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North Andover Board of Assessors Public Access .. Page 1 of 1
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Record Card
Parcel ID:210/107.D-0049-0000.0 Community:North Andover
SKETCH PHOTO
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1-
Summary 11 101
F
Residence
Detached Structure
Condo
Commercial
Comparable Sales ass BOSTON STREET
F
E
r
I
Location: 469 BOSTON STREET
I
Owner Name: HARTFORD,GLEN J
ANNIE S HARTFORD
Owner Address: 469 BOSTON STREET
City:NORTH ANDOVER State: MA ZIP: 01845
Neighborhood:6-6 Land Area: 1.01 acres
Use Code: 101 -SNGL-FAM-RES Total Finished Area: 1236 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 411,600 391,600
Building Value: 180,700 181,600
Land Value: 230,900 210,000
Market Land Value: 230,900
Chapter Land Value:
LATESTSALE
Sale Price: 178,000 Sale Date: 11/13/1995
Arms Length Sale Code: Y-YES-VALID Grantor: GODIN,ARKADY
Cert Doc: Book:04381 Page: 0020
I
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=992060 7/17/2007
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is North Andover MA 01845 1/26/2016
required for
every page. City/rown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form. 49
Important: A. General Information U �iV�
When filling out
forms on the
computer,use 1. Inspector: F Eta 0 1 2016
only the tab key
to move your Neil J. Bateson TOWN OF NORTH A
cursor-do not Name of Inspector HEALTH DEPAR i MEW
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
man City/Town State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
F --
1/26/2016
Ins a rs ignatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
rh Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Yes
9 ( Y 9 (gPd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
I
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Ufog Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Pumped 2013, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined?
Measured tank.
Reason for pumping:
Inspect tank&tees
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
9 years ago, 9/27/2007, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4"Cast iron out through floor. 4" PVC to septic tank.
Septic Tank(locate on site plan):
Depth below grade: 3
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'x 5'x 4'
Sludge depth:
3"
t5ins-3113
Title 5 Official inspection Form:Subsurface Sewage Disposal System•Pape 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? Tape Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Depth of liquid above outlet invert, filter clogged, clean same level back
to normal. No evidence of leakage. Pumped septic tank. Inlet&outlet covers has risers to grade
Grease Trap(locate on site plan):
Depth below grade: feet
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: Date
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.�" 469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
,
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�r 469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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 level &distribution equal. No evidence of carryover. No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ® Yes ❑ No"
Alarms in working order: ® Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump tank ok. Riser cover to grade over pump&floats. Pump ok. Floats ok.Alarm has both
audible&visual.
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M r 469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 24
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface. Twenty four infiltrators, two rows of
twelve infiltrators per row.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 14 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owners Name
information is
required for North Andover MA 01845 1/26/2016
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
ID
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Yr� 469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owner's Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 7/31/2007
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test pit data for design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�r 469 Boston Street
Property Address
Chris&Ashley Sandborn
Owner Owners Name
information is
required for North Andover MA 01845 1/26/2016
every page. Cityfrown State Zip Code Date of Inspection
�. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Summary Record Card generated on 1/25/2016 10:10:51 AM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-107.D-0049-0000.0
Parcel Id 18586
469 BOSTON STREET
CHRISTOPHER SANBORN
ASHLEY BERUBE
469 BOSTON STREET
NORTH ANDOVER, MA 01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.01 Acres
FY 2016
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
CHRISTOPHER SANBORN Owner
ASHLEY BERUBE
469 BOSTON STREET
NORTH ANDOVER, MA 01845
HARTFORD,GLEN Previous Customer Inactive 10/10/2007
469 BOSTON STREET
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 13782.0-469 BOSTON STREET Last Billing Date 11/13/2015
1090459 01 Cycle 01 Active
UB Services Maint.
Account No. 1090459
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 458.95 /1
UB Meter Maintenance
Account No. 1090459
Serial No Status Location Brand Type Size YTD Cons
32772688 a Active 00 b Badger w Water 0.63 0.63 846
Date Reading Code Consumption Posted Date Variance
10/22/2015 1108 a Actual 89 11/20/2015 -1%
7/24/2015 1019 a Actual 88 8/14/2015 521%
4/27/2015 931 . a Actual 14 5/19/2015 5%
1/30/2015 917 aActual 15 2/20/2015 -73%
10/24/2014 902 a Actual 52 11/14/2014 1%
7/25/2014 850 a Actual 52 8/13/2014 392%
4/24/2014 798 a Actual 10 5/15/2014 -21%
1/27/2014 788 aActual 14 2/14/2014 -85%
10/23/2013 774 aActual 89 11/18/2013 85%
7/23/2013 685 a Actual 47 8/15/2013 323%
4/24/2013 638 a Actual 11 5/20/2013 6%
1/25/2013 627 aActual 11 2/13/2013 -82%
10/23/201.2 616 aActual 59 11/9/2012 -23%
7/23/2012 557 a Actual 76 8/14/2012 660%
4/23/2012 481 a Actual 10 5/9/2012 25%
1/23/2012 471 aActual 8 2/13/2012 -25%
10/24/2011 463 a Actual 11 11/14/2011 -24%
7/22/2011 452 a Actual 14 8/15/2011 34%
4/22/2011 438 a Actual 10 5/16/2011 0%
1/25/2011 428 aActual 11 2/11/2011 -13%
10/21/2010 417 a Actual 12 11/12/2010 -48%
7/22/2010 405 a Actual 23 8/16/2010 130%
4/22/2010 382 a Actual 10 5/12/2010 -9%
1/21/2010 372 aActual 11 2/12/2010 -22%
Commonwealth of Massachusetts
C4/Town of .
System Pumping.Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of douse, Left/ t rear of hou , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left./Right rear of building, Under deck
Address
L , eG( �`�
CitylTown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown ' State ^Zip Code
r7
j Telephone Number
i
.6. Pulmping Record
1. Date of Pumping Date 2. Quantity Pumped: CC>
Gallons
3. Type-of system.- ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? MS , ❑ No If yes, was it cleaned? es ❑ No,
' 5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
G L S. Lowell Waste Water
Signitufe cf Hbul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
FINAL GRADE INNSPEC ION
io
Z
Date: Z;
Address:
fs
X4
LOAMED?
SEEDED?
COVER PER PLAN?
Other:
/ pORTN
O�tQ6eo I6
e -6
1-
4L fie"
� t«°'ic�a'ancw 1•
�1�q°'► Too
CHUg��
PUBLIC HEALTH DEPARTMENT
Lommunity Development Division
RT1(FIC4`I� OFC09VJ 'LTOY( E
As of:
October 4, 2007
21iis is to cert that the ind viduaCsudsurface d1 sposaCsystem received a
SWISTAC2'ORT-TYS(EMOYof the:
Fully RepairedSeptic System
By
john Soucy
469 Boston Wpad
.flap 1070; Tarce(49
North,,4ndover, W,4 01845
The Issuance of this cert f tate shaCC not be construed as a guarantee that the system wiCC
function satisfactoriC5.
i
i�
an 2'. Sa r
1PublicYleaCth Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
TOWN OF NORTH ANDOVER °t NORTH 1
Office of COMMUNITY DEVELOPMENT AND SERVICES o?
HEALTH DEPARTMENT p
400 OSGOOD STREET 'c• • 4
NORTH A-NDW�ER S^C
ETTS 01845 •"Ac" r�
,SHU`'tt
978.688.9540—Phone
Susan Y.Sawyer,REHS/RS 978.688.8476—FAX
Public Health Director OCT — 12007 -MAIL:healthde tc townofnorthandover.com
'�EBSITE:hi!p://www.townofnorthandover.com
TOWN OF NORTH ANDOVER
TOWN OF NORTH AND(�'VT_I DEFARTNSENT
SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (v<repaired;
by Sa-j c
(Print N e) af.located at D.
(Insta ation Address)
was installed in conformance with the North Andover Board of Health approved plan, originally
dated -Ind last Revised on , with a design flow of
Hy 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.
Bed inspection date: t •7
E eer Re esentative(Signature)
And-Print Name
Final inspection date: D 1&7 C c)
Engineer Represe tkive(Signature)
f �-<� J
And-Print Name
Installer./ AIPOA �(Signature) Date: /0 X/0 7
r 1
L4 17
V d
And-Pri t Name
Engineer: (Signature) Date:13/i 7
And-Print Name
tAORZ4
O�tjuzo 06�ti
O to
o ...1
[OCw[Mlwlt•V
04
4Arlo
SSACHUS�
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 469 Boston St. MAP: 107 D LOT: 49
INSTALLER: John Soucy
DESIGNER: N.E. Engineering
PLAN DATE:August 22, 2007
BOH APPROVAL DATE ON PLAN: September 11, 2007
INSPECTIONS
TANK INSPECTION: qhl l�
DATE OF BED BOTTOM INSPECTION:q
DATE OF FINAL CONSTRUCTION INSPECTION: September 25, 2007
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
® Existing septic tank properly abandoned
® Internal plumbing all to one building sewer
® Topography not appreciably altered
Comments:
SEPTIC TANK
ry
Bottom of tank hole has 6" stone base
Weep hole plugged
® 1500 gallon tank has been installed
H-10 loading Monolithic construction
® Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
® Inlet tee installed, centered under access port
® Outlet tee (gas baffle or effluent filter) installed,
centered under access port
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com
%40RT14t. q
O tiueo Obs
6 0
o
O CO[MKMI WKM 1'
4�RATeD
SSACHUS�
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
® 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
® Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
® Weep hole plugged
❑ Combo Tank installed. Size:
® 1000 gallon Pump Chamber installed
H-10 loading Monolithic construction)
® Inlet tee installed, centered under access port
® Pump(s) installed on stable base
® Alarm float working
® Pump On/Off floats working
® Separate on/off floats
® Drain hole in pressure line
® 24" inch cover to within 6" of final grade installed over
pump access port
® Water tightness of tank has been achieved
Visual testing
® Hydraulic cement around inlet & outlet
Comments: As per plan, the pump chamber was installed backwards.
DISTRIBUTION-BOX
® Installed on stable stone base
® Inlet tee (if pumped or >0.08'/foot)
® Hydraulic cement around inlet & outlets
® Observed even distribution
❑ Speed levelers provided (not required)
Comments:
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
14ORTli
Q A,�LID 16q�Q
6 O
O �►
H �
COC'IKIK WKw v
AORArED
SSACHUS�
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
SOIL ABSORPTION SYSTEM (General)
Bottom of SAS excavated down to 6 in into 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
❑ Retaining wall (boulder/ concrete /timber/ block)
❑ Final cover as per plan
Comments:
SOIL ABSORPTION SYSTEM (Gravel-less Chambers)
® Brand and Model of Chamber Infiltrator Quick 4
® Number of chambers per row_12
® Number of rows (trenches) 2
® Laterals installed and ends connected to header (and
vented if impervious material above)
® Elevations of laterals and chambers installed as on
approved plan
Comments:
CONTROL PANEL
® Alarm & Pump are on separate circuits
® Alarm sounds when float is tripped
® Location of control panel: In basement
❑ Rated for exterior if placed outside
® Alarm signal located inside
Comments:
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
tAORTy
O �t�eo 16'91.0
• s1? b` - 6 O
OJ16-
16
SSACHUS�
PUBLIC HEALTH DEPARTMENT
fommunity Development Division
SYSTEM ELEVATIONS
INVERT IN FIELD PLAN INVERT ELEV.
Manhole In 97.59 97.50
Manhole Out 96.46 97.40
Septic Tank IN 96.56 96.60
Septic Tank OUT 96.31 96.35
Pump Chamber IN 96.28 96.30
Pump Chamber OUT 96.65
Distribution Box IN 99.96 100.00
Distribution Box OUT 99.79 99.83
Lateral 1 INV 99.75 99.75
Lateral 2 INV 99.75 99.75
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com
Page 1 of 1
Sawyer, Susan
From: Shawn Brazel[sbrazel@neengineednginc.coml
Sent: Monday,September 10,2007 2:41 PM
To: Sawyer, Susan
Cc: BEN OSGOOD,A
Subject: [BULK]469 Boston Street
Importance: Low
Susan,
I've received and reviewed your comments concerning the septic system design at 469 Boston Street.
Our responses are a follows:
1. The elevations depicted on the design plan are correct.The form 11's were filled out before the final
topography survey was completed.They shall be revised,and resubmitted.
2. We would like to request that the plan be approved subject to an additional test pit being performed prior to
start of construction approximately 10 feet from the existing shed to confirm the soil type and ESHGW.
Thank You
Shawn Brazel
New England Engineering Services,Inc.
9/10/2007
. AS-BUILTX'17CHECKLIST
`5'Tf
LOT NUMBER ST
REET NAME
ASSESSORS MAP & PARCEL NUMBER
V LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
TIES TO LOT LINES &DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
✓ LOCATIONS OF DEEP HOLES &PE
RC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
�
TOP OF� FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK&D-BOX
ORIGINAL STAMP& SIGNATURE
IMPERVIOUS AREAS -DRIVEWAYS, ETC.
NORTH ARROW
LOCATION &ELEVATIONS OF BENCHMARK USED
i
2�
Date..................................
TOWN OF NORTH ANDOVER
41 PERMIT FOR WIRING
This certifies that .............
... �`:.� D�/..��.,� �
has permission to perform .......... ?v S.'4
4:�-4..I .............
wiring in the building of.................
at...........
........ .77................ .North Andover,Mass.
��—
Fee Lic.No.12t�lv....... .4......
Check # &7-re
7651
� 10RTM
♦ O�tt�♦D �s1'�'p
N A
1SSACHUSt�
Health Department
September 5, 2007
Mr. Benjamin Osgood P.E.
New England Engineer Services
1600 Osgood Street
North Andover, MA 01845
Re: Proposed Subsurface Sewage Disposal System for 469 Boston Street
Map 107D, Lot 49
Dear Mr. Osgood:
The proposed wastewater system design plan for the above site dated august 16, 2007 and 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 (NA) regulation
that has not met by this design follows each item for your convenience.
1. The ground elevations of the test pits and ESHGW noted on the plan differ from Form
11 submitted with the design plan. Please clarify as to which numbers are correct
2. Only one deep observation hole is located within the soil absorption system. Due to the
proximity of this hole to the majority of the SAS it is recommended an additional deep
hole test be performed at the northern end of the proposed area in which the SAS is to
be installed. You may however wish to request a Local Upgrade Approval (15.102(2))
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.
Wne1'4
Saw r, EHS S
Public Heal Director
cc: Owner
File
1600 Osgood Street HEALTH DEPARTMENT Page 1 of 1
Building 20;Suite 2-36 E-Mail:healthdept@townofnorthandover.com
North Andover,MA 01846 Phone:978.688.9640 Fax:978.688.8476
s �f O oTh Commonwealth of Massachusetts Map-Block-Lot j
�,� ••� O�� 107.D-0049-
-----------------------
Board of Health Permit No
s r BHP-2007-0267
. : North Andover
P.I. FEE
,S34CHUSt� F.I. $250.00
-----------------------
Disposal Works Construction Permit
Permission is hereby granted John- - - - -------------------------------------------- -------------------------------------------------
to(Repair)an Individual Sewage Disposal System.
at No 469 BOSTON STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2007-026 Dated September 18,2007
-----------------------------------------------------------------
Issued On: Sep-18-2007 Board of Health
µOR7k Map-Block-Lot
a+ ti Commonwealth of Massachusetts p
a „•' '• 0 107.D-0049-
o Board of Health ------------ ----------
• North Andover
� '°•{-°��� Certificate of Compliance
�Ss�cHusts
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair)
by ---John-Somy -
Installer
at No469 BOSTON STREET
----------------------------------------------------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-2007-026Dated September 18,2007
----------------------- . - -
-----------------------------------------------------------------
Printed On: Sep-18-2007 Board of Health
-0 SEPTIi SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
Bos_�#-',
For lans ` - irU��'tlrlol
(Address of septic system) P b y
0�/- - (Engin r)
Relative to the application of Q eP� ��
(Installer's name) And dated
adate)
Dated -34 /6
o a T s ate With revisions dated 'Al-44-
(Last revised da e)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally, this is the first (1'� inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to: healthdept(ktownofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank, D-Box,pipes, stone, vent,pump chamber,retaining waU and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
apl2roved 121ans. No instructions by the homeowner, general contractor.2tjny other 12ersons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: � Spy,� oday's Date)
1'7
G� ® C o
a — rint ame r
ed) IT
The Commonwealth of Massachusetts ���l
Department of Public Safety
ooawrw•r i fee Ctid*d
BOARD OF FIRE PREVENTION REGULA'T'IONS 527 CMR 1200 3/80 Ow hank)
APPLICATION FOR PERMIT TCS PERFORM ELECTRICAL ORl
All work to be performed in accordance wRh the Masaachpsatla Electrical Code,527 CMR:12.'00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date �;f?"� 7
City or Town of ,�/ 2i7/,��.�;v�yi,% To the Inspector of Wirer
The undw*gned applies for a permit to perform the electrical work dewdbed below_
Location(Street&Number) '
Owner or Tenant
Owner's Address
(a` ei8'permit in cmryu"Ion with a buNdktg permit: Yes ❑ No Er--- (Check Appropriate Box)
pu'pee`oi:t�utfiling 1 J</C�C�. 9��/c y �E — -- ! +Authorization No.
UndgrdNo of Melena
Undgrd ❑ No of tMs(ers
Date........f.....................
NORTH
°',��'° •'"o TOWN OF NORTH ANDOVER
OL - iNo.of Tranefomws
° p PERMIT FOR WIRING
~ Generators KVA
KVA
» No of hig
1ing
,SSACHU'J .. ..
FIRE ALARMS No.of
.. �j t:^ ................ Na of Dn and
This certifies that ......... ntliatinp Devices
has permission to perform ..........: P7Z4........ .. ............. 4a of Sounding
t f ro.of Self
�f re�Fcx 1,�A...................................... >etevsou Devices
wiring in the building of.................. .. c�lor
/ a ...... T': ,North Andover,Mass. ❑M ne bn❑
rn
Fee�...��•.••.• Lic.No. •• ELECTRICALowwtap
1NSPECrca�E'
Check #
7 ,651
r; u ng pWtN-OoWatlara.Covwa"or ft substwmu aqumoot yEsn NO ❑
I have submitted valld proof of same to this offkv. YES LI NO U.
H you have c plem the type of curage by chec idng the appropriate box.
INSURANCE eJ 80 ase❑ OTHER❑ (Please Specify)
Estin*od Value of Electrical Work
Wbrk to Start Z?
Signed under the of perjury:
FIRM NAME Ua N0."a;L59
Uoerroee �'�' ('' -
Signature Lac NO. 2
Sue,TdL No.
Address l' c rx i' r 2' ! lL�.,,7_1+�.._____ Alt.Tel.Na - l v'� f3-7 z
OWNER'S INSURANCE WAIVER: I am aware that the kwmft to"not Ave the insurance coverage or its suww d eawyw".'"
required by Maseachusmts G nersi tawe,and that my signature on tide permit appiicatim walrres this requirement
Owner ❑ Agent,O M6new check one)
Telephone No. PERMR FM s
(t3ipnahero of Owner a Agent) —
NORTH
(%.. 0 q�0
6
OL
O �►
F- p
A_O cocmc�..Kiwa« 1
7�AOA.{TE D
�SSgc Huse
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
September 11, 2007
Glen Hartford
469 Boston Street
North Andover, MA 01845
RE: Septic System Design; 469 Boston Street, North Andover,Map 107D, Lot 49
Dear Mr. Hartford,
The North Andover Board of Health has completed the review of the septic system design plans,
for the above referenced property, submitted on your behalf by New England Engineering
Services, dated August 22, 2007. This plan has been approved.
This plan is valid for two years from the date of this approval. The design has been approved for
use in the construction of an onsite septic system for a 4-bedroom house (maximum 9-room).
During this time, a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer, designer and the Town of North
Andover. In the event an imminent health problem such as sewage backup into the dwelling is
occurring,the North Andover Board of Health may reduce the time period for which this plan is
valid.
This approval is subject to the following conditions:
1. The request by the engineer to perform an additional soil test pit prior to the start of
construction approximately 10 feet from the existing shed to confirm the soil type and
Estimated High Ground Water Elevation has been approved. The installer must comply with
this requirement. If conditions are found significantly different than the engineer will modify
the plan accordingly.
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.
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
i
✓ 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 Commission, Zoning
Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector.
The issuance of a Disposal System Construction Permit shall not construe or imply
compliance with any of the aforementioned requirement.
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health Department may be reached at 978-688-9540 with any questions you
may have.
Sincerer;
r S an Y. Sawyer /IfS
Public Health Director
Encl: list of licensed septic system installers
Cc: New England Engineering Services, Inc.
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Jd M Y
TOWN N OI NORTH ANDOVER RTH
Office of COMMUNITY MM tiITI DE ELOPIII N T .'SNI) SERVICES Z` Q�
SALT -i DEPARTMENT
1600 OSE.GOD STREET,ItlsE"I BU1.1 I}INC: 20:1 SUITE 2-36 � u,
NORTI1 ANDOV 1 R, MASSA.C.11USI TTS 01.8=I5 �"acwwsfi2
9-/K6W9540—Phone
Susan 1'.Sawyer, REI ISMS �}7 .b sS.�4%ti.... I::.
Public Health Director E-MAIL: Ilealt�der?trii:towiioftior-tl,arr - 51
Vv�EBSIT-F_,:. 3 tt .;u'it��� .tot_r afar r ? v .?";G:OM
191 .
SEPTIC PLAN SUBMITTAL FORM
Date of Submission: p�
0\��U�N
N P�
Site Location: y� &S_fm �� - �, ( a Uc'
Engineer: P
New Plans? Yes b, $225/Plan Check# (includes l"submission and one re-
review only)
Revised Plans?Yes $75/Plan Check#
Site Evaluation Forms Included? Yes 1/ No
Local Upgrade Form Included? Yes No '✓
Telephone#: 9 D'lQ(�/117� 9 Fax#:
E-mail:
Homeowner
Name:
OFFICE USE ONLY
When the submission is complete (including check):
➢ _ Date stamp plans and letter
➢
x,,-'---'Complete and attach Receipt
➢ _Copy File; Forward to Consultant
➢ _ Enter on Log Sheet and Database
Page 1 of 1
DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Tuesday, September 11, 2007 9:51 AM
To: DelleChiaie, Pamela
Subject: FW: [BULK] 469 Boston Street
Importance: Low
can you pull this one too
thanks
-----Original Message-----
From: Shawn Brazel [mailto:sbrazel@neengineeringinc.com]
Sent: Monday, September 10, 2007 2:41 PM
To: Sawyer, Susan
Cc: BEN OSGOOD, JR
Subject: [BULK] 469 Boston Street
Importance: Low
Susan,
I've received and reviewed your comments concerning the septic system design at 469 Boston Street.
Our responses are a follows:
1. The elevations depicted on the design plan are correct. The form 11's were filled out before the final
topography survey was completed. They shall be revised, and resubmitted.
2. We would like to request that the plan be approved subject to an additional test pit being performed prior to
start of construction approximately 10 feet from the existing shed to confirm the soil type and ESHGW.
Thank You
Shawn Brazel
New England Engineering Services, Inc.
9/11/2007
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Page 1 of 1
DelleChiaie, Pamela
From: Marianne Peters [mpeters@millriverconsulting.com]
Sent: Monday, September 10, 2007 4:53 PM
To: 'Daniel Ottenheimer'; dobrzut@millriverconsulting.com; Grant, Michele; DelleChiaie, Pamela;
Sawyer, Susan
Subject: Soil Eval -Granville Lane/Lot 4 -Sept 24 @ 10:00
Soil Eval scheduled for 9/24 @ 10:00 w/Ben Osgood for Granville/Lot 4.
Marianne Peters
Mill River Consulting
2 Blackburn Center
Gloucester, MA 01930
978-282-0014 ph
978-282-0012 fx
www.millriverconsulting.com
9/11/2007
r
t
TOWN OF NORTH ANDOVER NO*Tp
Office of COMMUNITY DEVELOPMENT AND SERVICES �� •``
HEALTH DEPARTMENT p
1600 OSGOOD STREET; BUI LDI NG 20; SUITE 2-36 �•". ., F•
NORTH ANDOVER, MASSACHUSETTS 01845
�SS1GHUgEt
Susan Y. Sawyer, REHS, RS 978.688.9540 _Phone
Public Health Director 978.688.8476 _FAX
heal thdept(o2ownofnorthandover.corn
www.townofnorthandover.com
APPLICATION FOR SOIL TESTS
DATE: MAP& PARCEL: !
LOCATION OF SOIL TESTS: yo ��
OWNER: �14, 1 all-4, N Contact#.
APPLICANT: �t—Ot Contact#.
ADDRESS "7(D� � /� VI • �Q. Q�l'�JC_.
. s Id
ENGINEER: i . Contact#.
CERTIFIED SOIL EVALUATOR: OSJr.
Intended Use of Land- Residential Subdiv' ' SingleFamily Home Commercial
IsThis. Repair Testing: l/' Undeveloped Lot Testing: Upgradefor Addition:
Inthe Lake CochichewickWatershed? Yes No ✓�
THE FOLLOWING MUST BE INCLUDED WITH THISFORM
Proof of land ownership(Ta(bill,or letter from owner permittingtest)
➢ 8.5_x 11-Plot plan& Location of Testing(please indicate test pit siteson theplan)
Fee of$425.00 per lot for new construction. This coversthe minimum two deep holes and
two percolation tests required for each disposal area Feeof$360.00 per lot for repairs or upgrades.
GENERAL INFORMATION
➢ Only Certified Soil Evaluatorsmayperform 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 A least two deep holes and at Int one percolation test, ztthe discreti on of the BOH
representative.
➢ Full paymentwill be required for all additional testswithin two weeks of testing.
➢ Within 45 daysof testing,ascaled plan(no smaller than 1=100)shall besubmitted to the Board of Health
showi ng the I ocati on of ad I tests(i nd udi ng aborted tests).
➢ Within 60 days of testing soil Evaluation forms shall besubmitted.
PIease DoNot Wr ite Bel aw T h is L i ne
N.A. Conservation Commission Approval Date:
Signature of Conservation Agent:
Date back to Health Department: (stamp in):
(001 gi--j IWA51- TWA- wl NACC,-
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M e r� 'rt''►� l of� -�j TGT /�'Q.Gq
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Commonwealth of Massachusetts
City/Town of 0r4� 7klUe i
Percolation Test
Form 12
rG 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 Glen Hartford
computer, use
only the tab key Owner Name
to move your 469 Boston Street
cursor-do not
use the return Street Address or Lot#
key. North Andover MA 01845
City/Town State Zip Code
& 978-682-6002
A AV Contact Person(if different from Owner) Telephone Number
iemm
B. Test Results
7/31/07 10:35
Date Time Date Time
Observation Hole# PT1 _
Depth of Perc 27/20"
Start Pre-Soak 10:35
End Pre-Soak 10:50
Time at 12" 10:50
Time at 9" 11:08
Time at 6„ 11:32
Time (9"-6”) 24 min.
Rate (Min./Inch)
8 min. per inch
Test Passed: ® Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
Thomas Hector —
Test Performed By:
Randy Burley, Mill River Consulting
Witnessed By:
Comments:
t5form12.doc•06/03 Perc Test•Page 1 of 1
r
s
CommonwealtUAi
f Massac usetts
City/Town of Aoer
l Fora 11 - Soil Suitability Assessment for ®n-Site Sewage Disposal
DEP has provided this form for use by on-site professionals and local Boards of Health. Other forms may be used, but the information must
be substantially the same as provided here- Before using this form, check with your local Board of Health to determine the form they use.
A. Facility Information
1. Facility Information
Owner Name L3 5+o�n Ste- 1�Dle-tMap/Lot
_1 O T
Street Address , l (�J p r
City/Town /V It , `State Zip Code
B. Site Information
1. (Check one) New Construction ❑ Upgrade ❑ Repair
2. Published Soil Survey available? Yes ❑ No ❑ If yes: I q 8 -1
' I f Year Published Publication Scale Soil Map Unit
ra4f rOP(0A 00d
Soil Narne Soil limitations
Surficial Geological Report available? Yes ❑ No � If es: _ _-_-----__—_--
3. y 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 ❑
S Wetland Area: National Wetland Inventory Map
Map Unit Name
Wetlands Conservancy Program Map
Map Unit Name
DEP Foran 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 1 of 7
T T
\ Commonwealth of Massachusetts
- - City/Town of ,Jor-A h A v\ 0%)e rl
Forma 11 - Soil Suitability Assessment for On-Site Sewage Disposal
, ❑
6. Current Water Resource Conditions (USGS) �uo� � Range: Above Normal ❑ Normal Below Normal
Monthly ar
7. Other references reviewed:
C. On-Site Review (minimum of two holes required at every proposed disposal area)
31 a I o'3 a P. C «�� 78
Deep Observation Hole Number: —T I
Time weather
Date
1. Location
Ground Elevation at Surfaceroof Hole T{, 00
IJG
Location (Identify on Plan ) &YCtfdl `Car'
2. Land Use: k75'% t 4+1 Q.( Surface Stones Slope(%)
(e.g.woodland, agricultural field,vacant lot, tc.) ( 2
!a .e er W GPOu nd r a�n Q !� cLG S ale.
Vegetation Landform Position on landscade (attach sheet)
3. Distances from: Open Water Body c�OQO Drainage Way 5W _ Possible Wet Area f56U
feet feet
eet
Property Line 1_ Drinking Water Well > 1,5(3 Other
feet feet
4. Parent Material: ��a�ion Unsuitable Materials Present: Yes E] No '
If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock[:] Bedrock❑
5. Groundwater Observed: Yes ❑ No X
If Yes: Depth Weeping from Pit De th Standing Water in Hole
Estimated Depth to High Groundwater: 97
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 2 of 7
Commonwealth of Massachu etts
- - - - City/Town of
Form 11 - Soil Suitability Assessment for ®n-Site Sewage Disposal
inches elevation
Deep Observation Hole Number: _FP I
Soil Soil Matrix: Redoximorphic Features Soil Coarse Fragments Soil Structure Soil
Horizon/ Color-Moist (mottles) Texture % by Volume Consistence Other
Depth Layer (Munsell) (USDA) (Moist)
(I n.) Depth Color Percent Gravel Cobbles
&Stones
SL
Wy 5Y 5 COMM,b Z
�6S
Additional Notes
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 3 of 7
CommonwealtVIC)f Massachusetts
City/Town of ��� AAAove
Form I I - Soil Suitability Assessment for ®n-Site Sewage Disposal
C. on-Site Review (Cont.)
Deep Observation Hole Number: Date Time Weather
1. Location q
Ground Elevation at Surface of Hole �^
Location (Identify on Plan ) c�� eor le-;A- a* � oo5e-
o
2. Land Use: �e_61-eK144� Surface Stones Slope (%)
(e.g. woodland, agricultur I field,vacant lot,etc.) `
�l�t 55 G!'o0 nta w Q �a e
Position on landscape (attach sheet)
Vegetation Landform
3. Distances from: Open Water Body ;00o Drainage Way Tpa Possible Wet Area f.5-Oct
feet feet
eet
Property Line 3(o— Drinking Water Well > t5_0 Other
feet feet
4. Parent Material: AU'x,OH _T_1 Unsuitable Materials Present: Yes ❑ No,�
If Yes: Disturbed Soil❑ Fill Material❑ Impervious Layer(s) ❑ Weathered/Fractured Rock❑ Bedrock❑
5. Groundwater Observed: Yes ❑ No X
If Yes: Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater:
38
Estimated
u " --
inches elevation
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal ^ Page 4 of 7
Commonwealth f Massachusetts
City/Town of VdrAln f�vo�er
—_
Form
- Soil Suitability ASsessrnent for ®n-Site Sewage Disposal
- �
Deep Observation Hole Number:
Soill Soil
Soil Soil Matrix: Redoximorptle Features Soil Texture Corse by Vou Fragments Structure Consistence Other
Horizon/ Color-Moist (mottles) (Moist)
Depth Layer (Munsell) (USDA)
(In.) Depth Color Percent Gravel Cobbles
&Stones
0 -13 IMS l� 5 L
03 L --
5-Ytk
a�-8� .SY lo�R5�8
Comm
Additional Notes
DEP Foran 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page 5 of 7
Commonwealth of Massach �el
etts
C ity/Town of /�o f4\ �"'CZ
== Form 11 - Soil Suitability Assessment for ®n-Site Sewage Disposal
D. ®etermination of High Groundwater Elevation
1. Method used: ❑ Depth observed standing water in observation hole A. inches B inches
❑ Depth weeping from side of observation hole `4 inches B inches
,Depth to soil redoximorphic features (mottles) A. B.in hes in Z spa
❑ 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 ❑ 97„ Tel
I- Lower boundary: 86\� TPR
R
b. If yes, at what depth was it observed? Upper boundary: �Q inches
inches
F. Certification
I certify that I have passed the soil evaluator examination"approved by the Department of Environmental Protection and that the above
analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017.
Signature of Soil Evaluator Date /� cj q
'' 2Kt4Nn�h �SC QST. e "O�• l `'l�
Typed or meted Na22me of Soil E luator / *Date Soil Evaluator Exam
PoV4 Uyr , ll Rkv¢r C� 5� �+n I )o4 --A o��cr
Name of Boarb of Health Witn ss Board of Health
Note: This form must be submitted to the approving authority with Percolation Test Form 12
DEP Form 11 Soil Suitability Assessment for on-Site Sewage Disposal • Page 6 of 7
Commonwealth of Massachusetts
_ City/Town of /U04.�1 Avxjc)ve ,
- = Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
Use this sheet for field diagrams: See P
DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal Page 7 of 7
H°Rr�q Wic.AtLion for Septic Disposal System G
TO Y'S DATE
° pConstruction Permit - TOWN OF
49
''' $ 225.00
ORTH ANDOVER —Full Repair
MA 01845 $125.00 -Component
b�sS^cHus
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 /Repair 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 A. Facility Information
key.
Address or Lot#
eoca-
City/T n
2.- * PE OF SEPTIC SYSTEM*:
ump ElGravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
� r
Name
Address(if different from above)
City/Town State Zip Code
Telephone Number
3. Installer Information
�Lo�'
Name Name of Company
ko .1�ok L'
Address
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
JV Q44,1-h
NameName of Company
f �S � S •
Address
i
City/Town _ States Zip Code
V�Yw c&-(,- 1
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
NORTH !`7
OEtac Application for Septic Disposal System - ,
reqs
p Construction Permit — TOWN OF TO A 'S DA .,
"•��'� '"y` ORTH ANDOVER MA 01845 $ 250.00-Full Repai
�,SS^CH�S t� $125.00 -Component
PAGE 2OF2
A. Facility Informationcontinued....
5. Type of Building Residential Dwelling or❑Commercial
B. Agreement
i
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 An ver, and noW place the system in operation until a Certificate of Compliance has
been i u d by this r of Health.
i
t�
ame Date
/A ;--7.
pproved B oard of Health Representative)
7-�
tZ p
pponisapproved for the following reasons:
For Office Use Only:
L Fee AttachedP Yes No
2. Project Manager Ohligation Form Attached. Yes No
3. Pum Sys tem? Ifso Attach co offlectrical Permit Yes
PumpPv No
4. Foundation As-Built. (new construction ronly): ;els
esNo
(Same scale as approved plan)
5. Floor Plans?(new construction only): No
Application for Disposal System Construction Permit•Page 2 of 2
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