HomeMy WebLinkAboutMiscellaneous - 59 WINDKIST FARM ROAD 4/30/20180
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MAP # LOT # y ''
PARCEL # STREET i�d Y- /'-a..,n.�
CONSTRUCTION APPROVAL *j 7
HAS PLAN REVIEW FEE BEEN PAID? f� n YES NO
PLAN APPROVAL: DATE ( �( APP. BY
DESIGNER: PLAN DATE f0/�
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CONDITIONS
WAFER SUPPLY:
WELL PERMI�
,3
WELL TESTS:
PLUMBING SIGNOFF
COMMENTS:
FORM U APPROVAL:
DATE ISSUED
CONDITIONS:
FINAL APPROVAL:
TOW WELL
DRILLER
CHEMICAL DATE APPROVED
BAC A I DATE APPROVED
BACTERIA II DATE APPROVED
WIRING SIGNOFF
APPROVAL TO ISSUE YES NO
BY
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
DATE:
BY:
SEPTIC SYSTEM INSTALLATION
IS THE INSTALLER LICENSED? _ YES NO
TYPE OF CONSTRUCTION: y NE REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YE NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YE NO
DWC PERMIT PAID? ES NO
DWC PERMIT NO . -Iy /_ INSTALLER:_
BEGIN INSPECTION YES NO:
EXCAVATION INSPECTION: NEEDED:
PASSED
CONSTRUCTION INSPECTION:
NEEDED:
AS BUILT PLAN SATISFACTORY: ES:
APPROVAL ` O BACKFILL: DATE: BY
FINAL GRADING APPROVAL: DATE S BY
FINAL CONSTRUCTION APPROVAL: DATE
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Owner
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Commonwealth of Massachusetts
Title 5 Official Inspection Fo
Subsurface Sewage Disposal System Form - Not for Voluntary,
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner's Name
N. ANDOVER
City/Town
SF'r' 151014
OHNGR7 M ANpOV
'�)'tPART n... FR
MA 01845 09/05/14
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
John J. Soucy
Name of Inspector
Soucy's Sewer Service, Inc.
Company Name
78 North Broadway
Company Address
Salem
City/Town
603-898-9339
Telephone Number
B. Certification
NH
State
13397
License Number
03079
Zip Code
1t
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
natu
09/05/14
Date
Thehystem inspector shall submitA 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner's Name
N. ANDOVER MA 01845 09/05/14
City/Town 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 - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner's Name
N. ANDOVER MA 01845 09/05/14
City/Town 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
obstruction is removed
distribution box is leveled or replaced
❑ Y
❑ Y
❑ Y
❑ N
❑ N
❑ N
❑
❑
❑
ND (Explain below):
ND (Explain below):
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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner's Name
N. ANDOVER MA 01845 09/05/14
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 invert or available volume is less
than 1/2 day flow
t5ins • 3/13
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
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 09/05/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® 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 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner
Owner's Name
information is
inspected for the condition of the baffles or tees, material of construction,
required for every
N. ANDOVER
page.
City/Town
C. Checklist
MA 01845 09/05/14
State Zip Code Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No .
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
W W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
State Zip Code
09/05/14
Date of Inspection
D. System Information
Yes
❑
No
Description:
Yes
❑
No
❑
Yes
❑
No
Number of current residents:
2
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)):
Detail:
See Attached
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑ Yes ® No
Current
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
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
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner
Owner's Name
information is
N. ANDOVER
required for every
page.
City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA 01845 09/05/14
State Zip Code Date of Inspection
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
Soucy's Sewer Service
1500
gallons
Maintenance and Inspection
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
D. System Information (cont.)
State
01845 09/05/14
Zip Code Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
1999
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from rivate water su I well or suction line'
❑ Yes ® No
261
feet
V pp y feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
15"
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
Sludge depth:
❑ Yes ❑ No
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
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is N. ANDOVER
required for every
page. CityTrown
D. System Information (cont.)
Septic Tank (cont.)
MA 01845 09/05/14
State Zip Code Date of Inspection
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
401
2"
711
14"
Tape and sludge tool
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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
l5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 09/05/14
page. City/Town 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 • 3/13 Title 5 Official Inspection Form: 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 59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 09/05/14
page. City/Town 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.):
FLOW CHECKED GOOD. NOTE: "D" BOX REPLACED PRIOR TO INSPECTION. SEE PERMIT.
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.):
* 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
D. System Information (cont.)
Type:
MA 01845 09/05/14
State Zip Code Date of Inspection
❑ leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
® leaching trenches
number, length: (2) 3' X 70'
❑ 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.):
NO SIGNS OF HYDRAULIC FAILURE
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection 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
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
MA 01845 09/05/14
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
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
MA 01845 09/05/14
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
t5ins • 3/13 Title 5 Official Inspection Form. Subsurface Sewage Disposal System • Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
D. System Information (cont.)
Site Exam:
® Check Slope
®
Surface water
®
Check cellar
❑
Shallow wells
MA 01845 09/05/14
State Zip Code Date of Inspection
4'
Estimated depth to high ground water. 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: Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
DUG HOLE WITH AUGER APPROXIMATELY 50' FROM REAR OF S.A.S., NO WATER AT 41
.
(GRADE ELEVATION DIFFERENCE 5' HIGHER AT S.A.S. LOCATION.)
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 59 WINDKIST FARM ROAD
Property Address
KATHY CROSETT
Owner Owner's Name
information is N
required for every N.ANDOVER MA 01845
page. City/Town State Zip Code
E. Report Completeness Checklist
09/05/14
Date of Inspection
❑ 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 8/18/2014 9:15:59 AM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-109.0-0050-0000.0
Parcel Id 18864
59 WINDKIST FARM ROAD
CROSSETT, ALEX
59 WINDKIST FARM ROAD
NORTH ANDOVER, MA
01845
Class 101 Single Family
Zoning2 1 Residential
Size Total 2 Acres
FY 2015
Property Type
Zoning3
1 Residential
1 Residential
UB Mailinct Index
Name/Address
Type
Loan Number
Active/Inact. From
Until
CROSSETT, ALEX
Payor
59 WINDKIST FARM ROAD
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No
Cycle
Occupant Name
Active/inactive
Bldg Id. 13777.0 - 59 WINDKIST FARM ROAD
Last Billing Date 8/4/2014
1090454
01 Cycle 01
Active
UB Services Maint.
Account No. 1090454
Service Code
Rate
Charge
Multiplier/Users
MISCFEEADMIN FEE
11
9.18
11
WTR WATER
01 ALL METER SIZE 175.52
/1
UB Meter Maintenance
Account No. 1090454
Serial No Status
Location
Brand
Type Size
YTD Cons
33406214 a Active
00
b Badger
w Water 11
699
Date
Reading
Code
Consumption
Posted Date
Variance
7/25/2014
970
a Actual
38
8/13/2014
176%
4/24/2014
932
a Actual
13
5/15/2014
-10%
1/27/2014
919
a Actual
16
2/14/2014
-57%
10/23/2013
903
aActual
36
11/18/2013
14%
7/23/2013
867
a Actual
31
8/15/2013
80%
4/24/2013
836
a Actual
17
5/20/2013
20%
1/25/2013
819
aActual
15
2/13/2013
-18%
10/23/2012
804
aActual
18
11/9/2012
-49%
7/23/2012
786
a Actual
35
8/14/2012
250%
4/23/2012
751
a Actual
10
5/9/2012
-41%
1/23/2012
741
a Actual
17
2/13/2012
-39%
10/24/2011
724
a Actual
29
11/14/2011
-44%
7/22/2011
695
a Actual
50
8/15/2011
268%
4/22/2011
645
a Actual
13
5/16/2011
-4%
1/25/2011
632
aActual
15
2/11/2011
-77%
10/21/2010
617
aActual
61
11/12/2010
9%
7/22/2010
556
a Actual
56
8/16/2010
273%
4/22/2010
500
aActual
16
5/12/2010
-21%
1/21/2010
485
aActual
19
2/12/2010
-22%
10/22/2009
466
a Actual
24
11/11/2009
-10%
7/24/2009
442
a Actual
27
8/12/2009
23%
4/24/2009
415
a Actual
22
5/13/2009
-2%
1/23/2009
393
aActual
23
2/10/2009
40%
10/22/2008
370
a Actual
38
11/12/2008
-39%
7/22/2008
332
a Actual
61
8/15/2008
207%
4/23/2008
271
a Actual
19
5/19/2008
33%
1/28/2008
252
aActual
16
2/19/2008
-85%
10/24/2007
236
aActual
106
11/16/2007
59%
7/20/2007
130
a Actual
63
8/15/2007
212%
Commonwealth of Massachusetts
Map -Block -Lot
109.00050
BOARD OF HEALTH
------
-- _.Permit
PermitNo
North Andover
BHP -2014-0765
FEE
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John Soucy
to (Repair) an Individual Sewage Disposal System.
at No 59 WINDKISTFARM ROAn"' �__.-.... _..--.---.--__.-.- --------------- -_-.
as shown on the application for Disposal Works Construction. Permit No. i3.HP-2014-076 D tuber 03, 201.4
.. - ---- ......
27
_._.. .. .
Issued On: Sep -03-2014 BOARD OF HEALTH
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
.� Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Q
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
59 WINDKIST FARM ROAD
Address
N. ANDOVER
City/rown
2. System Owner:
KATHY CROSETT
Name
59 WINDKIST FARM ROAD
Address (if different from location)
N. ANDOVER
City(f own
B. Pumping Record
1. Date of Pumping
09/05/14
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
GOOD
6. System Pumped By:
ROGER ROBEY
Name
SOUCY SEPTIC
Company
7. Location where contents were disposed:
G.L.S.D.
Signature of KAuler
hftp://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
MA
State
_ MA
State
978-549-3205
Telephone Number
— 2. Quantity Pumped
■❑ Septic Tank
01845
Zip Code
01845
Zip Code
1500
Gallons
❑ Tight Tank
If yes, was it cleaned? ■❑ Yes ❑ No
Vehicle License Number
09/05/14
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 9/9/2014
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair of D -Box
By: John Soucy
At:
59 Windkist Farm Road
Map 109.0 Lot 0050
North Andover, MA 01845
The Issuance/�f this certificate shaly�ot be construed as a guarantee that the system will function satisfactorily.
SuRan Sawyer
Public Health Agent
FF71LE COPY
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.lownofnorthandover.com
NORTH
9
Town of North Andover
,sSACNU`+t
HEALTH DEPARTMENT
CHECK #:
� DATER 111
LOCATION:
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal
❑ Body Art Establishment
❑ Body Art Practitioner
❑ Dumpster
❑ Food Service - Type:
❑ Funeral Directors
❑ Massage Establishment
❑ Massage Practice
❑ Offal (Septic) Hauler
❑ Recreational Camp
❑ Sun tanning
❑ Swimming Pool
❑ Tobacco
❑ TrashlSolid Waste Hauler
❑ Well Construction
SEPTIC Systems:
❑ Septic - Soil Testing
❑ Septic -Design Approval
❑ Septic Disposal Works Construction (DWC)
❑ Septic Disposal Works Installers (DWI)
❑ Title 5 Inspector
Title 5 Report
❑ Other. (Indicate)
7005
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 59 Windkist Farm Road
INSTALLER: John Soucy
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
MAP: 109.0 LOT: 0050
C,,, 1 Z 1 L -7 7
ep eapV4 AY:
INSPECTIONS & f ) `L -k,V
D -Box INSPECTION: I/X// v
DATE OF BED BOTTOM INSPECTION: Pa#Isv— /
DATE OF FINAL CONSTRUCTION INSPECTION:s Sv it�t.
DATE OF FINAL GRADE INSPECTION: 1,,,a�•J
Gs�
SITE CONDITIONS
❑
Contractor rerts any changes to design plan
❑
Existing septic tank properly abandoned
❑
Internal plumbing 61.1 to one building sewer
❑
Topography not appreciably altered
Comments:
SEPTIC TANK
❑
Building ewer in continuous grade, on
compacted firm base
❑
Cleanouts per plan
❑
Bottom of tank hole has 6" stone base
❑
Weep hole plugged
❑
1500 gallon tank has been installed
H-10 loading
❑
Monolithic tank con ruction
❑
Water tightness of tohas been achieved by
visual testing
❑
Inlet tee installed, centered under access port
❑ Outlet tee\nstalled, centered under access port
Comments:
(gas baffle ffluent filter)
❑
inch ver to within 6" of finish grade
installed over a access port
❑
Hydraulic cemen around inlet & outlet
Comments:
PUMP CHAMBER
❑
Bottom of tank hole has 6" stone base
❑
Weep hollugged
El1500
galloi1 Pump Chamber installed
❑
H-10 loading
❑
Monolithic tan onstruction
❑
Inlet tee installe centered under access port
❑
Pump(s) installed n stable base
❑
Alarm float working
❑
Pump On/Off floats rking
❑
Separate on/off floats
❑
Drain hole in pressure lin
❑
cover at final grade nstalled over pump
access port
❑
Water tightness of tank has been achieved by
testing
❑
Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
❑
Alarm &Pum are on separate circuits
❑
Alarm sounds hen float is tripped
❑
Location of cont I panel: basement
❑
Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX
Installed on stable stone base
[V]�
H-20 D -Box
Q'
Inlet tee (if pumped or >0.08'/foot)
[�
Hydraulic cement around inlet & outlets
❑
Observed even distribution
Speed levelers provided (not required)
Schedule 40 PVC Pipe
Comments:
1 s ,
A -li
t
la
H
.1
aoi
t � f
In+ i
r
rs
r
/ i
J; 1 14
d*
�,.•�. �.> Z J• � ,.fig � w'
t}
14,
— l rll�l b r%oh ,
i Y -L -vim c/
�. ,�, � p .� cam; b,-•. ,
• ��° Commonwealth of Massachusetts Map -Block -Lot
• • 109.00050
BOARD OF HEALTH -----------------------
Permit No
North Andover BHP -2014-0765
-----------------------
FEE
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted JOhn_SOUCy
---------------------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System.
at No 5-9-WINFARM ROAD "
----------------------------------------------------------------- ---------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2014-076 D ed--5zpt mber 03, 2014
-----------------------
----------- ---- -----------
Issued On: Sep -03-2014 -
----------------- BOARD OF HEALTH
Hof
6994
s gORT1�
Of t...o •� 1h0
3j .. . , • Oc
1 • 9
Town of North Andover
HEALTH DEPARTMENT
,sSAC NU
CHECK #:An&
DATE:
LOCATION: A !
H/O NAME:
CONTRACTOR N
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
TrashlSolid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
Septic Disposal Works Construction (DWC) 425,0-0
Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Q
t&3FA
Application for Septic Disposal System
Construction Permit - TOWN OF
NORTH ANDOVER, MA 01845
09/2/14
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
Q Repair or replace an existing system component —What? DISTRIBUTION BOX H-20
A. Facility Information
59 WINDKIST FARM ROAD
Address or Lot #
N. ANDOVER
City/Town
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump 0 Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
■❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement
[:1 Pressure Dosed (D -Box Present) S.A.S. &DVED
2. Owner Information
KATHY CROSETT
Name
59 WINDKIST FARM ROAD
Address (if different from above)
N. ANDOVER
City/Town
3. Installer Information
JOHN SOUCY
Name
78. BROADWAY
Address
SALEM
City/Town
4. Designer Information
N/A
Name
Address
City/Town
SEP U 2 2014
TH DEPARTMENT
MA 01845
State Zip Code
978-738-0610
Telephone Number
SOUCY SEWER SERVICE INC
Name of Company
NH
State
603-898-9339
03079
Zip Code
Telephone Number (Cell Phone # if possible please)
Name of Company
State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
°� Application for Septic Disposal System
jf °„4 SY
Construction Permit - TO`�1N OF
NORTH ANDOVER, MA 01845
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: ❑■ Residential Dwelling or ❑Commercial
B. Agreement
09/2/14
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environme ode, as well as the Local Subsurface Disposal Regulations for the Town of
Nortrsued;v
v,and not to place the system in operation until Certificate of Compliance has
been this Board P#Health.
ame y ' W” 6 Date
Applica do Approved By: oard of Health Representative))
6 � f
Na& Date
App4ation Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached.
2. Project Manager Obligation Form Attached.
3. Pump System? Ifso, Attach copv ofElectrrcal Permit
4. Foundation As Built? (new construction ronly).
(Same scale as approved plan)
5. Floor Plans? (new construction only):
Yes _,_�_ No
Yes No
Yes \ No
Yes
Application for Disposal System Construction Permit • Page 2 of 2
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
This is to certify that
the individual subsurface disposal system
constructed ( x ) or repaired ( ) D -Box
by North Andover Licensed Installer
Dave Maynard
at
Lot 4 Windkist Farm Road, North Andover, MA 01845
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 as described in the Design
Approval Site System Permit Number 956 dated 6/24/98.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
i
Board of Health Inspector
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTWICATION
The undersigned hereby certify that the Sewage Disposal System (11 constructed; ( ) repaired;
by
ra,
was iustalled .in conformance with the North Andover Board of Health approved plan, System
Design .Perinit # q dated 1,2y ,.- _.. , with an.approved design flow of 440
.gaaous per day. Ilse materials us6d were in conformance with those specified on the approved
plan; the system was.installed in accordance with the provisions of 310 CZAR 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.
installer: p� Lic. #: Date: t�
Design Engineer:
17
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Town of North Andover, Massachusetts
BOARD OF HEALTH
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Form No. 2
19 27
Applicant___ C��o-��d-� V IJ29r, /o/ems • Test No.
Site Location � � � 61`'t� 1�% S 7� C a "v� ROS. '
Reference Plans and Specs. G�""'-5¢''-•-.sem t spy^ i
ENGINEER DESIGN a TTEE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
� D
,4 /J
--CHAIRMAN, BOARD OF HIEALTH
Site System Permit No. n6—
LOCATION. /0
NEW PLANS: YES
REVISED PLANS: S
DATE -
DESIGN ENGINEER:
SEPTIC PLAN SUBMITTALS
$60.00/Plan
$25.00/Plan
0
When the submission is all in place, route to the Health Secretary
.r
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 6 - , z:2 - % CURRENT INSTALLER'S LICENSE# //%
LOCATION: l f�I� 7� Gc->- �c� 16
LICENSED INSTALLER:
SIGNATURE: TELEPHONE# G0.3
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
$75.00 Fee Attached?
Foundation As -Built?
Administrative Use Only
Yes No
Yes � No
Floor Plans? Yes �� No
Approval Date:
&ORTM 1
Ot t.�•D e, 't'p
° OL
O p
,SSACMUStt
Applicant_
Site Location
Form No. 3
Town of North Andover, Massachusetts
BOARD OF HEALTH
_.L.—
sln
DISPOSAL WORKS CONSTRUCTION PERMIT
I// / v
_ a-v� A
NAME zD /
7`
TELEPHONE
Individual Soil Absorption
Permission is hereby granted to Construct (/,j or Repair ( ) an
Sewage Disposal System as shown on the Design Approval S.S. No._-�—
CHAIRMAN, BOARD OF HEALTH
D.W.C. No. I /
Fee
25—
I
:ah;.7iti22�.•a:'?>.+:}�i?r;�i+t'`M ,.. +�a^:;t �?k�tif!�`ri+aGiS, ..;:i4?^tftuSF',tr'«0 i��it�'; rfiti*;,r�c'". .. .. .. ? .. .. � +.'c .. .. •-;r .+ . .. „ , .b':� ti �, t±cilS�3tEdt�
FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: V111e
,1 , z G Phone
LOCATION: Assessor's Map Number Parcel
Subdivision
,J Lot (s)
Street�i?/Cfj�jS %�--,l��y� �- St. Number
************************Official
RECOMMEN TIO OF WN NTS:
Conservation Administrator
Comments
Planner
Comments
Use Only************************
Date Approved
Date Rejected
Date Approved
Date Rejected
Food Inspector -Health Date Approved
Date Rejected
Date Approved 5`A
Septic nspector-Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit T,� c �� =�u ,� 97 _
Fire
ODepartment.,lir (� i
•�K-1/ter i 1J! `Ij ��
Received by Building nspector Date
FORM 11 - SOIL EVALUATORgeFOR M
Date: %
No.
Commonwealth of Massachusetts
y9 r4 140 Massachusetts
, Massac
• • • sment or On-site Sewa a Dis osal
Soil Suitabila Asses
Date: /
Performed By.
Witness BY:
pwrer's Name,
Colonial tli ll aye
k�
Lone on Address a {/✓ 1G( NT S� YI�•S Address. and
To
57—
�— reepne %D
3,,s
A,7 d44&(, M9 o
9)0.
LoewLstruction [9 Repair ❑
Office Review
Yes '
Published Soil Survey Available: No ❑ .
L
/ , /S' pfd Soil Map Unit b
Year Published
Publication Scale t............
......
................
' �C�i�'IQ.. ... ..
Drainage Class I�/el� "" Soil Limitations
Surficial Geologic Report Available: No
[Yes
Publication Scale
.. ........................
YearPublished ..................................... _.
• Unit)......................................................................
..
Geologic Material (Map ..................................
Landform za
Flood Insurance Rate Map: ^
Yes
Above 500 year flood boundary No U�—�/ ❑
Within 500 year flood boundary No lJ Y es
Within 100 year flood boundary Noes ❑
Wetland Area:.................................................................
.................
Map (map ma unit ..........
National Wetland Inventory .. --
maunit) ............................................
Wetlands Conservancy Program Map (map
Current Water Resource Conditions (USGS): Month
Range :Above Normal ❑Norrnal ❑Belt" 1 Normal ❑
Other References Reviewed:
iiDEP A PROVED FORM • 12107/95
l
Location Address or Lot Ao. P f2.t C,tl9, L-0 7—
FORM 11 - SOIL EVALUATOR FORM
Page 2.of3
On-site
On-site Review
ZDeep Hole Number ` Date:. GTime:..
Weather S`/�✓rv'1 G.f�
Location (identify on site plan)
Land use 6%( o!% we 9S Slope (%) 3"9 Surface Stones✓
Vegetation
Landform
Position on- landscape (sketch on the back)
Distances from:
Open Water Body feet Drainage way feet
Possible Wet Area feet Property Line feet
Drinking Water Well feet Other
DEEP OBSERVATION HOLE :.OG'
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, -Boulders, Consistency, %
GraveC
{�V2
F=S�
�o��L
Mr�SS�ut,ru�v�s
_
i►�v�ti7 �� rz
0-F
�f u
/0 L
1
FS L
Z�S`'I`Sl�
VZ44'sct ra #--te
ivrHSSr��n F=t
.Al 3 P
pgw fLoar3 rb 7 Z"l
�34�w
Parent Material (geologic)
7-11 -1
DepthtoSedrock:
Depth to Groundwater:
Standing Water in the Hole:
,��
Weeping from Pit Face: _
Estimated Seasonal
High Ground Water:
iiDEP APPROVED FORM - 12107/95
` FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No -1
IOU Ll�' L'O 7—
On-site Review
30-....
Date:....:.:tt" /440 Time:.. 2. ` Zo Weather S
Deep Hole Number
Location (identify on site plan)
Land Use LJ 9'3'0
Slope (%) '� Surface Stones F�
..... I..I......
Vegetation ..:0... , w!{cT1c, f�(Ngl.. +Sr71 S4)E") C440I , C.u�K......: _ ..::....
Landform
.............
Position on - landscape (sketch
on the back)
Distances from:
Open Water Body
feet Drainage way feet
Possible Wet Area ....
._.... feet Property Line . feet
Drinking Water Well
.. . feet Other
DEEP OBSERVATION HOLE .OG'
Depth from Soil Horizon
Soil Texture Soil Color Soil Other
(USDA) (Munsell) Mottling (Structure, Stones, Boulldl)rs, Consistency, %
Surface (Inches)
10 4 Y0 Z, M'i4 v V/,� P+u *isck
h !3
c MSK vi v0TS
Zo—Z� V�>Lj
S H 6 3 M ns S ! uti i'U L„z� rS Lo GcY
(" I
Z U
�S �, Z�S�I��t� 1'S'f N-5/9
,M 3P
'3e(,ow fi—at(.✓ E�altS i2ool3 7� 7 Z
'+-"! (��
Parent -Material (geologic) - DeptMoSedrock:
Weeping from Pit Face:
Depth to Groundwater: Standing
Water in the Hoie: ! OU
Estimated Seasonal High Ground Water: 7 4 ti -
DEP APPROVED FORM - 12107195
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
s��i2NI lZ�
Location Address or Lot No. l U l T
On-site Review
Deep Hole Number l7`4- r Date: 5—// 4- 7 Time: 0 Weather 70" (-CE-4'e-
Location (identify on site plan)
..:....... .....
Land Use .. FQ(Z Sr Slope M 3 Surface Stones
MOPa 1FSI�
Vegetation ..:�%�_� j ,
Landform .. DR-LIM L(Tl..
Position on landscape (sketch on the back)
Distances from:
Open Water Body � �O d feet Drainage way .7 O feet
Possible Wet Area 7 Z,00 feet Property Line 100 feet
Drinking Water Well -7100 feet Other
DEEP OBSERVATION HOLE
Depth from Soil Horizon Soil Texture Soil Color Soil
Other
Surface (Inches)
(USDA) (Munsell) Mottling (Structure, Stones, Bounders, Consistency, %
0-6
G t�-W Al C"K Hz-( lq (3 LE
L S
&I" AM
S-24 3Z U S 5 f l0 5V51b
C 4-8
C,ov;S
iRUPOSEID DISPOSAL AREA
DepthtoBedrock: 7�U
Parent Material- (geologic)
Depth to Groundwater. Standing Water in the Hole:
-- Weeping from Pit Face:
'r
Estimated Seasonal High Ground Water:
DEP APPROVED FORM - 12/07/95 . .
FORNI 11 - SUIL L� ALLr� i UK rU1,01
Pare 3 of 3
0
Location Address or Lot No.� ��-'� Y`�
termination for Seasonal High Water
Method Used:
Depth observed standing in observation hole inches
iinches
Depth weeping from side of observation hole
E Depth to soil mottles inches 29 0 �J
Ground water adjustment ................. Teet �
index Well Number .......... Reading Date ................ Index well level
Adjustment tactor ... .....
Adjusted around water level
Deoth of Naturally Occurrino Pervious Material
Does at least four feet of naturally
the soilabsorption r(systeal 'm? st in all.areas
observed throughout the area proposed
If not, what is the depth of naturally occurring pervious material?
^Artification
I certify that on L7_1 (date) I have passed the soil evaluator examinatior
ion approved by the Department of Environ ee et u Protect training, e peruse and ex d that Lhe above aeraen �:
was perTormed by me consistent with Lh q
ire
described in 310 CMR x.017.
Signature
�� ! ��-� Date
V
DFP APPROVED FORM - 12107195
FORM 12 - PERCOLATION TEST
Location Address or Lot No. l b r 4- WKL)KI S ( F6RA QJ)
COMMONWEALTH OF MASSACHUSETTS
-yok ff 41I00 U ,Massachusetts
Percolation Test*
Date:
Observation Hole #
P_Z 9
P-, 0
P-g+
97-4-I
Depth of Perc0/0/
Ntzr
r�
5`f
g
8 .
Start Pre-soak
Z11
2
lw,3�
End Pre-soak
Time at 12"
4-0
!0 : S4
Time at 9"
3:,34-
QST
#5n1vgoAIr, 9
TFsT
Time at 6"
4-:04
; U�
Time (9"-6")
&v
44
Rate Min./Inch
* Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed LJ Site Failed ❑
Performed By: PHILIP Ct1h(ST16AJSV4
Witnessed By: 5►9q i)V 5N MI Su3wN Fof21
Comments:..............................................................
.............................................................................
W, DEP APPROVED FORM -12/07/95