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HomeMy WebLinkAboutMiscellaneous - 58 OAKES DRIVE 4/30/2018 58 OAKES DRIVE 210/107.A-0145-0000.0 ) 72, �v 1 i i �i f i i � 5 NOTICE OF VARIANCE/DEED RESTRICTION Pursuant to 310 CMR 15.00 Title 5, and as a condition of the North Andover Board of Health Disposal Works Construction Permit# dated , notice is hereby given that real estate locate at 58 Oaks Drive, Essex County, North Andover, Massachusetts, (a/k/a Assessor's Map 107A/Lot 145), as described in a deed from Jeffrey F. Aufiero and Jennifer M. Aufiero to Brian K. Packard and Cara S. Packard dated October 22, 1997 and recorded on October 23, 1997 with the Essex County Registry of Deeds in Book 4873 and Page 82 and as Document#27369, is the subject of a variance from the Town of North Andover Minimum Requirements for the Subsurface Disposal of Sanitary Sewage A1.05 and C9.01(4). Said variance limits the maximum number of bedrooms at this dwelling to three bedrooms. This variance is within the jurisdiction of the North Andover Board of Health. Signed and sealed this 25th day of April, 2003. Brian I . Packar 0 X, Cara S. Pa and COMMONWEALTH OF MASSACHUSETTS Essex, s.s. April 25, 2003 Then personally appeared the above-named Brian K. Packard and Cara S. Packard and acknowledged the foregoing instrument to be their free act and deed, before me. --- // : 4d ,�- Ig . Essex. North County Registry of Deeds U0?Oevs_�,_ .'Pi Common Street Not ubhc: Mtchael E. Lombard ' `awrence, Massachusetts 01844 My Commission expires: 3/21/08 04/25/03 u. '77 Rpc° Tyr,- CFRT Cr 1 An DOC. _V ties Tot--1 ,._ THAN,!,( `7{ i F�7.'�i J. Burk.- 1 Lot & Street �%�s' 2x111, & Map/Parcel CONSTRUCTION APPROVAL Has plan review fee beenpaid: . YES NO Permit# b Plan Approval: Date: p 7> Approved by: Designer: �LC� Plan Date:�� Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved 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? NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: r SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? ,`YES N Type of Construction: NEW EPAIR�' New Construction: Certified Plot Plan Review YES Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: YE NO DWC Permit Paid? Y S NO DWC Permit# 9�, ' Installer: LC Begin Inspection: YES NO Excavation Inspection: Needed: Passed: By: Construction Inspection: Needed: hilt Plan Satisfactory: YES: Approval of Backfill: Date: By: 2,44,z�_) Final Grading Approval: Date: By: %% c, Final Construction Approval: Date: Ok&&Va By: Certificate of Compliance: Approval: Date: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Oakes Dnve ((l 6 Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Info When filling out DIVED forms on the computer,use 1. Inspector: only the tab key APR 1 + 2014 to move your Neil J. Bateson cursor-do not Name of Inspector use the return TOWN OF NORTH ANDOVER key. Bateson Enterprise Inb1EALTH DEPARTMENT Company Name 111 Argilla Road Company Address Andover MA 01810 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 "sSignature- Evaluation by the Local Approving Authority 4/8/2014 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 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 ' a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. City/Town 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 ❑ ® 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 invertor available volume is less than '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 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•3l13 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 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Yes 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 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped May 2013, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1700 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-3/13 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 "r 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 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: 11 years old, 5/20/2003, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 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.): Finished cellar unable to see piping leaving house, 4" PVC to tank Septic Tank(locate on site plan): Depth below grade: 1.5 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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. CitylTown 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" 81'Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" 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, outlet filter clogged. Clean filter level back to normal. Pumped septic tank. No evidence of leakage. Inlet tee &outlet tee has riser 2"deep 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 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owners Name information is required for North Andover MA 01845 4/8/2014 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 Forth:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 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. Pump ok. Floats ok.Alarm has both visual &audible. Pump tank has riser to grade over pump. * 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 25'x 44' ❑ 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. 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-3113 Title 5 Official Inspection Form: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 'r 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is North Andover MA 01845 4/8/2014 required for every page. City/Town 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 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 1P.e1� 3'► a I it �j-0 J_ % t4& q t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 or 17 Commonwealth of Massachusetts 'Me 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Oakes Drive Pr perry Address Ain-Made Tattan Owner 0 wrier's Name information is required for N rth Andover MA 01845 4/8/2014 every page. Ci !Town State Zip Code Date of Inspection . System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 3 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: 10/19/2002 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 on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Oficial 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 58 Oakes Drive Property Address Ann-Marie Tattan Owner Owner's Name information is required for North Andover MA 01845 4/8/2014 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Summary Record Card generated on 4/2/2014 12:26:42P by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.A-0145-0000.0 Parcel Id 17950 58 OAKES DRIVE TATTAN, JOHN & NNE-MARIE 58 OAKES DRIVE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.75 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until TATTAN,JOHN&ANNE-MARIE Payor 58 OAKES DRIVE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14344.0-58 OAKES DRIVE Last Billing Date 3/6/2014 2100348 02 Cycle 02 Active UB Services Maint. Account No.2100348 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 57.00 /1 UB Meter Maintenance Account No.2100348 Serial No Status Location Brand Type Size YTD Cons 35341125 a Active ERT HH b Badger w Water 0.63 0.63 335 Date Reading' Code Consumption Posted Date Variance 2/6/2014 344 a Actual 15 3/17/2014 -10% 10/30/2013 329 a Actual 15 12/20/2013 2% 8/2/2013 314 a Actual 15 9/18/2013 20% 5/3/2013 299 a Actual 12 6/18/2013 -16% 2/5/2013 287 a Actual 16 3/13/2013 -18% 10/31/2012 271 a Actual 17 12/13/2012 -9% 8/7/2012 254 a Actual 21 9/26/2012 59% 5/3/2012 233 a Actual 12 6/20/2012 -17% 2/6/2012 221 a Actual 16 3/14/2012 18% 11/2/2011 205 a Actual 13 12/15/2011 6% 8/2/2011 192 a Actual 12 9/14/2011 _1% 5/4/2011 180 a Actual 12 6/13/2011 -20% 2/4/2011 168 a Actual 16 3/15/2011 7% 11/1/2010 152 a Actual 14 12/13/2010 -4% 8/4/2010 138 a Actual 15 9/13/2010 -13% 5/4/2010 123 a Actual 17 6/9/2010 -10% 2/2/2010 106 aActual 19 3/11/2010 3% 11/2/2009 87 aActual 18 12/11/2009 -16% 8/4/2009 69 a Actual 22 9/11/2009 21% 5/4/2009 47 a Actual 18 6/16/2009 -11% 2/2/2009 29 a Actual 20 3/16/2009 36% 11/4/2008 9 a Actual 9 12/10/2008 0%e 9/10/2008 0 n New Meter 0 12/10/2008 0% 9/10/2008 2945 r Replacement -3 12/10/2008 -138% 8/4/2008 2948 m Manual estimate 20 9/12/2008 8% 5/2/2008 2928 m Manual estimate 17 6/18/2008 12% MSG 2/6/2008 2911 a Actual 17 3/14/2008 11% 11/2/2007 2894 a Actual 14 1/15/2008 -17%, Commonwealth of Massachusetts City/Town of . System Pumping Record Form 4 DEP has provided this form for useby 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 house, Left/ i ht 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 Cityfrown state Zp code 2. System Owner. V Name Address(if different from location) Citylrown ' ZIp Code -Y?o-- 1 Telephone Number z B. Pumping Record 1. Date of Pumping —�—` 2. Quantity Date Pumped: Gallons , 3. Type-of sYs.tem: Cesspool(s) &-Se�Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ No If yes, was it cleaned? es ❑ Na 5. Condition of System: 6. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Locati ere contents were disposed: O- S Lowell Waste Water Sig Hau Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 NEW ENGLAND ENGINEERING SERVICES INC June 3, 2003 FT Reilly and Son 206 Andover Street Andover, MA 01810 RE: 58 oakes Drive North Andover, Septic system as built plan Dear Mike: Enclosed are 5 copies of the as built plan for 58 Oakes Drive. You need to sign the certification and forward it with the as built plans to the Town of north Andover. If you have any other questions don't hesitate to contact this office. Sincerely, >;Z Belamni C. Osgood, r.,EIT President +.t7 2003 4, J 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 �4 r ' Of NOR7H q TOWN OF NORTH ANDOVER HEALTH ]DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 ss�c►+use Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 April 18, 2003 New England Engineering, Inc. Ben Osgood, Jr. 60 Beechwood Drive North Andover, MA 01845 Re: 58 Oakes Drive Dear Mr. Osgood: This letter is to inform you that the proposed septic plans dated April 4, 2003 for the repair of the septic system at the above address can be approved as soon as evidence of a deed restriction limiting the use of the dwelling to a maximum of 3 bedrooms is submitted to the Board of Health office at 27 Charles Street. Please call the office if you have any questions. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: Homeowner File 4 y NEW ENGLAND ENGINEERING SERVICES INC April 7, 2003 Sandra Starr,Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 P.i=R - 92003 Re: 58 Oakes Drive,North Andover, Septic system design Dear Sandra: a Enclosed are 5 copies of revised septic system design plans, one with an original stamp for the above referenced property. The following corrections were made to the plan. 1. The vent detail has been revised to indicate the installation of a charcoal filter/animal screen. 2. A thrust block detail and a note indicating that thrust blocks shall be installed at all force main bends has been added. 3. A special design note indicating the need for a deed restriction limiting the home to three bedrooms has been added. This plan is being submitted for approvaL If you have any questions regarding the information submitted,please do not hesitate to contact this office. Sincerely, Benjamin CagiodJr.,EIT President Cc Owner 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 / L yORTM TOWN OF NORTH ANDOVER °�, ,• '" . o HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 AC14 <� Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 April 2, 2003 Ben Osgood, Jr. New England Engineering Services, Inc. 60 Beechwood Drive North Andover, MA 01845 Re: 58 Oakes Drive Dear Mr. Osgood: This is to notify you that the proposed plans dated January 20, 2003 for the repair of the septic system at the site referenced above have technical deficiencies that must be addressed before the plan can be approved. They are: • A deed restriction limiting the dwelling to 3 bedrooms, or in other words no additional construction on the house until it is connected to sewer. • A note on protection for the vent. If you have any questions, please call the office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: Homeowner File Town of North Andover, Massachusetts Form No.2 f iORTh BOARD OF HEALTHo / O I DESIGN APPROVAL FOR ssACHU ` SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Z.Zl)�-j Test No. Site Location Reference Plans and Specs. . ��C�C. 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. CHAIRMAN,BOARD OF 14EALTH Fee Site System Permit No. t . NEW ENGLAND ENGINEERING SERVICES lk INC January 30, 20011- Sandra 002Sandra Starr, Administrator North Andover Board of Health_ 27 Charles Street North Andover, MA 01845 Re: 58 Oakes Drive and 93 Wintergreen Drive Septic system design Fees Dear Sandra: Enclosed is a check in the amount of 130.00 dollars to cover the fee increase for the review of the above referenced plans. Sincerely, C. O od, Jr., EIT Benjamin President FEB 3 X003 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 r SEPTIC PLAN SUBMITTAL FORM LOCATION: 5, ©R-K E.s Q a.t,is NEW PLANS: (�." $160.00/Plan REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: NO DATE: DESIGN ENGINEER: �N&-L-flN O N",A)�;c✓LrN (r-- DATE TO CONSULTANT: When the submission is all in place, route to the Health Secretary. NEW ENGLAND ENGINEERING SERVICES INC January 23, 2003 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 58 Oakes Drive,North Andover, Septic system design Dear Sandra: Enclosed are the following documents for the above referenced property. 1. 5 copies of septic system design plans, one with an original stamp. 2. Application for approval and required fee. 3. Copy of soil evaluator sheets. 4. Form 9A application for local upgrade approval. This plan is being submitted for approval. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, BenjaC. Osgood, J ., EIT President 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 t i • i FORM 11 - SOIL EVALUATOR FORM Page l of 3 Date: 1911WO2- No. Commonwealth of Massachusetts Massachusetts Soil uitabilit AssessmentsOn-site Sewage Disposal Date: Performed By: ................� ��1 ....... . .......................... Witnessed By: .p L Auon Address or �J/�lG �� Os'w's Name, �'^^�� Address,and ✓ a�`jGy�,'� v�yy� Loi d f�Q �iCl Telephone I � +— /\lo' r¢xI)-G �G'i A ew Construction ❑ Repair C� Office Review Published Soil Survey Available: No ❑ Yes . Soil Ma Unit Year Published �� Publication Scale l /.. ... . P --7.............. Soil Limitations ....�.�� . Drainage Class 7 Surficial Geologic Report Available: No ® Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) Landform ................................... ............ .... 4 Flood Insurance Rate Map: Above 500 year flood boundary No ❑Yes 10 Within 500 year flood boundary No ❑Yes ❑ 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 A�01.#W' eQ, Range :Above Normal ❑Normal ®Below Normal ❑ Other References Reviewed: DEP APPROVED FORM 12/07195 r t FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. On-site Review Deep Hole Number Date:.: Time; , WeathercIpy �Qo 9,�� Location (identify on site plan) Land Use ..: .! .�'A-44. ' Slope (%1 ." Surface Stones -- - VegetationG/.P��£, .... Landform Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way ` Q feet Possible Wet Area G'. feet Property Line .. .... feet Drinking Water feet Other DEEP OBSERVATION HOLE LOO' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulledl,rs, Consistency, % GravD 2- ifs i /-� 4'� 7t: 4 Gr 112 �6 Parent Material(geologic) 7-1CDepthtoSedrock: _ Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: �_�,__ Estimated Seasonal High Ground Water; - DEP APPROVED FORM- 12ID719S FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. On-site Review Deep Hole Number : Date: :!!:: ,9�Oz" Time:.JcWeathefn'qv' Location (identify on site plan) ! ' " Land Use ......:. : :. _7)a /Ti 4 Slope (%) Surface Stones _ 3/. Vegetation Landform . .::. ..:..: l�. . . �'��.... Position on landscape (sketch on the back) ! . Distances from: Open Water Body 40evd> feet Drainage way/:��.. feet Possible Wet Area / 2 o feet Property Line feet Drinking Water Well./�Q feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure,Stones, Boulledi'rs, Consistency, % Gravo � • 75Y11G�8 27 q v c 5f6- Parent Material (geologic) eg`7" K 4-4 DepthtoBedrock: _ Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: 2 --- Estimated Seasonal High Ground Water; DEP APPROVED FORM- 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. ©��—'�� �� �' Ak. �'�`��" � Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole..........._ inches ❑ Depth weeping from side of observation hole......... ... inches ® Depth to soil mottles . .:...f inches #' ❑ Ground water adjustment ..............I... feet ,O-� 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 existin 01 areas observed throughout the area proposed for the soil absorption system. 3 If not, what is the depth of naturally occurring pervious material? Certification I certify that on 401YI�5 (date) 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 LZDate DEP APPROVED FORM-12107/95 Page 1 of 5 9A-APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5, 310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) To be submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non-conforming system with a design flow of<10,000 gpd, where full compliance, as defined in 310•CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or non-conforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: 6R)A J ?QcKaZD Address: S-3 DAKEEs Do_tQC, N0271-f A- Ac­­0/G Phone#: 1?7t3-(�S,3r 66,yy Address of facility: 01+9,E5 O RW ijoILT)4 7N" D oo tt- 2) Applicant(if different from above) Name: s AM c Address: Phone#: 3) Type of Facility: (Specify)_✓Residential Commercial School Institutional Jul,0 G-LC Y::�9M/L y 9(.v G"),y 6- Page 2 of 5 4) Type of Existing System: _privy cesspools) conventional system , other(describe) Type of soil absorption system(trenches, chambers, pits, etc.) F,E D 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system_u o KNo, gpd Approved: _yes Approval date: no Why: b) Design flow of proposed upgraded systema3o Why f g2,,(2cp c) Design flow of facility 330 gpd 6) Proposed upgrade of existing system is: a) J_Voluntary required by order, letter, etc. (attach copy) Required following inspection required by 31 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) Describe the proposed upgrade to the system: `NS i ALL /lEw JSvo (,�Yc-�o.� lY9N K , PO AAP CKRMgr/1-, /� I> c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s)(list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per inch(state actual perc rate) Up to 25% reduction in subsurface disposal area design requirements (state required& proposed size) Relocation of water supply well (identify well, describe relocation) __�,/Reduction of required separation between bottom of SAS & high groundwater(specify proposed reduction& perc rate) -I;vo rye Jh ll-veo • r Y Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met(specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404& 15.405,or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) 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 ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater feet As determined by: Evaluator's name: A)mi-,�,t4 0A) Evaluator's Signature: Date of evaluation: to I1 G 1 20o z 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property 9or well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the department is the approving authority,then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: -LD M ,{ 1 G 26-02 s l o e s rem t t^A P�l ^ wG �e,S b&, ckL) rQvAe- cQ�c.ivicrs k S Oj—� U<n2 D r,Gr-+2 X 0 Lr b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. _ Cvs-r 15 %>ROK(13W0L) c) A shared system is not feasible. d) Connection to a sewer is not feasible. A10 S Fi ,QZ 10)An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications,site evaluation forms), must accompany this application. Is the DSCP application attached? ✓ yes no Page 5 of 5 11) Certification ; 1, 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 knowing violations." Facility Owner's tdgnature Date Print Name Name i6f Preparer ate Z70 - 686 —176 S 6,,2 Bet-,-eyoo30 01ziue Telephone No. &Address of Preparer NOTE: Title 5,310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. Town of North Andover AORTh Office of the Health Department 04+,.o Community Development and Services Division . 27 Charles Street c� North Andover,Massachusetts 01845 �9SswCHus Heidi Griffin Telephone(978)688-9540 flctif7g Public Health I)irectnj• Fax(978)688-9542 FILE TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE June 17, 2003 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by Mike Reilly at 58 Oakes Drive has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactoril Jonath arkey Ch ' ,North Andover Board of Health BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( )constructed; ('0) repaired; by /14t 14- 2e ," located at 5a O A-Kc---s- -1--T �� was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# , plan dated , with a design flow of 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: Engineer Representative Final inspection date: L- O Engineer Representative Installer: Lic.#: Date: . 6--S.iQ P S,9 / Engineer: Date:�ZC G_ -7 m TANGARD y 13021 Q 9FGISTER�� SSS/pNAI CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS Job The following is a checklist that incorporates all Title 5 and local regulations for septic plans. Name of Applicant: :]5t14V�AjCL9b Name of Designer: N68-5 Plan Date: Z o Q,3 Revision Date: Date of Review: Property Address: �� OGIC �'� Map: 1,07A Lot: _ BOH Reviewer: Type of Plan(new or upgrade):_ Number of Bedrooms in Assessor's Records: gpd)Garbage Disposal Allowed: 6 General Information: N.A. =North Andover Septic Regulations Other numbers refer to Title 5 OK Problem N/A Street number and map/lot-220(4)(u) Maximum scale of l "=40'for plot plan-220(4) Maximum scale of 1 "=20'for profile and component details-220(4) Legal boundaries of the facility being served-220(4)(a) Names of abutters from recent tax map- NA 8.02j Number of bedrooms,design talcs.,-NA 8.02i Name&address of record owner&applicant- NA 8.02k Name&address of designer-NA 8.021 Holder and location of all easements-220(4)(b) Date plan drawn&any revision date- NA 8.02m All dwellings and buildings,existing and proposed-220(4)(c) Location of all existing or proposed impervious areas-220(4)(d) {/ All distances on site plan—NA 8.03a-c Elevation of proposed driveway-NA 8.02t Location and elevation of foundation drain-NA 8.02y Location and dimensions of the system incl.reserve(new const.)-220(4)(e) Limits of excavation of leach area on site plan-NA 8.02z Locus plan-220(4)(t) (Not to scale) North arrow-220(4)(g) Existing and proposed contours-220(4)(g) Locations and logs of deep holes-220(4)(h) Locations and logs of percolation tests-220(4)(i) Date(s)of soil testing-220(4)(h)&(i) Existing grade elevation of each deep hole-220(4)(h) Elevation of percolation tests—N.A. 8.02n Name of approving authority representative-220(4)(h)&(i) Name of soil evaluator-220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines,drains,and subsurface utilities-220(4)(m) Observed and adjusted g.w.elevation in the vicinity of the system-220(4)(n) Complete profile of the system to scale-220(4)(o),NA 8.02c Cross section of leaching facility-NA 8.02w (Not to scale) Location of benchmark(s)within 50-75 feet of facility-220(4)(q) Note listing all variance requests with proper citations-220(4)(p) �� Local upgrade approval request form submitted-403(1) / 2 Original R.S./P.E. stamp,signature&date-220(1)&(2) P.E.,discipline specified within stamp. MGL C. 112 s. 81M sfc. supplies(w/in 400'),pub. wells(w/in 250'),pvt. wells(w/in 150')-220(4)( Location of watercourses,wetlands,wells,etc. Win 150'of system—NA 8.02r Wetland disclaimer—NA 8.02s RLS plan reference&certification required(prop line setbacks)-220(3) Plan contains designer's certification statement Use approvals/standards checked for I/A system-DEP docs., Perc rate>30 MPI-not allowed for new,LUA for upgrade-245(1)&('3) / Perc rate > 60 MPI-must use modified tight tank or UA technology-245(4) t/ Proposed system qualifies as "shared" system-002(definitions) Flow is over 2,000 gpd-No R.S.allowed-220(1) Design flow was set in accordance with code-203 ✓� Existing system location and note on proper abandonment-354 Leaching facility at least 1' above Base Flood elevation—NA 9.05 All piping Sch 40 minimum—NA 10.01 Basement floor minimum 1' above groundwater elevation—NA 5.04 r/ Foundation drain present with elevation—NA 8.02y On-site Soil and Groundwater Review OKE Problem N/A �j Proper deep observation hole logs on plan-220(4)(h) �✓ All deep holes and peres shown,including aborted tests—NA 8.02n Soil evaluation forms submitted within 60 days of field work-018(2) Proper percolation test log-220(4)(i) Ample deep observation holes in primary disposal area(minimum 2)- 102(2) t� Ample deep observation holes in secondary disposal area(minimum 2)- 102(2) Ample perc testing(one in each disposal area, 3 in prim.>2,000 gpd)- 104(4) Deep hole testing conducted within two years—NA 7.05 Hole Identification Numbers: ground elevation el. acceptable soil el. 71.— bL —7J Leach facilitv invert el. 101,---fAJ ground water el. 713 refusal el. bottom of leach facility el. /Q 0 thickness of acceptable soil 6, 17 T, V before&after soil R&R separation to groundwater (D separation to refusal soil class 2 3 perc rate loading rate septic tank below g.w. table (yes or no) pump tank below g.w. table (yes or no) l.f in fill -255(l) Setback Distances(Given in feet) 15.21 1 YES Q Is the lot in the Lake Cochiewick Watershed? NA 6.00&5.02 OK Problem N/A Septic Tank Leach Facility Property line 10 10 1/ Cellar wall 10 20 Inground pool 10 20 Slab foundation 10 10 Deck,on footings,etc. 5 10 Waterline 10 10 ✓/ Private drinking well 75 100 t/ Irrigation well 75 100 Wetlands 75 100 1/ Public well 400 400 ✓ Wetlands bordering surface 150 150 water Supply or trib. (in Watershed) I� Trib.To Surface Water supply 325 325 Reservoirs 400 400 Tributaries to reservoirs 200 200 r/ Drains(wat. supply/trib.) 50 100 Drains(intercept g.w.) 25 50 Foundation drains 10 20 Drains(Other) 5 1.0 ✓ Drywells 20 25 Downhill slope 15'to 3:1 slope 3 4 w/o barrier Building Sewer OK Problem N/A e` G Y 1 Grease trap required for certain uses(check 230 for details) Pipe diameter listed(4" minimum)-222(1) Pipe schedule listed-222(3) 17 tr Pipe cast iron or Sch 40 PVC—NA 11.02 Watertight joints specified-222(3)&(4) Pipe laid on compact,fin base-222(5) L' Pipe laid on continuous grade in straight line-222(7)@ Cleanouts precede all changes in alignment and grade-222(8) Cleanout provided every 100 feet-222(8) _/ ✓ Manhole at any 90 degree alignment cange-222(8) Invert elevation at building: 90, 6D Invert elevation at septic tank: qT 60 Length of run: _- 7 pe: GCS 4 (minimum of 0.01 -0.02 desired)-222(6) 10'offset to private well or suction line-222(2) Septic Tank OK Problem N/A Tank is accessible-228(3) No structures above tank—(228(3) Tank can accommodate both primary&reserve—NA 9.04 200%of flow(required&provided given. 1500 min.)-220(4)(f)&223)(1)(a) 2-3" drop from inlet to outlet-227(5) Minimum of 4'liquid depth-223(2) yj 3"air space above tees/baffles(minimum)-227(4) ✓✓ 9"air space above flow line(minimum)-227(4) Tees are not to be replaced by baffles-227(1) Tees extend 6" above flow line-227(l) Inlet tee extends 10" below flow line(minimum)-227(6) Outlet tee extends 14" below flow line(more for deeper tanks)-227(6) Gas baffle installed on outlet-227(4) Access manhole cover above center of tank&each tee(except 2 compart) / 228(2) r/ 3-20" manholes-228(2) 1 childproof,24"riser/manhole w/in 6"of final grade if<]000gpd-228(2) Inlet and outlet tees on center line-227(1) Soil compaction below tank specified(if soil is non-native)-221(2) 6" of<=3/4"stone beneath tank specified-221(2)&22 8(1) If> 1,000 gpd AND not a single fam.dwell. must be 2 tks or 2 comp.-223(1)(b) If plan specifies disposal must be 2 tanks in series or 2 compart.tank-223(1)(c) Buoyancy calcs.required if tank at or below water table-22](8) Tank is watertight-221 (1) 9" of cover over tank(minimum)-228(1) H- 10 loading(min.)-H-20 if traffic-226(3) Top of tank<=36" below grade-22](7) All pumping to tank(if applies)in accordance with-229 Tank is set to keep old system in service during install if possible 4 5 Tight Tank(Check here if not present: ) OK Problem N/A 500%of design flow or 2000 gallons provided—260(2)(a) 3-20"manholes—228(2) Soil compaction below tank specified (if soil non-native)—221(2) 6"of<=3/4"stone beneath tank specified—221(2)&228(1) Buoyancy calcs.Required if tank at or below water table—221(8) Tank is watertight—221(1) 9"of cover over tank specified(minimum)—228(1) H-10 loading(min.)—H-20 if traffic—226(3) Top of tank<=36"below grade—221(7) All pumping to tank(if applies) in accordance with—229 AN alarm set at 3/5 tank capacity—260(2)(c) Min. 1-24"frame w/cover at finished grade—228(2)(f) Year round access for pumping—228(2)(g) Distribution BOX(Check here if not present: ) OK Problem N/A Inlet elevation: /10L9_ Outlet elevation: IDI , VD !/ 0.17'drop from inlet to outlet(minimum)-232(3)(b) ✓ 6" sump(minimum)-232(3)(e) All outlets at same elevation-232(3)(b) V Outlet pipes laid level for first 2 ft. - 232(3)(c) �j Pipe Sch 40-NA 10.01 . 4/ Number of outlets: 1�2_ Number of laterals: Size of outlets: el 11�1 ✓/ Inlet baffle/tee nun. l" over outlet invert for all d-boxes-232(3)(a), ✓` Soil compaction below distribution box specified(if soil is non-native)-221(2) 17 - 6" of stone beneath distribution box specified-221(2) Box is watertight-221 (1) Top of box<=36" below grade-221(7) Buoyancy calculations required if box is at or below water table-221(8) Pump Chamber(Check here if not present: ) OK Problem N/A Volume specified: 220(4)(r) Pump on elevation- 220(4)(r) Pump off elevation: 220(4)(r) Alarm on elevation: 9J. 220(4)(r) Number of cycles per day-220(4)(r)(also 254(1)(d)if gravity from d-box) Minimum 2" delivery line to d-box if gravity-254(1)(c) Pressure dosed Lf.if flow>=2,000 gpd-254(1)(a)&254(2)(a) Cycles per day is consistent with chamber volume-23 1 Volume calculations include flowback volume-2') 1(2) 5 6 24 hour storage capacit above pump on elevation-231(2) ✓ Number of pumps: _ 2 if system serves>2 dwelling units-231(6) Capacity of pump(s)- r/Q gpm @ ,0 'TDH-220(4)(r) Pump can pass 1 1/4 "solids(minimum)-23](7) Pump controls specified-220(4)(r) Alarm equipment specified-231(2) Alarm is in building and powered on separate circuit from pump-2') 1(9) Pump sequence correct(off-lead on-lag on-alan-n on)-231(8) Pump performance curves included-220(4)(r) Manual operating switch-NA 12.01 Check valve,bleeder hole-NA 12.01 1 childproof,24" riser/manhole to final grade-2'31(5), Soil compaction beneath pump chamber specified(if soil is non-native)-221(2) �L 6"of<=3/4"stone beneath chmbr. specified-221(2)&228(1), f/ Buoyancy calculations if chamber is at or below water table-221(8)@ 9" of cover over chamber(minimum)-228(1) H- 10 loading(min.)-H-20 if traffic-226(')), Chamber is watertight-221 (l) Top of chamber<=36" below grade-221(7) Leaching Facility(general-complete for all designs) OK Problem N/A� 50%larger if garbage disposal-240(4) Trenches to be used whenever possible-240(6) No vehicle or imperv. area above l.f.unless unavoidable-240(7);NA 13.02 Vented if under impervious cover-241 (1) Vented through same pipes as distribution system-241 (1)(a) Vent protected from precipitation/animal entry-241 (1)(b) Vent is placed beyond traffic or impervious area-24 1 (1)(c) All lines connected to vent if bed or trenches-241(1)(d) 9" cover over peastone-240(9) Reserve area provided(new construction)-248(1) Reserve 4' from primary leach area—NA 9.04 4'(5'if perc rate<=2 MPI)separation to g.w.-212(a)&(b) 4'(down to T with variance or I/A-upgrades only)of natural soil under l.f. GW separation is adjusted to highest existing grade if facility cuts into a hillside Pipe slope minimum of 0.005 -251(9) Require 5'removal and replacement if in fill-255(5) ✓ Top of leach facility<=36"below grade-221(7) Final grade over l.f. minimum 0.02 ft/ft-240(10) ✓ Surface&subsurface drainage away from l.f.-240(1 1)&245(5) \J 4T_ ✓ Minimum design flow 440 gpd without deed restriction—NA 13.01 3:1 slope where grading required-255(2) V Toe of fill slope stops 5'from property line or swale installed-255(2) Impermeable barrier if<3:1 slope or< 15 feet to—3:1slope-255(2) Impermeable barrier/retaining wall poured concrete—NA 9.02 Retaining wall stamped by P.E. -255(2)(b) Top of retaining wall>=top of peastone elevation-255(2)(f) 10'offset from edge of leach facility to edge of ret. wall-255(2)(g) ✓ Perc test(s)done in most restrictive layer- 104(2) Perc test 4' below leaching elevation—NA 7.06 Design flow listed and required/provided leach area given-220(4)(f) Leach pipes SCH40 PVC—NA 10.01 Leach pipes minimum 4" diameter except for dosed system—NA 14.04 6 7 Leach lines capped,vented,or connected together-251(9) Pressure dosing guidance followed if pressure distribution-254(2)(c), Pressure dosing required over 2,000 gpd or with I/A remedial use-231(1) Leaching Trenches(Check here if not present: ) OK Problem N/A Number of trenches: Minimum of 2 trenches-NA 9.0](2) Depth of trenches(max eff. 2'): -247(l) Width of trenches(2'min.,4'max.): -251 (1)(b) Length of trenches(100'max.): -25 1 (1)(a) Trenches are vented(when>50')-251 (1 l) Trenches follow contour lines-251(2) Trench spacing 3 times effective width or depth minimum-251 (])(d) In fill or reserve between trenches, 10' min. -NA 14.01& 14.03 Available leach area given(Min. 500 s.f.)-NA 9.01(2) Bottom=L x W x# — s.f. Sidewall=L x D x# x 2= s. f. Effective leach area given Loading factor: Effective area=total area s.f. x LTAR = g/day Effective area is>=design flow of facility being served 2"of 1/8"- 1/2" 2x washed peastone.-247(2) Trench depth of 3/4" to 1 1/2�" double washed stone-247(1) Leaching Pits(Check here if not present: ) OK Problem N/A #of pits/pit systems: (dosing chamber if>1,231 (1)) Dimensions of each pit or system:L W D Depth of pits(max eff.2'): -253(1)(a) Available leach area given Bottom=L x W x#of systems= s.f. Sidewall=L+W x D x 2 x#of systems= s.f. Total area=bottom +sidewall — s.f. Effective leach area given Loading factor: Effective area=total area s.f. x LTAR = g/day Effective area is>=design flow of facility being served Minimum of 2 pits at least 13'X16'—NA 9.01(3) Distribution for galleries/chmbrs. in trench config.-pipe every 20'-253(6) Distribution for galleries/chmbrs.in bed config.-ea.pipe serves<=40 s.f.-253(6) Spacing-2 times the effective width or depth(the greater)-253(1)(c) 2"of 1/8"- 1 /2"2x washed peastone.-247(2) 3/4" to 1 1/2" double washed stone-247(1) Each pit has at least one 20" access cover. 24"CI to grade over 2,000 gpd -253(3) Surrounding aggregate thickness between 1'(min.)and 4'(max.)-253(1)(b) Vents,if necessary,extend under covers of pit(s)-241 (e) Leach Fields(Check here if not present: ) O , Problem N/A t/ Number of fields: (need dosing chamber if> 1,231 (1)) 7 I 8 Length(100' ax.): -252(2)(b) Width: 0 Total area: L x W = 13 s. f. - Minimum 900 square feet-NA 9.01(1) Distribution lines connected with solid pipe—NA 15.01 Effective leach area given / Loading factor:— 22 Effective area=total area s.f x LTAR _ J� g/dav Effective area is>=design flow of facility being served --✓ Minimum of two distribution lines-252(2)(a) 6'line separation(max.)-252(2)(d) 4'maximum separation from edge of field to line-252(2)(e) 10'minimum separation between adjacent leach fields-252(2)(f) Between 6" and 12" of 3/4- 1 1/2" stone beneath field-252(2)(g) &247(2) 2"of 1/8"-1/2" 2x washed peastone.-247(2) Final Grading OK Problem N/A Slope over leach area minimum of 0.02 feet/foot—240(10) Grading shall divert drainage away from leach area—240(l 1) ✓ Grading slopes away from dwelling 5/24/01 8 c Form No.3 r Town of North Andover, Massachusetts BOARD OF HEALTH NORTH O h p �,'•°,,,,p�.�•�,� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSES Applicant NAME ADDRESS TELEPHONE Site Location W Permission is hereby granted to Construct ( ) or Repair (,J'a"n Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. �CHAIRMA o-e D.W.C. No. Fee d APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: �J^�c CURRENT INSTALLER'S LICENSE# LOCATION• nc,�t S Vkj.Q_ LICENSED INSTALLER: F YT �Q"VYA-�� SIGNATURE: A/dTELEPHONE#__aaq-4a�j-) � CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION,PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 7G0 $175.00 Fee Attached? Yes �� No '�� Foundation As-built? Yes No Floor plans on file? Yes No Approval Date: INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at `� �,,�Q> � relative to the application of �rt��\� dated 11_'bra D-a for plans by 1Je�� �,� and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed- generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. C) Final Grade Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer Date: Disposal Works Construction ermit# 42V `` BOARD OF HEALTH Ti ,,yN OF i+.'oRYH ANDD DRi NORTH ANDOVER, MA 01845 BOARD OF HEALTH 978-688-9540 ` c8 r APPLICATION FOR SOIL TESTS -_ DATE: . 11*2 MAP &PARCEL: (0 7A 5 LOCATION OF SOIL TESTS: _5-8 O A1kc- s CQ\Qr OWNER: C3,-tar Pcir 14,C,(LD TEL. NO.: q-29- 6e2 ADDRESS: 3 ©j4K1=s P P-Lo F ENGINEER: TEL. NO.: CERTIFIED SOIL EVALUATOR: ��,�c iia IZp Sao Ile� D �� Intended Use of Land: Residential Subdivision FSingle Family Home Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area Fee of$200.00 per lot for repairs or upgrades. (If time isnot critical fee-for-repairs-is$75.00) GENERAL INFORMATION I. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan(no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests(including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commissi n Approval: Date Received: // OpZ Check Amount: o Check Date: // $ lo- S11"I", PLA W 13,447 ,3146 5 oc 287 IAI Al "NO ,4.333 10-A 21- lei( < 298 LOT- I()-,\( : I I IAC -6.944 290 289 1 15 -6.906 -(,024 19 C4� 51.104 O 110 44.145 as 3.0 ac 26 'j, 52.080 If 1.09 ac 1.28 ac 155' 151, 15s, 19C 152' iSY �49 60 61 62 3 4 68 67 27 2 1.01 Re 69 1.01., 1.02., 9 10 7 8 3.887 Re 1.02 Re 1.018 Re 1.015 Re 63 46 2.59 Re c 400 FEET = I INC 64 6 1.01 Re j FORM 11 - SOIL EVALUATOR FORM Paas 2 of 3 Location Address or Lot l-4o. 5-0 pig r S no L Jed 1 Nc7 C-� y - - On-site Review _ Deep Hole Number Date:///#//V L Time: Weather GLavD y o Location (identify on site plan) Land Use a c?09 S Slope (°,6) f Surface Stones N�`✓>` Vegetation //-a dE j t^Y r "�^ Landform Position on landscape (sketch on the back) . . ` rev Distances from: Z Open Water Body '7'lcpv feet Drainage ways v," feet ;;.l Possible Wet Area >/OVfeet Property Line . 7f�= feet r c Drinking Water Well _';V feet Other000 L I DEEP OBSERVATION HOLE LOGS Depth from Soil Horizon Sol Texture Sob Color Soil Other Surface(Inches) (USDA) tMunsell) Mottling (Structure.Stones,Boulders,Consistency,% Graven 0 — ZA 5 L Z — � $ Irv✓ L 5 /�R r/ �on•�p,v NI/� Parent Material(geologic) of p„p&,toged : > ,7 Z Death to Groundwater Standing Water in the Hole: ,� � Weeping tion Pit Face: �0 Estimated Seasonal High Ground Water: Z r-ORI- 6: _-te 1>try6u�A�-cam W i r.'i CE 5 s 6Z;' 8 r _ r/ G . Nov.-�/ L- Xe-'A %4 rO rZ DEP APPRON•m FORM•1210719S i FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot leo. 5-8' OR/C S pot a✓�.� jt7 a Nio. ,vtii,a'- ^,v 49 On-site Review _ Deep Hole Number Date: Time: Weather 4 4 Location (identify on site plan) Land Use HiOo P s Slope (%) Surface Stones Al A., �f�r� �/t—r/9//rGG'�TJ/� G A/ Vegetation ` � Landform Position on landscape (sketch on the back) . .,... Distances from: Open Water Body .7/�(7 feet Drainage way feet Possible Wet Area feet Property Line 7 r feet Drinking Water Well -'7�/15'1" . feet Other DEEP OBSERVATION HOLE LOG' i i Depth from Soil Horizon SoTexture oColor Sod(inches) pts (UA) (Munseli) ! Mottling (Structure.Stones.Boulders.Consistency. % Graven L yez MINIMUM OF-ITT= ,I Parent Material(geologic) 2 � aptt�tae•�: �'� Depth to Groundwater: Standing Water in the hole: r/ Weeping from Pit Face:_ / 2 ~ Estimated Seasonal High Ground Water rFOr-?,41 i= w i,�1 e s s'e v /►�y Dyi9 ti X e A VA '7-0Z ; SET APPROVED FORM-12107115 G FORM 12 - PERCOLATION TEST Location Address or Lot No. fr I COMMONWEALTH OF MASSACHUSETTS /Vo< 7'/'! ,/}7-NI12o v,—rrI Massachusetts Percolation Test* Date: f /oZ. Observation Hole # / Depth of Perc Start Pre-soak End Pre-soak 1 , Z Time at 12" Z z. Time at,9-,� Time at 6" Time (9"-6") Rate Min./Inch �-o iviinimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed ❑ Site Failed ❑ ......................................................................................................................................__._.....---........... Performed By: i'c" ir� n,��, ,� 1,�-,c�c, oi�.�►�,� Witnessed By: ,�v�/.•v ,r,Qc,,,v,,� ,r_ Comments: . :. DEP APPROVED FORM-12107/95 1 C SO I/V :IOL=.71.0 N i SOi ilvIE f l jiNlc .".i TI`I i\,-i E AT " O ERNIC-- ; 1- T I ivi E s ` tnN 4 i ;IVIL � Y