOX 72.5 74.5 — — AND ELEVATION OF THE EXISTING SYSTEM DIST. BOX IN 90.72 COMPONENTS. DIST. BOX OUT 90.59 INV. IN CHAMBER 90.54 "1 HEREBY CERTIFY THE LOCATIONS, ELEVATIONS, TIES, COVER MATERIAL; EXPOSED COMPONENT COVERS ETC., SHOWN ON THIS AS—BUILT SUBSTANTIALLY BOTT. CHAMBER 90.20 AGREE WITH THE APPROVED PLAN AND HAVE D THAT THE BREAK OUT ELEVATIONS, IF APPLICABLE, HAVE BEE OF APPROVED DESIGNS PLANS. 4 O VLA L G SIGNATURE OF DESIGNER 0 No. y 62.12173.37' A�ocF�FGISTERX���`� S�ONAL EN PARCEL Ct o -(10,955 S.F.) to 0) a I WEAL LOT ARRA (1.4 AC.) EGROUND air 'mac I �C¢ W vC J ot �! v � � ip 9600 O a i W SEPTIC TANKAPPROX 37' atr. � VENT Dpjw � + 0—BOX 26 p- I� r LEACH FlELo W/4444 INFILTRATOR CHAMBERS INSPECTION PORT O c> 150.0' SALEIit STRUT ' AS BUILT PLAN OF SUBSURFACE D � ® AL SYSTE LOCATED IN JUL 2 9 2013 NORTH ANDOVER, MASS./459 SALEM STREET OtNN AS PREPARED FOR r� ALTff DEPARTMENT REINHOLD WINTER TM: 38 O_ DATE: 7-25-13 a SCALE: 1"=40' TL: 55 0 20 40 80 MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 Blackburn, Lisa From: Isaac Rowe <irowe@millriverconsulting.com> Sent: Friday, July 19, 2013 3:14 PM To: Blackburn, Lisa; 'Dan Ottenheimer'; 'Pam Lally' Cc: 'Susan Sawyer(ssawyer@townofnorthandover.com)'; irowe@millriverconsulting.com Subject: RE:459 Salem St. Attachments: 459 Salem St- Final inspection form.doc Susan/Lisa, Attached is the final inspection form. Everything looked good. Let me know if you have any questions. Thanks, Isaac M. Rowe,R.S. Project Manager Mill River Consulting 6 Sargent Street 1 • ���'"" Commonwealth of Massachusetts Map-Block-Lot • 038.00055 • Rx BOARD OF HEALTH - --------------------- North ----------------- North Andover CERTIFICATE OF COM�posal ANC' RTIFY,That the Individu ,i System (Repair) �- by o Bateson ----------------- ------- -------------------------------- ------------------------------------------------------------- Installer at No ATE -459--------S------------LEM--SRET ----------------------------------------------------------------------------------------------------------------------------------- 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-2013-078 Dated___June_17,_2013_--___- ----------------------- ----------------------------------------------------------------- Printed On:-Jun-17-2013 BOARD OF HEALTH • � ' "=% ' Commonwealth of Massachusetts Map-Block-Lot 038.00055 • BOARD OF HEALT ----------------------- H ,. . Permit No North Andover BHP-2013-0786 ----------------------- FEE -- -------- FEE $250.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson ---------, --------------------------------------------------- to(Repair)an Individual Sewage Disposal System. I v11 (vapcoy- at No 459 SALEM STREET -- - - ------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2013-078 Dated June 17,2013 ` ---------------------- ---------------------------- Issued On: Jun-17-2013 Al r 'Cf NORiN�� 6522 �'•OL • Town of North Andover HEALTH DEPARTMENT cNustt CHECK#: DATE:10tl.--7 1� LOCATION: H/O NAME: 1 CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ Septic Disposal Works Construction(DWC) $ 950—p ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Vkent Initials White-Applicant Yellow-Health Pink-Treasurer A 6522 T Of 4 ORT11 F -•` .o�. Lp s Town of North Andover sti'•,,,,,.: HEALTH DEPARTMENT ,SSgCHUSt� CHECK#: _ DATE: l�7 LOCATION: S H/O NAME: CONTRACTOR NAME: TyQe of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ 4 ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ 3 Septic Disposal Works Construction(DWC) $ �U ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ l ,j Health gent Initials White-Applicant Yellow-Health Pink-TrFqsurerl, -� pORTq, Application for Septic Disposal-System - i•cRo,yam ti� TODAY'S DATE sConstruction. Permit — TOWN OF ORTH ANDOVER, MA 01845 (jp-CFull Repair omponent ,SSACNUSe4 - Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use [B<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 �/-S9 S%�le r� Address or Lot# City/Town R, CE D 2.- *TYPE OF SEPTIC SYSTEM*: JUN 17 2013 ❑ Pump Gravity(choose one) ***If pump system, attach copy of electrical permit to application*** TOWN OF NORTH ANDOVER ❑ HEALTH DEPARTMENT Conventional System (pipe and stone system) 21'n"filtrator 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) City/Town State Zip Code cl79 CQ V-3 - ca.3 1 Telephone Number 3. Installer Information o� �i.g-f-�S�n/ -��S d� ,�i✓T- .-.�iyc Name Nam Company Address City/Town State /., Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name / Name of Company Address Ally Citylfown P State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 M°�TH Appiication..for Septic Disposal System F p Construction Permit ' TOWN. OF TODAY'S DATE ORTH ANDOVER MA 01845 $.250.00-Full Repair sS^CMUSE $125.00.-Component PAGE 2 OF 2 A. Facility.lnformation 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 PVthis Board of Health. — 13, 13 Name Date Applicatio pproved : (Board of Health Representative) Name Date pplic ion D sapprov d for the following reasons: For Office Use OnIV: I. Fee Attached? Yes Ll No 2. ProlectMariager Obligation Form Attaebed.? Ye No 3.: Pum, LSrstem? Ifso)Attach copv ofElectrrcal Permit`,. No 4. Foundation As Built?(new constructio only): Yes_ No (Same scale as approved plan) A FloorPlans?(new construction only): No Appifcation for pispotal System Construction permft Page 2 of 2 EP'�'IC SYSTEM.INS�ALhEk'pRGJECT NI IAGEMEN' OBLIGATIONS As the North Andover•licensed installex for the construttion for:fihe septic system for.the property at •For plans by (Address of septic system) (Engineer) Relative to tht.application of �-T•2Sv A.J (in'staller's name) Aad dated ngma a e . Dated P —13-13 With revisions dated o n s a e (Last revised date) I understand the following obligations for management of this project: 1. As the installer,.I am.obligated to obtain.alI permits and Board offHealth approved plans:p�'or_to :performing any work on a site: I must have the roved tilans and the permit on site when anv work is 2. As the installer;.I.must-CO'for any and id-inspet tibns: I£hotneowner,contractor,.project manager, or any other,person not associated with ray company schedules-an inspection and the system is not ready,then item three•sh-4 b o.applicable. 3.`• As thg irtsWleir,I atn•xegtiired to.havethe necessary work•eotnpletedprior,to the applicable inspections as below; . ++npr�r-and that r�c estin pection,without comliletioti•of the items in acc. ance. T.• e 'f tli ttt• 0 b levied • s me..and or Bo'tiom'ldf•E.ed�^Generally,this•is the fitst.(1`).:inspeetion UnI githere is wretaining wah, liich shou`ld•be-A66. st: TheldstalTpf:must quest the iiispecti6a but does.hot have to be present-. . b. Find:�ongrn�etiori Itisp —Eng is i ri?us't iisi. their lr�s ection for elevations;'ti`es,etc. r ' nt fnorthandover. om from the e4 ee'r must As-l�ii of OK(or e-mail } �p� .o? o . .be subriiitted-to the.Bo;Lrd of Health,after'•whi&mstailer.calls for.an inspection time. 'Installer must be present for this.inspectiona ith a pump:system, ail'electrical Riofk;tnust be ready and able to causepump.tti-*ork arid•alarm.to fiuiirtion.. C. " in . '—installer must request. . when. grading'— complete: Installer'does not have to be•on4ite.' 4. As•the installer,'I understand that only I-= 6aform the voik(other than iimpk cxeavaiion)and Y am required to complete the•installation of the system identified in the:attached.application for installation:J furtli'er.. understand that work done•by others uijliceiised iris setitic systems iii North Andover tail Co reasQns for denial of the systern andlorrevocatiota or sust�efisiQri of•rnv license•to operate in.the Town.af North Andover cibni cant fines Lo all lysd% also'possilile. .: 5.. ,As the.instxller,I understand that.I tn�ist he-on-,site during tho•perf6imance.of the following constatcdon steps:.. e. Detemdnatiori that.dreproperelevadoa of the ezearatlon has been reached. b. Inspection ofthe`sand and stone-to be used. C. Final fnspecdorr byBoa&ofHealth swffor consultant. d. InstallatiotY.•oftank,D Bom pipes,stone, vent,pump chamber,retarruffg wafand other components. 6. 4stbg in to 1 ;I.WWrsUnd that I am sblWyrhe ponsiblp for the installation of the system as per the �thtrj2ersons sh.alabsolve. me Qf this obligation. Undersignedlicensed Septic.Bmtallex: q. ('Today's Date). L3 �.in" • S�TTL"EDl�c , FILE COPY y • • PoQATED'A� North Andover Health Department o Community Development Division June 11, 2013 Reinhold Winter 459 Salem Street North Andover, MA 01845 Re: Subsurface Sewage Disposal System Plan for 459 Salem Street,Map 38,Lot 55 Dear Mr. Winter: The proposed wastewater system design plan for the above site dated April 10, 2013 with a final letter in response to the review was dated May 28, 2013 has been approved. The design has been approved for use in the construction of a replacement onsite septic system. This plan is generally good for 3-years from the date of approval however, as this is for a repair system,this is reduced to 2- years. The plan received the following local upgrade approvals. 1) Only 1 deep hole in the disposal system 2) Separation from S.A.S. to ESWT from 4 feet to 3 feet 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 is also subject to the following conditions: 1. Please keep the attached DEP Form 9b for your records (attached) 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 septic system designer, septic system installer or other representative to ensure that all other.state and municipal requirements are met. These may include review by the Conservation Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 459 Salem June 11 2013 Commission, Zoning Board, Planning 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. 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. r y, . S . er HS/RS ealth erector Encl. Form 9B cc: Merrimack Engineering File r Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Commonwealth of Massachusetts City/Town of North Andover a a Local Upgrade Approval Form 913 wM 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 Reinhold Winter key to move your Name cursor-do not 459 Salem Street use the return key. Street Address North Andover MA 01845 ill 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: Vladimir Nemchenok ❑ PE x RS Name 66 Park Street Andover MA 10810 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 459 Salem Street t5form9b•rev.7/06 Local Upgrade Approval* Page 1 of 2 Commonwealth of Massachusetts r City/Town of North Andover o Local Upgrade Approval Form 9B �M B. Approval continued pp (continued) ❑ Reduction in separation between the SAS and high groundwater: Separation reduction 1 ft. Percolation rate 4 min./inch Depth to groundwater 3 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 Dept Approving Authority Susan Sawyer June 11, 2013 Print or Type Name and Title i nature Date 459 Salem Street t5form9b•rev.7/06 Local Upgrade Approval* Page 2 of 2 Ofe MORT.��• 6447 • Town of North Andover ` '•�;, o�: ,' HEALTH DEPARTMENT ,SS�CMUSt4 CHECK#:59 O q DATE:Zj1q/)3 LOCATION:45�q `iA ( 2 m H/O NAME: W✓v ,'r CONTRACTOR NAMEA I I I Tuve of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: Septic-Soil Testing $� ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer �r 6447 t NOR7lj Ou�"�,:•:�O i r Town of North Andover HEALTH DEPARTMENT ,SSACHUSt� CHECK#: V DATE:103 LOCATION:4,5q 3A(P [DL_ H/O NAME: CONTRACTOR NAME.B I I 1 h()R S 1 & Type of Permit or License: (Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service:Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: Septic-Soil Testing $ 100 ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer �l .N� TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ° 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER,MASSACHUSETTS 01845 Susan Y.Sawyer,RENS,RS 978.688.9540-Phone Public Health Director 978.688.8476-FAX .. ..,... ; healthde t to ofhorthandi ver.cN ' www.townofnorthandover.cc APPLICATION FOR SOIL TESTS j 13° 20131 �`��� TOWN OF NORTH ANDOVER DATE: '"'T'� MAP&PARCEL: HEALTH I)EPARTMENT LOCATION OF SOIL TESTS: 9� OWNER: Ill jL `A 1 - Contact#:�1�+�'j) G�� -' 777/ r APPLICANT: '-/A K6 Contact#: ADDRESS: ENGINEER: jjL�i4Wd(i 1114H Contact#: -7p 47 S` -3 575S- CERTIFIED 5JCERTIFIED SOIL EVALUATOR: � Intended Use of Land: Residential Subdivision - ingle amily Hom Commercial Is This: Repair Testing:z,--Undeveloped Lot Testing: Upgrade for Addition:-% In the Lake Cochichewick Watershed?' ` Yes No THE FOLLOWING MUST-BE INCLUDED WITH THIS FORM ➢ Proof of land ownership(Tax bill,or letter from owner permitting test) ➢ 8.5"x 11"Plot plan&Location of Testing(please indicate test nit sites on the plan) ➢ Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of3$ 60.00 per lot for repairs or upgrades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass.Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. ➢ Within 45 days of testing,a scaled plan(no smaller than 1"-100')shall be submitted to the Board of Health showing the location of all tests(including aborted tests). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval D Signature of Conservation Agent: Date back to Health Department: (stamp in): P i eORTGA GOR� REINHOL0 6 L YNDA WINTER DEED REF. LOCA TION.• 459 SALEM STREET PLAN REF. CITY. STATE: NORTH ANDOVER MA SCALE.• 1a 40 ' DA TE. 2/12/92 { ✓OB f.• 91/ 921OB66 (OZ.19' 73.-37 N G, e; 101�� � " 0 4oL n+ M Waa�7 r N M V67 > t MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS LAND SURVEYORS PLANNERS 66 PARK STREET-ANDOVER,MA 01810•(978)475-3555,373-5721 FAX(978)475-1448•E-MAIL info@m6,rrimackengineering.com May 28, 2013 Susan Sawyer Director of Public Health 1600 Osgood Street Building 20, Suite 2035 .North Andover,MA 0l 845 RE: 459 Salem Street Dear Ms Sawyer, We are in receipt of your review letter for the above referenced site dated May 21, 2013. With.regard to item#1. of your letter,the reviewer makes note of a wetland located on 466 Salem Street which is directly across the street from the subject site. The proposed soil absorption system is 95 feet from the front property line and Salem Street is a 5,0 foot 14 Right of Way, so it can easily be deduced that the wetland could not be within 145 feet of the proposed system even if the wetland was located tip to the front property line of 466 Sa lem Street. Since the State setback to a wetland is 50 feet and the Local setback is 100 feet;it is clear that the design is in compliance with both State and Local regulations as it relates to wetland setbacks. With regard to item#2,there are no records nor does the owner have a clear idea of where the existing soil,absorption system is, it would be irresponsible to guess at the location of the existing soil absorption system. Note 2 on the plan clearly specifies to the contractor what action should be taken if the existing soil absorption system is encountered during construction. Lastly, with regard to item#3 of your letter,the design specifies a vertical offset to the seasonal water table of 3.6 feet,however the plan and Form 9A request an LUA of 1.0 feet allowing the soil absorption system to be as close as 3.0 feet to the seasonal water table. Since certain existing conditions and elevations are estimated, it is common for final constructed conditions to vary a tenth or two from.what was proposed. If that were to happen,and it is likely it may, then granting of an LUA to exactly 3.6 feet could result in anon compliance as the as-built may result in a soil absorption system 3.5 or 3.4 above the seasonal water table thus deeming the granting of the LUA meaningless and the need to go back to the Board for a greater LUA. We therefore request an LUA to the full 1.0 foot allowed, with the intention of constructing the Soil absorption system to thehighest offset possible. page 2, Susan Sawyer, May 28,2013 We feel this letter clearly addresses your concerns and the plans as originally submitted, meet the requirements of Title 5 and the NA Board of Health Regulations, and we respectfully request that the plan be approved for construction as the owners are anxious to proceed with construction and upgrade of their failed septic system. Very truly yours, 0 William Dufresne Merrimack Engineering Services MERRIMACK ENGINEERING SERVICES,INC. 66 PARK STREET-ANDOVER,MASSACHUSETTS 01810 '3 64 ; 2 Ot NORTp,M s ,• Town of North Andover ] HEALTH DEPARTMENT ,SSAC14US�� - CHECK#: DATE: LOCATION:q C�q `�T - H/O NAME CONTRACTOR NAME: r mi 6 f Fn-o, Tyne of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ r ,-- . Q1 Septie Design Approval $ _ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer • SS IL KA North Andover Health Department Community Development Division May 21, 2013 Vladimir Nemchenok Merrimack Engineering Services 66 Park Street Andover, MA 0 18 10 Re: Subsurface Sewage Disposal System Plan for 459 Salem Street, Map 38, Lot 55 Dear Mr. Nemchenok: The proposed wastewater system design plan for the above site dated April 10, 2013 and received on April 29, 2013 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 provide a statement or clearly show on the site plan view that there are no wetlands within 150' of the proposed system(NA 3.2). Wetlands were determined to be present on#466 Salem Street. 2. Please indicate the location of the existing leaching facility. 3. Please indicate whether the Local Upgrade Approval request to reduce the offset to the groundwater table is to 3' or 3.6'. The profile view indicates 3.6' but all other notes refer to 3'. North Andover Health Department, 1600 Osgood Street, Suite 2035, Page 1 of 2 North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 t 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. Since re. , Z'sanY. -a wyer,, HS/RS Public Health Difector cc: Reinhold Winter File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 - - - - - - - V3� 13 Ito, , TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES ` HEALTH DEPARTMENT ``w.E,;Ap': 1600 OSGOOD STREET; SUITE 2035 NORTH ANDOVER,MASSACHUSETTS 01845 978.688.9540—Phone Susan Y.Sawyer,REHSIRS 978.688.8476—FAX Public Health Director E-MAIL:healthdWia�townofnorthandover.com WEBSITE:http://www.townofnorthandover.com SEPTIC PLAN SUBMITTAL FORM Date of Submission: `=f d 1-7�"_ 1� Site Location: 64"A' Z � Engineer: I�I EIzN.I►�IaCGI�% t'�� l� �,1 LL I�Frce��� New Plans? Yes $225/Plan Check# (includes 1st submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes ✓ No Telephone#: X75--3555 Fax E-mail: I.1 C&y r. Lg2r Homeowner Name: OFFICE USE ONLY When the submission is complete(including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt ➢ Copy File;Forward to Consultant RECEIVED ➢ Enter on Log Sheet and Database APR 29 2013 TOWN OF NORTH ANDOVER 'HEALTH DEPARTMENT 6 S4 Commonwealth of Massachusetts RECEIVEwft City/Town of North Andover r Form 11 - Soil Suitability Assessment for On-Site Sewage DisposQM A. Facility Information Reinhold Winter Owner Name 459 Salem Street 38/25 Street Address Map/Lot# North Andover MA 01845 City State Zip Code B. Site Information 1. (Check one) ❑ New Construction ® Upgrade ❑ Repair 2. Published Soil Survey Available? ® Yes ❑ No If yes: 2008 1:15,840 420/421 Year Published Publication Scale Soil Map Unit Canton Soil Name Soil Limitations 3. Surficial Geological Report Available? ❑ Yes ® No If yes: Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ❑ No Within the 500-year flood boundary? ❑ Yes ❑ No Within a velocity zone? ❑ Yes ❑ No 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name 6. Current Water Resource Conditions (USGS): 03/2013 Range: ❑ Above Normal ® Normal ❑ Below Normal Month/Year 7. Other references reviewed: Soil Evaluation Forms.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8 Commonwealth of Massachusetts Cityrrown of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Deep Observation Hole Number: T-1 4-3-13 9 am sunny 40's Date Time Weather 1. Location Ground Elevation at Surface of Hole. 94.0 Location (identify on plan): See Plan 2. Land Use Residential none 8-15 (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Lawn Ground Moraine on slope Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body >100 Drainage Way >100 possible Wet Area >100 feet feet feet Property Line 35 Drinking Water Well >100 Other feet feet feet 4. Parent Material: Till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ® Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 72 88.0 inches elevation Soil Evaluation Forms.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 2 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal 7( C. On-Site Review (continued) Deep Observation Hole Number: T-1 Redoximorphic Features #Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other Depth Color Percent Gravel Cobbles& (Moist) Stones 0-45 Fill 45-51 A 10YR2/2 FSL Wk Gran Friable 51-64 B 10YR4/6 SL Massive Fraible 64-110 C 2.5Y5/4 72 5Y6/3 >5 SL 10-15 Massive Friable Additional Notes: Soil Evaluation Forms.doc•rev. 1/10 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts .1 upCity/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: T-2 4-3-13 9 am sunny 40's Date Time Weather 1. Location Ground Elevation at Surface of Hole: 92.2 Location (identify on plan): see plan 2. Land Use Residential none 8-15 (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Lawn Ground Moraine on slope Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body feet>100 Drainage Way feet>100 Possible Wet Area >100 feet Property Line 50 Drinkin Water Well >100 Other p y feet g feet feet 4. Parent Material: Till Unsuitable Materials Present: ® Yes ❑ No If Yes: ❑ Disturbed Soil ® Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ❑ Yes ® No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 66 86.7 p g inches elevation Soil Evaluation Forms.doc-rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal -Page 4 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: T-2 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA) Cobbles& Structure Consiste)ce Other Depth Color Percent Gravel Stones 0-40 Fill 40-45 A 10YR2/2 FSL Wk Gran Friable 45-56 B 10YR4/6 SL Massive Friable 56-106 C 2.5Y5/4 66 5Y6/3 >5 SL 10-15 Massive Friable Additional Notes: Soil Evaluation Forms.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: ❑ Depth observed standing water in observation hole A. B. inches inches ❑ Depth weeping from side of observation hole A. B. inches inches ® Depth to soil redoximorphic features (mottles) A. 72 B. 66 inches inches ❑ Groundwater adjustment(USGS methodology) A. B. inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed? Upper boundary: 51 /56 Lower boundary: 110/ 106 inches inches Soil Evaluation Forms.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal i F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. 4-3-13 Signature of Soil Evaluator Date William Dufresne/#640 5-9-96 Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam Isaac Rowe Mill River Consulting North Andover Name of Board of Health Witness Board of Health Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. Soil Evaluation Forms.doc-rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8 Commonwealth of Massachusetts City/Town of North Andover w Percolation Test Form 12 �M Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. 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 the local Board of Health to determine the form they use. Important: A. Site Information When filling out forms on the computer, use Reinhold Winter only the tab key Owner Name to move your 459 Salem Street cursor-do not Street Address or Lot# use the return key. North Andover MA 01845 Cityrrown. State Zip Code (978)683-6232 Contact Person(if different from Owner) Telephone Number B. Test Results 4-3-13 10:35 am Date Time Date Time Observation Hole# P-1 Depth of Perc 78" Start Pre-Soak 10:35 End Pre-Soak 10:50 Time at 12" 10:50 Time at 9" 11:20 Time at 6" 12:01 Time(9"-6") 41 Rate(Min./Inch) 14 Test Passed: ® Test Passed: ❑ Test Failed: ❑_ Test Failed: ❑. William Dufresne Test Performed By: Isaac Rowe Witnessed By: Comments:. t5form12.doc-06/03 Perc Test-Page 1 of 1 < Commonwealth of Massachusetts City/Town of North Andover Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. 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 'VE® Important: when filling out 1. Facility Name and Address: APR 2 9 2013 forms on the computer,use Reinhold Winter Residence ITOWN only the tab key Name HEALTH DEPARTMEtVT to move your 459 Salem Street cursor-do not Street Address use the return key. North Andover MA 01845 Citylfown State Zip Code qkA 2. Owner Name and Address(if different from above): (( � SAME � Name Street Address Cityrrown State (978)683-6232 Zip Code Telephone Number 3. Type of Facility(check all that apply): ® Residential ❑ Institutional El Commercial ❑ School 4. Describe Facility: 4 Bedroom 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): Unknown t5form9a.doc•rev.7/06 Application for Local Upgrade Approval*Page 1 of 4 i Commonwealth of Massachusetts City/Town of North Andover a Form 9A - Application for Local Upgrade Approval �,M 5 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: Unknown 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 li 2. Describe the proposed upgrade to the system: Total 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. 14 Percolation rate min./inch. Depth to groundwater 3.0 ft. t5form9a.doc•rev.7/06 Application for Local Upgrade Approval*Page 2 of 4 Commonwealth of Massachusetts City/Town of North Andover a o 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 4-3-13 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 a pump causing unreasonable financial hardship 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 a 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: 4. Connection to a public sewer is not feasible: Oa) I&VAILA IM 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 RComplete plans and specifications Site evaluation forms- F-1 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." 00, Facility Owner's Signature Date �- 8ETA0166D 4, cv L /Z Print Name hi i DuFb.�l-itJ /�lct%E�61a �Ll N/�►/ i Name of Preparer I Date GG fkrnacIn- Preparer's address Cityrrown V / t2l 10 ('1-79) gIC7---�* G State/ZIP Code Telephone t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4 Blackburn, Lisa From: Isaac Rowe [irowe@millriverconsulting.com] Sent: Wednesday, April 03, 2013 2:30 PM To: Blackburn, Lisa; 'Susan Sawyer(ssawyer@townofnorthandover.com)' Cc: 'Dan Ottenheimer'; 'Pam Lally'; 'Isaac Rowe' Subject: RE: 459 Salem St. Attachments: 459 Salme St-Soil testing results 4-3-13.pdf Susan/Lisa, Attached are the results of today's soil testing at the above referenced property. Please let me know if you have any questions. Thanks, Isaac M. Rowe, R.S. Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930-2719 Phone: (978) 282-0014 Fax: (978) 282-1318 irowe(@millriverconsulting.com www.millriverconsulting.com -----Original Message----- From: Blackburn, Lisa [mailto:LBlackburn@townofnorthandover.com] Sent: Thursday, March 21, 2013 3:49 PM To: Dan Ottenheimer; Isaac Rowe; Pam Lally Subject: 459 Salem St. Good Afternoon, Here is another soil tests that needs to be scheduled. Lisa Blackburn Health Department Town of North Andover 1600 Osgood Street Suite 2035 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688-8476 Email lblackburn(@townofnorthandover.com Web www.TownofNorthAndover.com -----Original Message----- From: noreply(@townofnorthandover.com [mailto:noreply townofnorthandover.com] Sent: Thursday, March 21, 2013 3:20 PM i I b { P r g i 34 00, IVED u, 11 APR G 3 2013 TOW!f OF NORTH ANDOVER HE LTH DEPARTMF�p(,'� d� # ! F 40 4A + S F / 3 ALI Jo- I �1 : r; _. .. Blackburn, Lisa From: Isaac Rowe [irowe@millriverconsulting.com] Sent: Monday, March 25, 2013 4:25 PM To: Blackburn, Lisa; 'Dan Ottenheimer' Cc: 'Isaac Rowe' Subject: RE: 459 Salem St. Lisa, This soil test is scheduled for 4/2 at 930am. Thanks, Isaac M. Rowe, R.S. Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930-2719 Phone: (978) 282-0014 Fax: (978) 282-1318 irowe(@millriverconsulting.com www.millriverconsulting.com -----Original Message----- From: Blackburn, Lisa [mailto:LBlackburn(@townofnorthandover.com] Sent: Thursday, March 21, 2013 3:49 PM To: Dan Ottenheimer; Isaac Rowe; Pam Lally Subject: 459 Salem St. Good Afternoon, Here is another soil tests that needs to be scheduled. Lisa Blackburn Health Department Town of North Andover 1600 Osgood Street Suite 2035 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688-8476 Email lblackburn(@townofnorthandover.com Web www.TownofNorthAndover.com -----Original Message----- From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Thursday, March 21, 2013 3:20 PM To: Blackburn, Lisa Subject: Blackburn, Lisa From: Blackburn, Lisa Sent: Thursday, March 21, 2013 3:49 PM To: Dan Ottenheimer; Isaac Rowe; Pam Lally Subject: 459 Salem St. Attachments: 20130321151957102.pdf Good Afternoon, Here is another soil tests that needs to be scheduled. Lisa Blackburn Health Department Town of North Andover 1600 Osgood Street Suite 2035 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688-8476 Email lblackburn(@townofnorthandover.com Web www.TownofNorthAndover.com -----Original Message----- From: noreply(@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Thursday, March 21, 2013 3:20 PM To: Blackburn, Lisa Subject: This E-mail was sent from "RNPOA428C" (Aficio MP C5000) . Scan Date: 03.21.2013 15:19:56 (-0400) Queries to: noreply@townofnorthandover.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. I Please consider the environment before printing this email. I 1 I TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD/:2 u � II . A3_ MAR - 4 OWNER & ADDRESS SYSTEM LOCATIO-N (example: left from of ho ej)� �a� "oo,od Gc�� � U:\•I'E OF PUMPING; lc� QUANTITY PUMPED0ALL01v) l'OOL: NO 1,'_'Y E S SEPTIC TANK: NO YES '.ATURE OF SERVICE: ROUTINE l/ EM ERCENC.Y U(3.�FRVAT10NS: GOOD CONDITION. FULL TO COVER HFAVY CREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSI-VE SOLIDS FLOODED SOLIDS CARRYOVER .O�HER (EXPLAIN) >v,.• 'LM PUMPED BY: CU FNTS: U�'"I'I:N'I'S' 'I'1ZANSFCIZRED TO: ' Commonweaith of-Massachusetts ECEIVED City/Town of NORTH ANDOVER MASS CUSETTS VP stem Puming Record SEP - 6 2006 S.,Form 4 • TOWN Of NORTH ANDOVER HEALTH DEPARTIMENT DEP has provided this form for use by local Boards of Health. �heystm-PuTffping Record rnu: be submitted to the local Board of Health or other approving authority. A. Facility Information - Important: When ruing out 1. System Location: forms on the . computer, use only the tab key Address -• - to move your cursor•do not Clty/Town use the return v State Zip Code key. 2. System Owner Name Address(If different from location) - - Clty/Town Slat�70 Zip Code Telephone Number - - B. Pumping Record -- 3� aCD ;. Date of Pumping Date — -- 2• quantity Pumped: - — Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): - ___-- --__— ✓��I�11�. _Q1 ?.-- _ 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No r Condition of System: 6. Sy em Pumped By: ame Vehicle License Number c5t a jm�. Company 7. Location where contents were disposed: a Si ature of Hau .._.._ -_ Date http://www,masg;gov/dep/water/ provals/t5forms,htm#inspect t5form4.doa 06/03 System Pumping Record- Page t of rUHIVi U LOT REASE FORM' a0Ar0t • INSTRUCTIONS: This form is used to verify that all necessary a rova g Boards and Departments having jurisdiction have been obtained. This does not s from the applicant and/or landowner from compliance with any applicable or re u. not relieve q Irements: *****************************APPLICANT FILLS OUT THIS SECTION i APPLICANT LCA .:.) I PHONE =S7339— LOCATION: Assessor's Map Number U i; PARCEL- 0 -6055� SUBDIVISION LOT(S) STREET S i ST. NUM BER � *********** ***********************OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: i CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS s1 TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED 1S DATE:.REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm ���' �� 6r" COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 9W_LIM DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address Owner's Name: Owner's Address: Date of Inspection: 922�//9/U, Name of Inspector: (please print)J/6,h/7�. �/f//i�YE Z� Zq Company Name:., / // Mailing Address• . Telephone Number: 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: A/_ Passes tt Corfditioh�ally Passes N ds Further Evaluation by the Local Approving Authority F 51s Inspector's Signature: ( Date: 1 6 3 The system inspector shall sA mit a copy of this inspection repor7th proving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector/and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 g Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A //CERTIFICATION(continued) Property Address: /✓�/ �ABX/ Owner:/// Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 7A. Syst m 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 Pl;�s"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 follow_ ing statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approa1 Df.Board of Health)::,, -� - broken pipes)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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION(continued) Property Address: ;�, c 5 Owner• // Y Date of Inspection: i 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 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 env.'irdnment: 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 t 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 `-"`faiTure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 p -� Page 4 of 11 OFFICIAL INSPECTION FORINT—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �. �`Y� /cam c Owner: 9 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No D,ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Statjc liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or_ esspool v iquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. 7ZAny 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. _ y portion of a cesspool or privy is within 50 feet of a private water supply well. 35�!y 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.] _I(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,cons tiered aJarge.system the system must serve a facilitywith a design flow of 10,000 gpd to 15,000 gpa... You must indicate either"yes"or"no"to.4ach 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. t 4 ® -oA Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Y�C�Y/ I- V Owner:/ %7�' Date of Inspection: aL 9 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health > _ Were any of the system components pumped.out in the previous tw{o 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: Yes,rrto yExisting 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)[3 10 CMR 15.302(3)(b)] 5 " Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: / �(5r//6??,61, Owner: / de ; Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CNJU 5.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 111) Does residence have a garbage grinder(yes or no):V_6. P'e G O Yom-'-N o –r(5 R-Q MO O-k Is laundry on a separate sewage system(yes or no).V40[if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no)NQ , Water meter readings;if a+ailable(last 2 years"usage(gpd)): x 0 ' Sump pump(yes or no).6 Last date of occupancy:0U _ t COMMERCIALANDUSTRIAL 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: Lea V < Was system pumped as part of thd inspection(yes or no): Li _?5 yes,volume pumped/006 gallons--How was-qu gatilymped determined? Reason for pumping: /iU S' 19-e C T' A A)i L TYPE,0OF°SYST,EM ` ALASeptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —ivy _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): Approx ,age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 v w a Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: r BUILDING SEWER(locate on site plan) Depth below grade: (t d Materials of construction: te<ast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: V'"(locate on site plan) Depth below grade: 6 .9, -r, 6- W/-t-J, Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of ludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: „ Distance from bottom of scum to bottom oLoutlet tee or bafflel How were dimensions determined: a- Pe y/-<- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as re ate outlet invert,evidence of leak ge,Ste.): GREASE TRAP:_(locate on site plan) Deptfi'beow grade: a it 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,�� SYSTEM INFORMATION(continued) Property Address: , 61 7 Owner: / Date of Inspection: 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/da},, 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of le a into or out of bo tc.): / IVO /7'L 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.): l 8 r .... Page 9 of 11 " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C J/ �SYSTEM INFORMATION(continued) Property Address: ,r Owner: Date of Inspection: f/y/ k / SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number•; leaching chambers,number: leaching galleries,number: aching trenches,number,length: / S Cy 1/ leaching fields,number,dimensions: x�U f'Q G,It ,�e� 0 overflow cesspool,number: innovative/alternative system Type/name of technology: Comilients(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Jv I�1 e6/j- o O L CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): r , ,:•- r; . _ 1. .m_, ._ g i PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: t3y' Owner: Date of Inspection: 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. 1 ilk a G -.._ s r- Page 11 of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �S5OJ t� /I,yT, Owner: Date of Inspection: o� / f SITE EXAM Slope Surface water Check cellar Shallow wells `-"— Estimated depth to ground water feet Please indicate(eheck)`all nie'thods,used to determine the high ground water"elevatiowt v. 1, t/Obtained from system design plans on record-If checked,date of design plan reviewed:_'5_/ 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: n/1 n G( rh rd m -e S N C Giy 1J bj d 11 No MEMO 1 16 , MENp D � e� Od g - ,r TOWN-;OFNOI,tTH ANDOVER SYSTEM PUMPING RECORD ,{ /„�,•la'A`Fy°�py'+' s' I}'�k" �.'iX tt7'� tiv b� '' 1 �, F 1, � , f ..%7 tl ��^^"" � �.�n, 11 ff Y. ss• , se�, \ 1�,.? lt Y e pJ401i}� I+IjF:��TMf t i �1{ �k�Y�fS�' �,tj rr��f11{1�.�15'y�i�{•,f i , s. � .. .. - .. t y X11,,tI S�tSTEM OWNER ADDRESS SYSTEM LOCATION (example: left front of house) �t II. + r 1 1 "•3 �'t�'�'�� ;�p '$�# �h a�riN,'i�iV}I'kl,°�"`'j'd�^,aY�Y4� •��..,"t" :.:�,�lt L r 4.��'�6,5�.."'t`'t;r r�^ , � 'f ' ...... .. , .. _ r QUANTITY PUMPEDlb GALLONS I., �; p t Vf�s����/yl us, 'SEPTIC TANK: NO YES ----�. _ i` �NtI,TURE O011 F SERVICE:„ ROUTINE".' EMERGENCY �r+11k •ATiO. I! f .. { GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ,t I ROOTS K LEA RUNBACK <I EXCESSIVE SOLIDS CHFIELD FLOODED SOLIDS CARRYOVER,_,•,� OTHER(EXPLAIN) �•�j ,��?y�} 4kQS��YY1`�L°��rtj'��;i(�}p+n�,,ii�i( r} .'.'R' r f a i( (r %�,�u�i�r'','�(;r�•rhi�? �y'�1?"`r'Fs,�Fl� R �'a•2FP,4) .�.�w7�I: �.. ( .- .,�t,- / .. � :• � . }„t}-''d';.F Jit :f:+�y }}J' .. moi'• !` Tt f'S 4 i ' }...,,�'v v 1 1 A JUR - 6 20 , ��i ;��,E ,�U��,`` "ate,- ,,`�R r • C T1T FE T tt,�,l• ,� � , I,t,�t 122/ // 4 5 A I sf i1IC'6> °'A4 o �7IQ�{'ly ;y t ' f 1 f his Ikr ,I U' y c f 7 trt Al. x f 4c /�. of TOWN OF NORTH AN'DOVEk V l'k SYSTEM PUMP]Np UCOKL S STEM OWAIER ADDRESS sYSTE L � N sQ�e IVO QN61eVeZ MQ, DATE OF PUMPINQ; !O QUANTITY PUMPED; _- ._ ... ..1.�. �roQ.._... ... V0SPOOL: NO Y. ) __......... L'S / Sopcic 1'LnkNU ,��� ES NA ruKE ON SBRVICe: vu'rlN ,V r✓M�RUENC� MAY0 6 2005 TOWN yr i! r l"AiNDOVER OUSURVA nom: HEALTH DEPARTMENT OOOD C'ON'DITION PULL. 'T`U CovER r, HBAVY oltws . -- BAJ'P1,SS IN PLACE. AOM ".... . OXC698YVE SOLID FLOODED D RUNB�GK . -10LrOCARRY0YER OTKER EXPLAIN L, .c�Q....S.Sa r'vice� All)t �'UMMkNTS. _ 1-t 60I,(s 1,%ll newLeve .. �-x VN I E'N I'S rw�rr�r'frRRfiu ru 1�yJ�1 1 T DOVER � i,rV �•� ' ':� � W � z � r •'�MASS CH ��T'1 : '•� . ( � u•t'I'1�. , 1 � . .AUG :f'. r m '20D7 Al OT '' ��`J•'�.IJ'+A r�1/ ,'?)` i Sit )i+ 2. , ,i``+ir ..�,�.li�,,�(��Irtit1i�„r,tr• .. ;!.;�,1`•�1 J.7..!t'F1W r1�'!,.l �••t J^; +;.,+;,W{rli'�'J'•iY?.Sf{r;, � '. •�:(i;L/ VY,,,�`r r'1"G'�l,�y�r�i YYJj�� � +"'�'�lii �I.:�' ,}• ' 't 'rr K("Y.��, K' 1.,�''+�,w ,Lr."fy�li +'1':;v'w,�if, r?' 1�' �;"•'. '. «DEP,,h�s prov(ded�hli 0 TOWN OF NORTH R,NDOVER t rm for uae by local Boards of Health f�' 8'Tat�tii Furri � R cord must be'oubml4ed to tho.loca1;Board of Health or other ra.;,+.',< �s< (I(:v�tgb"^FiY1iC;lY,,.►}; '',1:, approving, authority., 'AFacility ,InfQrr>�ation . .,f�rW�n•fg•out •',1,.::, System.Locatoh ion;: Address to move your':;.:. . ` .cursor.•doi�(tiQt :, .•, •: .: ! fUR1'.N''.. pyyn ,Clty/T •;•,,.;I ;;,;�•.�'...,, ,,: .. StatO Zip Coda J'Y\:;. I'ia.W�.���.�I'\J,:lj?.":. ;1•;.S�StB •v" ,J ,'�.�.,y!,,j• :Fy � i• r,Yp.•{'•..r(l , .+ �la,r ai; '' t�Y ; .:4•. c�1 d' ., .7,a.«,.;:x,'s.'s;i t'' \,•7a.l.r Il•a• • � ,v-..,:,, rri\ i l>r�;r.�'\:iill:;t•�j�'�T�Yl't�11LJ.�.•.i•• i tly'.'I,j...!'� .. r'S. „1:a" �'r'`y• 'o•.;ts:V.:yr�1�••n Name ':1fi •")f• .,,, .'IJ,\:•+rr;b;,,e„Ijil.,Yw?•};J:�+' '/: ;.i• . .w' a�.;: ���:Address(If d�fennt rom bcsilon) �•\7. !•�, �'� ry .,'.CttylTovim;:°``..• :.Lil;b �• tti• . StatO ZIP Code i I, •.� t' ''' Telephone Number ;,��: ..'. ;is.'/. •li,.:V{'.,•!'�`�.t'.'[r'';', :lV+l•d^1; .\J,j,,;..1,'i „ .. ,.,N-' '�u, y Idtayy, 4i k'' 1 li¢, 1[vit11 1 ;!: N'if Y {ir••. 1(bli.li'!'�.J Yi, �` �.Il,>. • :,. • :w� N.” •f,:. ',�i.:b�tite�'.��;G•';,'.'6t:4,iXt,�.j>tyL';L Ctif; +Y'j..\,,:' ,•.5� ;a :of Pump },i.,:. , \.'.'. 2. Quin Det$ InSi :J, De tlty Pumped; Gallons Typa of ayatem ' ❑ Cesspool(s) teptic Tank ❑ Tight Tank C�(Other(describe ,1,:yi%atr':;,:;;,r!;r.;!',,:I';r;'•'ii+14, .;r,'.' K.•I .. :•r; :r::�<f`�� '�+'.rA,.,u n 1�,Vr,...Y;I,',I P!\,/ , d . Efflu' t Tee Flite{.present?:,❑ Yes [�'�' If yes was it cleaned? Yes i I i No • -:��:'. 1\ ( ,r `•V ^j,+i1y\['��tR 1�il�r{t('Q�li}'4 �t .. .. ,•a.'.r.,l.,r+((,.Y^;iC.;M'ir'V.!.S1VOi1 i1�,TQII'QI�Vyl�,t1,1,1�\•�f�,y +1:. • "'. .! yK y., "Y r7irti+1}�1 7jh+lri` 1•,•w�i Y,1 HJf % f I +,i v / `n �/��� •. .., ,:', <Y7�� .�,•t, r'ft��rh•�M1{{{1,frl,5ri+ry,7'�.9J,iy� ily�y 1 7 1 ilia• ;'. 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' ,;'.'., •�.�.�:/:'..Sir 1 :j,.�,:I:%I.(/•. r. v .�,'.I;,, w;( r, i' },�� ��,., • ':,• �%?':� 4�I'}'flim.,`,���'JJrri�d�;:;;t',,tl,`,w'1•, I�r,'4t�sr. �;lY ,' ',1 _ ' 9 r;tSlpnalur�ofHauleftp/'t;tr+ Y•;.:...i: Dete htipJ/wi ',mass,gov/dap!wales/appco.vaJs/t6forms,htm#Inspect r c5torrM.doa:OdrQJ ' ' �' Syclem Pump1119 Record page 1 . { Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping Record r Form 4 DEP has provided this form for use by local Boards of Health The'Sy§tem umpLg R ord must be submitted to the local Board of Health or other approving TOWClF a AND6VEt3 A. Facility Information 1 DE- Important: When filling out 1. System Location: forms the /,.,� computer,use �'( (/ I only the tab key Address ©� to move your jUCk cursor-do not use the return Ci /Town State Zip Code` key.. 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record )�l 1. Date of Pumping 2. QuantityPumped: ` p g 4/A! C DaGallons 3. :Type of system: ❑ Cesspool(s) Veptic Tank ❑ Tight Tank Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes`was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sy tem Pumpe By: e e Vehicle License Number IC tC P . Company 7. Location ere contents were disposed: a X101. gghftb of Haul Date http:/twww.rhass.gov/deptwater/approvalstt5forms.htm#inspect t5fonn4.doc 06/03 System Pumping Record•Page 1 of 1 i i i - I Commonwealth of Massachusetts W City/Town of No. Andover System Pumping Record Form 4 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. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use 459 Salem St only the tab key Address to move your cursor-do not No. Andover Ma 01845 use the return City/Town State Zip Code key. 2. System Owner: RECE ED r� Winter Name AUG 701 Address(if different from location) I vvyN OF NORTH AN HEALTH DEPq TMENT R City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping ZZ • l L 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) D-Se!rp-tic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: C�� D 0/ 6. stem Pum elyb,, Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: ewart' treatment Plant, 20 So. Mill Bradford, Ma 01835 Urof Hauer Date�? . ( ' Sign to o ving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED W City/Town of North Andover W° System Pumping Record OCT "I s 2012 Form 4 M 3 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms My UC UMU, UU L Ll M1 information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not North Andover Ma use the return City/Town State Zip Code key. 2. System Owner: Name mhan Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping �3e -a 2. Quantity Pumped: Inc Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature f Hauler Date n re of Receivi aci i Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1