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Miscellaneous - 575 SALEM STREET 4/30/2018 (2)
575 SALEM STREET 210/038.0-0053-0000.0 4 it CC Lot & StreetC��L�� Map/Parcel g CONSTRUCTION APPROVAL Has plan review fee been paid: ES NO Permit# Plan Approval: Date: Z3 Approved by: Designer: Plan Date: aa- Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approve`d--_. Plumbing Sign-Off: Wiring Sign-off` Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: a SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? _ YES NO Type of Construction: NEW REPAIR New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: S NO DWC Permit Paid? YNO DWC Permit# . , Installer: —4L Begin Inspection: YES ' NO Excavation Inspection: Needed: ,` J.i , f:[ �j� C 'l�� 5�,yI.��i -� ', - � ;,4) Passed: By Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: By: Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: 575 SALEM STREET JS-2003-0796 Proiect Detail Report Printed On:Wed Jun 25,2003 GIS#: 2036 lProject No: JS-2003-0796 Owner of Record JACKSON REALTY TRUST& Map: 038.0 Date Submitted: Jun-03-2003 575 SALEM STREET Block: 0053 Status: Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 575 SALEM STREET Zoning: Proposed posed Use: District; land Use: 101 Proposed Use Detail Subdivision _ 1 Description AND I BATH REMODEL 1 BATH'&KITCHEN of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2003-0064 6/25/03-Wed.-Mike Ryan,h/o called looking for Installation Form. It was dropped off this a.r By Shawn at NEES and given to Sandy. Mr.Ryan asked that form be faxed so that money in escrow can be released. Form faxed. Site testing and design plans were submitted and done in May and Nov.Of 2002 before this system was being used.--p.d. Tues.6/24/03-Ben Osgood sent a worker in to pick up installation cert.Form that he will sign and return back to us. Mike Reilly was in this a.m.To sign off on it before this. Ben will have t form returned for Sandy to sign off. File is in the active drawer.--p.d. s' ')' Building,Electrical&Mechanical Permits GREEN FLAG BEM-2003-0761 Permit History Type: Permit No: Issue Date Status Work Category Project No: Description of Work: Building BP-2003-0614 Jun-12-2003 OPEN Residential Alteration JS-2003-0796 AND 1 BATH REMODEL 1 BATH&KITCHEN Septic System BHP-2003-0147 Mar-31-2003 Signed Off JS-2003-0796 Repair-Complete GeoTMS@ 2003 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 575 SALEM STREET J3, JS-2003-0796 Protect Detail Report _ Printed On:Fri Jul 18,2003 GIS#: 2036 Project No: JS-2003 0796 Owner of Record JACKSON REALTY TRUST Map: 038.0 Date Submitted: Jun-03-2003 575 SALEM STREET BIock: 0053 Status: Open` NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 575 SALEM STREET Zoning: Proposed Use: District: land Use: 101 Proposed Use Detail Subdivision Description AND 1 BATH REMODEL,1 BATH&KITCHEN ,of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2003-0064 6/25/03-As-built submitted. 6/25/03-Wed.-h/o called looking for Installation Certification Form. Form faxed. • Tues.6/24/03-Engineer rep.picked up installation cert.Form that he will sign and return. Building,Electrical&Mechanical Permits GREEN FLAG BEM-2003-0761 Permit History Type: Permit No: Issue Date Status Work Category Project No: Description of Work: Building BP-2003-0614 Jun-12-2003 OPEN Residential Alteration JS-2003-0796 AND 1 BATH REMODEL 1 BATH&KITCHEN Septic System BHP-2003-0147 Mar-31-2003 Signed Off JS-2003-0796 Repair-Complete GeoTMS®2003 Des Lauriers Municipal Solutions,Inc. Page 1 of 1 FORM 9A - Application for Local Upgrade Approval Commonwealth of Massach usetts Norm A ti D o _Vj- ,Massachusetts (City/Town) Application for LOCAL UPGRADE APPROVAL Title 5, 310 CMR 15.000 DEP Approved Form Required by 310 CMR 15.403(1) 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 15.417. 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 a septic system constructed in accordance with either the 1978 Code or 310 CMR 15.000. Facility Address:E7,S `5A SEM S City/Town: iJ. Facility/System owner:���K 501 (Z EA t_Tv Address: c T,2,s-• _� n1, �s�e2hOr. 1�?�Eeec STree I City/Towr. 11A C-►W 0 E 1"/ Telephone: (978 ) k q•q -/-C/I-y State: i4 Zip: v I Type of Facility(check all that apply): Residential Describe facility { ❑Institutional El Commercial ❑ School Type of existing system: ❑Privy " ❑Cesspool(s) [Conventional System ❑Other(describe) Type of soil absorption system(trenches,chambers,leach field,pits,etc) v h n 0 w N Design Flow per 310 CMR 15.203: _Design flow of existing system — Design flow of proposed upgraded systemgpd d Design flow of facility gpd Proposed upgrade of system is: ❑Voluntary ❑Required by order, letter,etc.(attach copy) Required following inspection pursuant to 310 CMR 15.301 Provide date of inspection / / u-An,,,-^, ,j FORM 9A - Application for Local Upgrade Approval Department of Environmental Protection Pagel of 3 DEP Approved Form-3/20/02 Describe the proposed upgrade to the system livs i o%`� N A S ,p7l.c ,fttil K� A-Q AL1 C k F1 E L Local Upgrade Approval is requested for: ❑ Reduction in setback(s) (Describe reductions) ❑ Percolation rate for 30 to 60 min/inch Percolation rate min/inch ❑ Reduction in SAS area of up to 25% (SAS size and%reduction) SAS sq ft Reduction % �] Reduction in separation between the SAS and high groundwater Separation reduction_ft Percolation rate /p min/inch Depth to groundwater ft ❑ Relocation of water supply well(Explain) ❑ 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)()(1).The soil evaluator must be a member or aeent of the local aaarovin authority. High groundwater elevation determined by: ' (Print or type evaluator's Name) (Signature of evaluator) (Evaluation Date) 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: 12aNs ,-,9 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: caST Is, P RO N) r9-7-jl U 6 Department of Environmental Protection DEP Approved Form—320/02 Page 2 of 3 FORM 9A - Application for Local Upgrade Approval 3• A shared system is not feasible: P/-u-19 i 62 1�i7 RC F N iI 17S 4• Connection to a public sewer is not feasible: c� E 2 L%nfo� C l,oS� - Crl( 'R7 FC_©N0'ILA pgLJ-s T !— ti Ty i The Application for Local Upgrade Approval must be accompanied by all of the following: (Check the appropriate boxes) Application for Disposal System Construction Permit Complete plans and specifications Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other(List) 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.Tete. significant consequences for submitting false information,including, but not limited o,penalties alties or fine and/or imprisonment for deliberate violations. to, Facility owner's signature Print name C p Date �S J Name ofpreparer���7 ©Sop Preparer's Address. Date % z/ o �_C �-tl2) D �.l✓G City/Town: ( fM/11r?v State: M Zi 0/3 Preparer's tele hone: — p' P _079 1 686 176 8 NOTE: 310 CMR 15.403(4)requires the system owner to provide a copy of the local upgrade approval to the appropriate Regional Office of the Department of Environmental Protection,Bureau of Resource Protection,Division of Watershed Management,upon issuance by the local approving authority and before commencement of construction. Department of Environmental Protection Page 3 of 3 DEP Approved Form-3/20/02 ' i �C, ION: 5 76 t IN : Go- v_S S ,OL TION C,- --- I- .r' I .1 I l7ltil J�.- I r r I LD iifvl= i I Im E, i 11 I'v I 7Ni= iIVI= ,-. 1 k J I i I { _ / o I t i ~i I S � c I i E, `+ fiORTN a TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET _"�, .�•- �4r« NORTH ANDOVER,MASSACHUSETTS 01845 Sandra Starr R.S.,C.H.O. (978)688-9540-Telephone Public Health Director (978)688-9542-Fax 11`X TO: From: Fax: Pages: Phone::y / �J Date: / Re: CC: ❑ Urgent ❑ For Review ❑Please Comment ❑Please Reply ❑Please Recycle Please call 978-688-9540 for assistance with any questions. Thank you. xc: Address File Chrono File f TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( )constructed; (V repaired; by d �IA uc located at -7 was installed in conformance with the North Andover Board of Health approved plan, System Design Permit plan dated- 9-3–w") , with a design flow _9f Y�Q 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 S 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: ��lo Engi r Representative Final inspection date: 5���0 Engineer epresentative Installer: Lic.#: Date: M Engineer: RICHARD 9�yN Date: v � TAIVGARD y 13021 Q BONA : � �a°u 6yv�t3F i�l?RT'F9 BOARD OF HEALTH Ji 12003 QIP Fax K1220xi Log for Ar NORTH ANDOVER 9786889542 Jun 25 2003 1:45pm Last Transaction Date Time Type Identification Duration Peres Result Jun 25 1:43pm Fax Sent 817816653488 1:27 2 OK CA rl r FORM - U - LOT RELEASE FORM STRUCTIONS_ This form is used to verify that all-necessary approval/permits from - jurisdiction have been obtained.This does not relieve the r .,boards'and Departments having j licable requirements . �' er from compliance with any aPP ...� a applicant and or landown...- P ..a..a ML a a.a a a a a a.roln] ...a....a, c.a.,a,- ..wool= / PHONE APPLICANT / P ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER STREET I STREET NUMBER F� aaaaaa �a■a�aaraaar a.■raa.arraa.a.aaasa-aaa.■a.■aaaaaaaa�aaa■.a sasaaaaaraaaaaaaaa.aa■ OFFICIAL USE ONLY a a tiara aaa a.aaa•a.sa,rsa a as as-aa as a:a-:aa as a a.a-■-■.a a a ra a woman ■,aa a aa.a.a a a.a a.aa a.a.aa.a■ ATIONS OF TOWN AGENTS RECOaaaa.raaa•a.aaa.aarasaa.a■: aa.aa■ aa�aaaaaaa�aa.caraa.■.a.■a.■ac�aaaaaaaaaar.aaa.aaaaa.■ . DATE APPROVED CONSERVATION AD DATE REJECTED COQ — s DATE APPROVED TOWN PLANNER DATE REJECTED COMMENTS DATE APPROVED Foy?INSPECTOR-HEALTH DATE REJECTED (Y DATE APPROVED 2 SEPTIC INSPECTOR-HEALTH DATE REJECTED CONMIENI'S L \ PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT. DATE REJECTED COMMENTS DATE RECEIVED BY BUILDING INSPECTOR 575 SALEM STREET JS-2005-0194 Proiect Detail Report Printed On:Mon Aug 30,2004 Project Name: GIS#: 2036 Project No: JS-2005-0194 Owner of Record JACKSON REALTY TRUST& Map: 038.0 Date Submitted: Aug-30-2004 575 SALEM STREET Block: 0053 Status: Open NORTH ANDOVER,MA 01845 Lot: Work Category: Work Location: 575 SALEM STREET Zoning: Proposed Use: District: land Use: 101 Proposed Use Detail Subdivision Description Septic System Comments: of Work: Department Status GeoTMS Module: Status File No. Comments: LCDate: Board of Health GREEN FLAG BHJ-2004-0121 07/25/2003-Install Cert.&As Built received from NEES. Permit History Type: Permit No: Issue Date Status Work Category Contractor Project No: Description of Work: DWC-System Repair BHP-2004-0612 May-01-2003 Open JS-2005-0194 Repair-Complete Form U Signoff-construct BHP-2004-0613 Mar-25-2004 SIGNED OFF JS-2005-0194 Convert garage into family room Inspection History Inspection Type: Permit Type: Permit No: Insp Date: Status: Inspector: Project No: Comment: Final Grade DWC-System Repair BHP-2004-0612 Jun-25-2003 SIGNED OFF Brian LaGrasse JS-2005-0194 Final Inspection DWC-System Repair BHP-2004-0612 May-22-2003 SIGNED OFF Dan Ottenheimer JS-2005-0194 Bottom of Bed Inspection DWC-System Repair BHP-2004-0612 May-06-2003 SIGNED OFF Dan Ottenheimer JS-2005-0194 GeoTMS®2004 Des Lauriers Municipal Solutions,Inc. Pagel of 1 NOONAN & Mc DOWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice (978) 667-9736 Fax(978) 671-9565 Email: nm@conversent.net September 25, 2002 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770.A/014 575 Salem Street Assessors Map ?, Lot ? Dear Members of the Board, Please be advised that Noonan& McDowell, Inc. has reviewed the plan dated September 3, 2002, by New England Engineering Services, Inc. It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health"By-Laws" if the following is addressed: 1) Re-label test pit 1 on plan view to 2. 2) Test pit 2 A soil color does not match Board of Health file. 3) Identify location of waterline and either pressure or suction. 4) Add a proposed 98 contour for septic tank/pump chamber 228 (1). 5) Revise slope of pipe from house to septic tank to reflect inverts given. 6) Provide 3:1 slope around leaching area and revise profile 255 (2). 7) Add length of tees in septic tank 227 (6). 8) Add 12"max from inside face of septic tank to inlet/outlet tee. 9) Add a riser to profile for pump chamber 231 (5). 10) Add a vent detail for end of line connections 241 (1)(d). 11) End of leaching line finish grade is lower than edge of slope grade. (pond condition). 12) Add map and parcel numbers 220(4)(u). 13) Add sill elevation on plan view. TOS/ h OF NORTH AND QARD OF HEALTH E Sincerely, . r:? 27 2002 John L. Noonan P.L.S., P.E. F:office/boh/1770A014.doc Land Surveyors Civil Engineers Environmental Planners 4 _I t 1 i A. i i i .P Np - FORM 11 SOIL EVALUATOR FORM r Page I of 3 No. 6;2, Date: �S/Z Commonwealth of Massachusetts A�© 4p<5�47z Massachusetts Soil Suitahft Assessment for On-site Sewaze Disposal PerformedBy: .................................................................................. Date: WitnessedBy: ............... ........n;; .......... ................................ ............................................ ..... L..Ii.Add., Owrgr*s Nam, LAI A&kesi.aW Tckphom I Pew construction El Repair NJ Office Review Published Soil Survey Available: No ❑ Yes Year Published ��1 Publication Scale ...... Soil Map Unit .. ...... ... Drainage Class ........ Soil Limitations ff1......................................:....................._........._....... ........... Surficial Geologic Report Available: No 21 Yes ❑ Year Published Publication Scale GeologicMaterial (Map Unit) .............................................................................................................................. Landform ................... Flood Insurance Rate Map: Above 500 year flood boundary No El Yes Within 500 year flood boundary No EJ Yes El Within 100 year flood boundary No []Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ...................................... ................................................................... Wetlands Conservancy Program Map (map unit) ................................................................................................. Current Water Resource Conditions (USGS): Month Range :Above Normal E]Normal IMBek-wNormal El Other References Reviewed: DEP APPROVED POILNt•12/07/9s FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. On-site Review Deep Hole Number ..2 Date: ..�.. 1 ' ..` Time ��..�5 Weather�X— ,2 Location (id,4aqy on site plan) - � Land Use .. �. . Slope (%) / . Surface Stones : Vegetation . Landform Position on landscape (sketch on the back) - Distances from: Open.Water Bodyfeet Drainage way..'reC9 , feet Possible Wet Area ��.~�.. feet Property Line .:.:�0.�''� feet Drinking Water Well,..;;" feet Other .....:.:: DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) �� 7 �/ �� /-q/ g � Parent Material (geologic) � h/� �y� DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: ll Estimated Seasonal High Ground Water: — DEP APPROVED FORM- 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. On-site Review 1 a Deep Hole Number .:/:.:. ..::: Date: �p2 Time:.: �' Weathe��` Location (identif on site plan) _.- ibi�11 .�... '6 .......:.. Land Use .:.:.:... ....:..:..::. /llTlG Slope (%) _ .. . Surface Stones Vegetation Landform ._._ ��G/5y Position on landscape (sketch on the back) '.:.. 4 -. Distances from: Open Water Body feet Drainage way.. feet Possible Wet Area . feet Property Line ..:. ....,. feet Drinking Water Well ."�.IA feet Other ,....:.:. DEEP OBSERVATION HOLE LOG` Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) v2 �wdel i vy� 4� cz Mil LES REQUIKLU AT EVERY PRUPOSE9 DISPOSTL AREA Parent Material (geologic) 494DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: � Weeping from Pit Face: �Q N Estimated Seasonal High Ground Water: — --- DEP APPROVED FORM• 11/07/95 FORM 11 - SOIL EVALUATOR FORM Page 3of3 Location Address or Lot No. Determination or Seasonal ,Nigh Water Table Method Used: ❑ Depth observed standing in observation hole.................. inches ❑ Depth weeping from side of observation hole ............... inches Q Depth to soil mottles inches - �- ❑ Ground water adjustment ................... feet ` Zr Z2 Index Well Number .................. Reading Date .................. Index well level ................... Adjustment factor ................... Adjusted ground water level ........................................................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �> If not, what is the depth of naturally occurring pervious material? Certification I certify that on Ir/--57(date) 1 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. Signatur ate /" - DEP APPROVED FORM-1210719S CV ,Lin -- � LOCA. ION. .575 � T I IN CL — — — I _.:COL—. f ION i E Cl— i LD vC `• -W laA 3f!-Es I-KO-5) f i I\v J _____.---TP 2 COMBINATION 1500 DISTRIBUTION GALLON SEPTIC TANK `BOX 1000 GALLON PUMP CHAMBER d 0 45' ELBOWS �l O BENCHMARK: S ELEV 100.00 �10EXISTING FOUR BEDROOM HOUSE SILL ELEV 100.12 oar W . _. PRESSURE WATER SERVICE s w r RICHARD ��yc I C TANGa,• STREET13n SALEM _ 9 N/F NORTI1 ANDO � P►ND LAND COR? OVER . 11/F N000 �- N82°2535"E Lp►ND O ,,E 56.00 S86055 20„ X67°�2 1 70 70, E 1 575 SALEM STREET ASSESSORS MAP 38 PARCELS. 53 & 86 42,119 t SO FT Z � 45 MIL EPDM VENT RUBBER MEMBRANE G�� �w - 0 1 TP 1 T-4 PT 1 cv 8 —TP 2 r COMBINATION 1500 ~ GALLON SEPTIC TANK —' DISTRIBUTION `— BOX 1000 GAI I nN PI imp rHAMRrP Town of North Andover Office of the Health Department F: Community Development and Services Division t 27 Charles Street 04< `gipp*North Andover,Massachusetts 01845 9SS�CHUS` Sandra Starr 978.688.9540-Phone Public Health Director 978.688.9542-Fax rcFRT1 FIC.4rrE O F COV 91-1ANCE As of: ,dune 25, 2003 This is to cert that the individual su6surface disposal system repaired "A"" — Full System by ,john Soucy at 575 Salem Street North Andover, 31,4 01845 has been installed in accordance with the provisions of Title v of the State Sanitary Code and with the North Andover Board of Ifeafth regulations. The Issuance of this cert cate shall not 6e construed as a guarantee that the system will function satisfactorily. Sandra Starr Pu6lic Ylealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Form t4-.3 Massachusetts i Town of North Andover, � BOARD OF "ORT" 44, MIT 3= i " pUCTION PER o WORKS CONSTR DISPOSAL ' ELrpHoNE 1SSACMV�' DRE55 Applicant E Location bsorption Site Soil A Repair ( an Individual Or Rep �. Construct l roval S.S. No hereby granted w on the Design App Permission �s h stem as shown -- - Sewage Disposal Sy BOARD OF HEALTH HA�R►v1AN 9 Me p.W G• No i Fee TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT RVA5 RBNOVA7 OR DEMOLlSB A ONE OR TWO FAMILY DWELLING Awswrn i:'Y'Nz—'•.ai .i^. - z»xi Ti'.,. _,x.1�^ k'..tnM-.!. BUILDING PERMIT NUMBER: DATE ISSUED. X SIGNATURE: Building Commissionerawedor of Buildings Date Z SECTION I.SITE INFORMATION 0 1.1 Property Address:/ 1.2 Assamors Map and Pared Numbs \dop Number Pared Number IJ Zoning Information: 1.4 PropatyDimmsiom: Zoning Dlsttidx Use Lot Atm F B 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required I Provide 'red Provided Required Provided ,,f O D 0 1.7 Wag;Sapply XQI..CAM !D t•S. Flood Zeno idonnuioo: 1.8 sewage Disposal system: PabBo ❑ Private ❑ 7m- Oomide Flood Zan ❑ mmkipat ❑ On Site Mond Syuem ❑ J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M 2.1�', /�of/JR�cord Name(Print) _T Address for Service: Signature Telephone 2.2 Owner of Reead: Name Print Address for Service: 0 m 3Tel SECTION 3-CONSTRUCTION SERVICES 3.1 LyNot Applicable o S ' r C� / Licensed Coustniction Su + 'sod f —— t / �5�--- LicenseNumber _ - -- O A w ,�, �, , -�, Ad/jdm Expiration Oate r ro Telephone r 3.�V—Hj stlero5.d ome Improvem t Cantrnd�or J Not Applicable 0 Q L0�1 OD' �.e9�1.5t'/VL�sria'L �`fi• / Company Name l� ! 34 A,� (/ �• ���S . �� Registration Number r pts ILQ/ r as q Q z mss• - 6A-/1>1 Expiratia.Da G) nature Tek SECTION 4-WORKERS COMPENSATION(M.G.L C 151 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi Signed affidavit Attached Yes...... No......D SECTION Descriptim o Proposed Worst che& ble New Construction Existing Building 0 Repair(s) 0 Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: / SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be '-4' C� ' OFFICIAL US£.ONLYr � ;xy Completed (Cant 1. Building (a) Building Permit Fee i7rav Multilia 2 Electrical O�D (b) Estimated Total Cost of f Construction 3 Plumbing Building Permit fee(.):(b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATICW TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as OwnerlAuthorized Agent of subject property Hereby authorize to act on My behalf,in all matters relative to work authorized by this building permit application- Sipature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject: property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name. — Si titre of Ommer/Agent .Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 NU3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS 31ZE OF FOOTING R MATERIAL OF CR MIQEY IS BUILDING ON SOLI)OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *********************** *****APPLIC Ny FILLS OUT THIS SECTION*********************** APPLICANT J . �" PHONE LOCATION: Assessor's Map Number `'Y PARCEL SUBDIVISION LOT(S) STREET . dt I C Y� � ST. NUMBER USE RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FO.QbNSPECTOR-H TH DATE APPROVED DATE REJECTED r'LY11 ,(All S IC INSPECT HEALT -- - - DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised M7 jm COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION. [ —N Property Address: �5 C20� 3/ �12+A j Owner's Name: Owner's Address: &\!E- Date of Inspection: `-3—/tf 6 Z Name of Inspector: (please print) c Company Name: Mailing Address: x Telephone Number: QQ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported j 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(3 10 CMR 15.000). The system: Passes Conditionaliv-Passes Needs Further Evaluation by the Local Approving Authority 0�1- Fails Inspector's Signature: Date: Z— The system inspector shall submit a copy of this inspec n report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments T � ****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 s stem will perform in the future under the same or different Y 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: f ?C7-j , 1 Owner: kj. Date of Inspection: — 4 Z Inspection mmary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Pa es: I have not f nd any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes One or more system compone as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years d• or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exoltrati n or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank approved by the Board of Health. 'A metal septic tank will pass inspection if it is struc Ily sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avails e. ND explain: / Observation of sewage bi/ckup or break out or high stat water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribute n box. System will pass inspection if(with approval of Board of Healthy), broken pipe(s)are replaced obstruction is removed distribution box is leveled or rept ced ND explain: ' Th system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass ins ction if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: �L�d'� Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions ext which require further evaluation by the Board of Health in order to determine if the system is failing to protect publi ealth, safety or the environment. 1. System will pass unles oard of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning t a manner which will protect public health,safety and the environment: Cesspool or privy is within feet of a surface water Cesspool or privy is within 50 t of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and ublic Water Supplier, if any)determines that the system is functioning in a manner that protects the pu is health,safety and environment: _ The system has a septic tank and soil absorption syst (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 with' a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 5 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 10 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 certi ted laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• Owner: Sd 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 _ 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 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 I 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 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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the followine: (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–IATA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the'system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address•. 75- ,, Aj w O ner• Date of Inspection: Check if the followine have been done. You must indicate`ves"or`oto"as to each of the followins: 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 ? AWere 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: Ye o l� 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) [3 10 CMR 15.302(3)(b)J 5 L Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7s '5XIe., Owner: Cl+ Date of Inspection: -3 —&--o Z FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x" of bedrooms): Number of current residents:—1-- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yt s or no): it yes separate inspection required) Laundry system inspected(Aye�or no): Seasonal use: (yes or no):L Water meter readings,if available(last 2 years usage(gpd)): tAJA Sump pump(yes or no): � Last date of occupancy: COMMERCIAL/INDUSTRIAL 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): - Pumping Records GENERAL INFORMATION . //'', . Source of information: lflI Was system pumped as part of the inspection yes or no): If yes, volume pumped:_gallons— How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tattle, distribution box,soil absorption system _Single cesspool Overflow cesspool Privy pi�Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _,Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all corn onents, date installed(if known)and source of information: a a e rL Were sewage odors detected when arriving at the site(yes or no): Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 'r Owner: lKe Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast 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: YL(locate on site plan) Depth below grade: 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: Ll 6el ir es Distance from top o slud a to bottom of outlet tee or baffle: 02� Scum thickness: Inc PS , Distance from top of scum to top of outlet tee or baffle: 2�t Distance from bottom of scum to bottom of outlet tee or baffle: y How were dimensions determined: �71—A a& _ Comments(on pumping recommendations, inl t and outlet tee or baffle condition,structural integrity, liquid levels as related o tlet invert,eviden a of leakage, etc.): GREASE TRAP:_(locate on site plan) Depth below grade: — Material of construction: _concrete_metal_fiberglass_polvethylene_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.): L' i Page 8 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7S t°•w� Owner: Qj'?Ve(C gam/\ 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:D(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 leakae into or out of box,et 1 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.): i r Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS ME?�TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:,-5 Owner L Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not 19cated explain why: Type, leaching pits,number:_ leaching chambers,number: 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.): I - 1 L/t/V i_t..n, o LL 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 laver: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 L+ 4 w Page 10 of l 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSALl3YSTEM Provide a sketch of the sewage disposal system including ties t at least two permanent reference landmarks or benchmarks. Locate all wells in 100 feet. Locate where lic water supply enters the building. 0 ,•+. 13 D-13x z Z' s � e v= a Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C C SYSTEM INFORMATION(continued) Property Address:- —;a—' Owner: Date of Inspection: 1d �— SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting propertviobservation hole within ISO feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must de be}low you establisheo the high ground water elevation: jr P"w►, h d 1 /s Town of North Andover, Massachusetts Form No.2 r f 00R74 BOARD OF HEALTH o t,...,.�h F w DESIGN APPROVAL FOR • ;'.fib+,no A•�.h HUS SOIL SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 1C—/Z G �� Az4l Test No. Site Location ��� 64z"'fw . Reference Plans and Specs. 6 G� ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. • C RMA ,BOARD OF HEALTH Fee— Site System Permit No. r NOONAN & Mc D OWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice (978) 667-9736 Fax (978) 671-9565 Email: nm@conversent.net September 25, 2002 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770.A/014 575 Salem Street Assessors Map ?, Lot ? Dear Members of the Board, Please be advised that Noonan & McDowell, Inc. has reviewed the plan dated September 3, 2002, by New England Engineering Services, Inc. It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health`By-Laws" if the following is addressed: Re-label test pit 1 on plan view to 2. �9n �^ Test pit 2 A soil color does not match Board of Health file.------- Identify location of waterline and either pressure or suction. Add a proposed 98 contour for septic tank/pump chamber 228 (1). Revise slope of pipe from p p p house to septic tank to reflect inverts given. Provide 3:1 slope around leaching area and revise profile 255 (2). a,?� Add length of tees in septic tank 227 (6). L,9) Add 12"max from inside face of septic tank to inlet/outlet tee. c,9� Add a riser to profile for pump chamber 231 (5). ti Add a vent detail for end of line connections 241 (1)(d). , -11) End of leaching line finish grade is lower than edge of slope grade. (pond condition). 1/11 Add map and parcel numbers 220 p (4)(u)• Add sill elevation on plan view. imfif C3Ff4()P,€'11,',N_Dfsjd�-F j ROARS OF FlEAj.T F Sincerely, - --3_ John L. Noonan P.L.S., P.E. F:office/boh/1770A014.doc Land Surveyors Civil Engineers Environmental Planners • SEPTIC PLAN SUBMITTAL FORM LOCATION:S 1 5 Salem S1N }h fanaove� NEW PLANS: YES $160.00/Plan REVISED PLANS: $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE: \� 16 �oZ DESIGN ENGINEER: Kt,, DATE TO CONSULTANT: When the submission is all in place, route to the Health Secretary. A NEW ENGLAND ENGINEERING SERVICES INC ---1- f"VVN OF NORTH ANQ6,�=R/ a GOARD OF HEALTH 1 �1 p 7 Xd November 5, 2002 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 575 Salem Street,North Andover, Septic system design Dear Sandra: Enclosed are revised septic system design plans for the above reference property. The following changes have been made. Each item below is numbered to correspond to the item number in the letter from John Noonan dated September 25, 2002. 1. The test pits have been labeled correctly.. 2. The soil test information was verified by the health agent on site at the time of testing. 3. The pressure water line has been located on the plan. 4. The 98 contour has been added around the tank. 5. The slope on the pipe has been revised. 6. The slope has remained as a two to one slope on portions of the area around the system. Where the slope remains a two to one slope a barrier has been added. 7. The length of the tees in the septic tank have been added. 8. 12"max from the side of the septic tank to the tee has been added. 9. A riser has been shown on the profile over the septic tank/pump chamber. 10. The vent detail has been added. 11. The grades have been adjusted to prevent ponding. 12. The map and parcel numbers have been added. 13. The sill elevation has been added to the plan view. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, BenjaC. Osgood, President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 SEPTIC PLAN SUBMITTAL FORM LOCATION: 3-751 S EEM C-: NEW PLANS: YES $160.00/Plan L-� REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: YES NO DATE: t DESIGN ENGINEER: A)ew lin-t,-&j t .•'• e�/�He DATE TO CONSULTANT: When the submission is all in place,.route to the Health Secretary. NEW ENGLAND ENGINEERING SERVICES INC September 12, 2002 Sandra Starr, Administrator North Andover Board of Health 27 Charles Street North Andover, MA 01845 Re: 575 Salem Street, Septic system design Dear Sandra: Enclosed you will find the following documents pertaining to the above referenced property. 1. 5 sets of septic system design plans. 2. Application for approval. 3. Soil evaluator sheets. 4. Form 9A local upgrade approval form. 5. Check to cover the fee for approval. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, 9-- .2 �.-�. _ Benjamm C. Osgood, , EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at �5 7 S �-�. relative to the application of SvbSv2�'r" 1s4. dated --a�.r c�9�for plans by N. 6—C o E,yG, and dated _Cj! •-O�with revisions dated N114 I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b Final inspection — Engineer must first do their inspection for elevations, ties, etc. As- built or verbal OK from engineer eer must g be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work(other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other Persons shall absolve me of this obligation. Undersi Licensed Sept' taller �� Date: ,3"pA6�--©� Dispo 1 Works Construct on Permi # 'dl g I� Town of North Andover, Massachusetts Form No. 1 •" p10RTly BOARD OF HEALTH F H 11 �Eo i6a6•y�L O APPLICATION FOR SITE TESTING/INSPECTION A�R4TED pp`'(5 ��SSACHUS�� Applicant NAME A13DRESS TELEPHONE Site Location 7V`� Engineer��� eGOIi NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH FeeA4 Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 �I NORTH f� BOARD OF HEALTH qti a APPLICATION FOR SITE TESTING/INSPECTION Q�AATED PPp\�h SSACHUSE� Applicant � Q-�' (J NAME / U A)DDRE/S(-S�— TELEPHONE Site Location Engineerl G C q/o/x/ NAME Q ADDRESS TELEPHONE Test/I nspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee � � Test No.�6 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. i sr.:k NpRT pA� pF �I�p��E`�T�I 978 688 E54�A 01845 DATE. CATI pN z FpR Sp LOCATIIL TESTS ON 0": OF SOIL TESTS. AAP&PARCEL; � Sar A ),)p ecfL S�L _ SS: 5;2 67 ENG�ER. v� sy CE - TEL NO RTIFIED SOI h • VL 1 Use L EVALUATOR Intended : TEL. N °f L . a" h-.,� O" 7 Is Tbis: Residential subdivision 6 Repan. Testing: �c` � In the Lake C ogle Fancy Horne �_L TIIE Fp ochrche ck Watershed? Undeveloped lot to . COn mercial g 1 roof LO WING MUST Yes stuj 2. plot�ofland owne BE INCLUDED No P an 3. & rshi IT ITIS F Fee°f$425 Location o f(Tax 6� °r If T O two �per to . Testing ' letter from owne Percolati t for UD rales (If tune Sts require fo°nstruction r Perrlutting test) GENEal RCAL I is not crrtica ree each lis oss covers the are Hunan 1 Only Ce Fo ATIoN for repairs is$75��of$2�Per deep hole 3. At 1, ass- Re SOS Eval�tors P r lot for re aus and d east g stere ma 4' BOPaus equ yea hole d tw ans p°o f deep hole nq 5. FullHryepne sentativeeast two deep holesercolatioa tests essio Eng ce stc n 6. 0 I thin 4S days be treq,.ing for and at least one d for each se septic plans 7. within 6p acing the 0' a cal p ono additional tests wit Percolation test, a he discern arsPosal a. ea, of testing soil evalaall nests(uScl�i 1r than 1'hin ��;Weeks of testin retlon Of fthe Please n fob sla�I�ebO bed test�sh��subrrutted to ]VA. se Do No mrtted, the Boar t write BejOw This d °servation Conuniss. Dat ro Lin Date Received: n Approval: e Check Amount. ,-- Check Dare: ��3 �a tip.�: �,� • . dN o - o° SoauiL a-y� /j� O Sl ,o 2 _. o i TOWN OF NORTH ANDOVER INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Site: -5 ✓ Final Date: Installer: Tel: Date Yes No Initials A. Bottom of Bed / j 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. Co ments: (Use back of sheet for diagrams.) ysr ✓7 >='y/�-ti�E" .r1� ,ter 5� ,�/fir �=��j B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: ! " C. Building Sewer 1. Pipe diameter minimum^' 2. Schedule 40 pipe C,� �- 3. Inlet to tank cer.. Q.� �� T 4. Slope minimum l _ 5. Pipe properly set o. �� _ OI e1 hjG6. Pipe laid on con inu� 7. Cleanoutsrecede all, p (� r 8. Manholes at any 90°chi C f` 9. 10' minimum offset to wu �\ Comments: G3 D. Septic Tank �b� 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to w/in 6"of grade 5. Manholes over center and each tee 6. 3-20"manholes l/�L � C Z_ c w q 7. Outlet line cemented 8. 2"–3"drop from inlet to outlet 9. Pipe set 10. Compact base with 6"of 3/a"crushed stone under tank 11. Tank is watertight � 12. Tees 12"off side of tank r TOWN OF NORTH ANDOVER INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Site: ✓ Final Date: Installer: 061W SL),-;Cy Tel: Date Yes No Initials A. Bottom of Bed Al jw 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. Copmems: (Use back of sheet for diagrams.) (;(.Q.a rvs r ir54/Vb 'ivT B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Inlet to tank cemented 4. Slope minimum 0.01 or 1/8"per foot minimum 5. Pipe properly set on compact firm base 6. Pipe laid on continuous grade in straight line ✓1 7. Cleanouts precede all change in alignment and grade 8. Manholes at any 90°change 9. 10' minimum offset to water line IJ Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to w/in 6"of grade 5. Manholes over center and each tee 6. 3-20"manholes 1 19t/i\,,�j' C p 7. Outlet line cemented 8. 2"—3"drop from inlet to outlet 9. Pipe set 10. Compact base with 6"of 3/a"crushed stone under tank 11. Tank is watertight � 1.2. Tees 12"off side of tank 1 N&M Job number 1770/ Date Yes No Initials Comments: E. Pump Chamber 1. If separate from tank,compact base with 6"of 3/a"stone underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 1.0. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box 1. D-box level 2. Minimum 0.17"(2")drop from inlet to outlet 3. Minimum 6"sump 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe 9. First 2' from box laid level Comments: G. Soil Absorption system 1. All stone double-washed—3/a"— 1 1/z" -pea stone _ Bucket test done? 2. Minimum 2"of pea stone above distribution lines 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5. Toe of slope stops minimum 5' from edge of property; 5a. if not, then Swale. Comments: of 0(� N&M Job number 1770/ Date Yes No Initials H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agrees with plan. (Max.length 100') 3. Width of trenches agrees with plan-Minimum 2';maximum-4'. 4. Vent present if>50 feet or specified 5. Minimum distance between trenches 10' 6. Pipe slope minimum 0.005 or 6"per 100' 7. Depth of trenches below outlet invert minimum of 6". 8. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6"per 100' 3. Separation between pipes 6' maximum 4. Pipes connected at end&vent end raisedy 5. Separation between adjacent fields 10' minimum - 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines Comments: J. Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement 6. Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling �- 5. No areas over system that may pond 6. Grading meets 3:1 slope 7. Minimum of 9"of fill graded over system FORM 11 SOIL EVALUATOR FORM Page I of 3 No. Date: le 7-- Commonwealth of Massachusetts At4Apo(, z , Massachusetts Soil SuitahXU Assessment for On-site Sewage Disposal Performed By: .............. .. . . ;5-?' Date:.... .................................... . . /.... .... WitnessedBy: .................. ........7T��................................. ........................................... ...... ........ 7 W1 Address.arid Tckeptane NewConstruction El Repair R1 .Office Review Published Soil Survey) urvey Available: No El Yes F] �6?0;53 Year Published 1 ......... Publication Scale Soil Map Unit Drainage Class ........ Soil Limitations ...........................I.......................................... Surficial Geologic Report Available: No 21 Yes D Year Published Publication Scale GeologicMaterial (Map Unit) ............................................................................................................... Landform ........................................................................................................................................................................ . ....................... Flood Insurance Rate Map: Above 500 year flood boundary No El Yes El Within 500 year flood boundary No E]Yes D Within 100 year flood boundary No 0Yes 0 Wetland Area: National Wetland Inventory Map (map unit) ..................... ....................................................................................- Wetlands Conservancy Program Map(map unit) ............... .............................. ...... ......................... Current Water Resource Conditions (USGS): Month Range :Above Normal E]Normal 013elc-w Normal EJ Other References Reviewed: DEP APPROVED FORIM-12/07195 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. ��� -���� LTi/ Yom• f��1% On-site Review Deep Hole Number .2. Date:" .- Z TimeA ���'S� Weather��x' 1Z o Location (id,4ntqy on site plan) Land Use Slope (%) %:. Surface Stones : Vegetation Landform Position on landscape (sketch on the back) . ::.✓ij :: �� Distances from: Open,Water Body feet Drainage wayf .. feet Possible Wet Areae.. feet Property Line .:,�O: feet Drinking Water Well"15t, feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) l A, Parent Material (geologic) C �y� DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: 11 Estimated Seasonal High Ground Water: - DEP APPROVED FOPW- 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. On-site Review a Deep Hole Number .: : Date: Time:. ': Weathe��' Location (identif on site plan) �x �..:• i .�...��-�6 �...._. Land Use ......_ _:.. ... i� r �9G Slope (%) .�.. Surface Stones Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body ? �0 feet Drainage way..� feet Possible Wet Area feet Property Line ..:�.`...�.�... feet Drinking Water Well Y. feet Other :...::...:.":.::::...... ::...::::. DEEP OBSERVATION HOLE LOG` Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) 7 AO s s Parent Material (geologic) DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: �Q N Estimated Seasonal High Ground Water: DEP APPROVED FORM- 11/07/95 FORM 11 - SOIL LVALUATOR FORM Page 3 of 3 Location Address or Lot No. Determination for ,Seasonal ,Nigh Water Table Method Used: ❑ Depth observed standing in observation hole.................. inches ❑ Depth weeping from side of observation hole ................. inches Q Depth to soil mottles inches -7 ❑ Ground water adjustment ................... feet -00Z� Z Index Well Number .................. Reading Date .................. Index well level ................... Adjustment factor ................... Adjusted ground water level ........................................................ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in ei areas observed throughout the area proposed for the soil absorption system? � If not, what is the depth of naturally occurring pervious material? Certification 1 certify that on 1 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 require training, expertise and experience described in 310 CMR 15.017. Si natur r ate DEP APPROVED FORM-12/07/95 k i FORM 9A - Application for Local Upgrade Approval Commonwealth of Massach usetts Noiz-iji AA a -.p A- , Massachusetts (City/Town) Application for LOCAL UPGRADE ADDROVAL Title 5,-310 CMR 15.000 DEP Approved Form Required by 310 CMR 15.403(1) 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 15.417. NOTE: Local upgrade approval shall not be new desi flow to a cess ool or ri new for an upgrade proposal that includes the addition of a P p vy,or the addition of a new design flow above the existing approved capacity of a septic system constructed in accordance with either the 1978 Code or 310 CMR 15.000. Facility Address: 575 SA i pM S 1 Facility/System ownnler:�C K Say v Address: Ic 1 T(z�s'r 2v,a.1 ICY. City/Town:i► C��v E�./ STr e Telephone:�y78 1 ���3� _ State: rl7 4 Zip:8�y Type of Facility(check all that apply): 5 Residential Describe facility ❑Institutional ❑Commercial School `J .SINCrL L' F/-1-M�Ly D w^�L1N Type of existing system: ❑Privy ❑Cesspool(s) D@Conventional System ❑Other(describe) Type of soil absorption system(trenches,chambers,leach field,pits,etc) ci h n G w ni Design Flow per 310 CMR 15.203: Design flow of existing system gpd Design flow of proposed upgraded system�O Design flow of facility d gpd Proposed upgrade of system is: ❑Voluntary ❑Required by order, letter,etc.(attach copy) Required following inspection pursuant to 310 CMR 15.301 Provide date of inspection FORM 9A - Application for Local Upgrade Approval Department of Environmental Protection Page 1 of 3 DEP Approved Form—3/20/02 _ Describe the proposed upgrade to the system lass;R LSP49 1C ,—,q-,mss K 1'v P A-12 LCaCYi HES Local Upgrade Approval is requested for: ❑ Reduction in setback(s) (Describe reductions) ❑ Percolation rate for 30 to 60 min/inch Percolation rate min/inch ❑ Reduction in SAS area of up to 25% (SAS size and%reduction) SAS sq ft Reduction Reduction in separation between the SAS and high groundwater Separation reduction_ft Percolation rate /p min/inch Depth to groundwater 19 ft ❑ Relocation of water supply well(Explain) ❑ 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)(i)(1).The soil evaluator must be a'member or agent of the local anyrovine authority. High groundwater elevation determined by: ' SA ti> n P-jq s'-1-kl-a(L-- (Print or type evaluator's Name) (Signature of evaluator) (Evaluation Date) 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: ( t—s �. ;l�C s�i �u .v c) i L(iv w S cN P f, RGz'?l3 Th lS 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: _- Cos- !S Pnof4)04-11 U&7 Department of Environmental Protection DEP Approved Form—3/20/02 Page 2 of 3 / FORM 9A - Application for Local Upgrade Approval Pg 3. A shared system is not feasible: —tL� 4. Connection to a public sewer is not feasible: ti LM�J �F�...;�2 Cl�yIc 0 ti%G.1�i C r�u 5 it �- i .y T o The Application for Local Upgrade Approval must be accompanied by all of the following: (Check the appropriate boxes) Q� Application for Disposal System Construction Permit Complete plans and specifications [. Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other(List) 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. Facilityowner's signature ` G Print name �?jP„'U w , c.� Date ( //2/o 2 � � �J�12 yr - Name of preparer / e,- ei ��^ QS��`�� �2 Preparer's Address. Date />2/ a z_ LU c a OQ��G City/Town: 4 )�L�( �/ �u�� State. .N Preparer's telephone: ' Zip: car--=�`�._ P SG/'7f3 ) G£�6�176 @� NOTE: 310 CMR 15.403(4)requires the system owner to provide a copy of the local upgrade approval to the appropriate Regional Office of the Department of Environmental Protection,Bureau of Resource Protection,Division of Watershed Management,upon issuance by the local approving authority and before commencement of construction. Department of Environmental Protection Page 3 of 3 DEP Approved Form-3/20/02