HomeMy WebLinkAboutMiscellaneous - 60 LONG PASTURE ROAD 4/30/2018 -60 LONG PASTURE ROAD -
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Commonwealth of Massachusetts
Title 5 Official Inspection Form REIV
Subsurface Sewage Disposal System Form-Not for Voluntary Assessme s 5 N12
60 Long PastureTH AN
Property Address HEALTH DEPARTMh-
James Vitas E l
Owner Owner's Name
information is
required for North Andover MA 01845 8/29/2012
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 Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil James Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
P Y
Andover MA 01810
re"m' Citylrown State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience.in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
MAI
8/29/2012
Inspector's SignatukJ Date
The system iMpector 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•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�oR*M Town Of North Andover
William J. Scott
Community Development & Services Director
27 Charles Street (978)688-9531
North Andover, Massachusetts 0 184 5
9ySNCH�15Et
Fax 978-688-9542
Board of
Appeals July 5, 2000
(978)688-9541
Building Gene Willis
Department Christiansen& Sergi
(978)688-9545 160 Summer Street
Haverhill, MA 01830
Conservation
Department
(978)688-9530 Re: Lot 4 Long Pasture
Health
Department Dear Gene:
(978)688-9540
This is to inform you that the revised septic system plan dated June 12, 2000 for
Public Health the site referenced above has been approved.
Nurse
(978)688-9543
If you have any questions,please do not hesitate to call the Board of Health
Office at 978-688-9540.
Planning
Department
(978)688-9535 Sincerely,
Sandra Starr,R.S., C.H.O.
Health Director
SS/smc
cc: Crowley
File
Apr-12-00 01 :08P Paul D. Turbide, PE/PLS 978-465-0313 P.02
April 12, 2000
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MA 01845
RE: Title V review for Lot 4 Long Pasture Road
Dear Sandra,
(The Town performed the original review for this system design in March 1997. We
did not perform that review and therefore we shall only review the one item that has
been changed [as per memo on the newly revised plans by the original design engineer),
namely the design increase from four bedrooms to five bedrooms.)
I find that the revised plans dated March 2, 2000 adequately address the regulations for
the increase in design bedrooms from four to five-
([ note that the deep hole tests are older than two years. The Local Board may have to
determine whether the site has been altered as per the North Andover Regulation 7.05
before allowing the design change.)
1f you have any questions or comments please feel free to contact us.
Sincerely
Carlton A. Brown, PEIPLS
PORT
ENGINEERING
Civil Engineers&
Land Surveyors
One.Harris Street
Newburyport,MA
01950
(978)465-8594
Received Mar-09-00 12: 13 from 508 688 9542 G page 2
Mar-09-00 12 :07 North Andover Com. Dev. 508 688 9542 P.02
SEPTIC PLAN SUBMITTAL FORM
LOCATION: % 7 tc. PQgS�GI _
NEW PLANS: YES S 125.00/Plan 1
REVISED PLANS: YES S 60.00/Plan
SITE EVALUATION FOR-NIS INCLUDED: YES O
DATE: (� d
t
DESIGN ENGINEER:
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three pians and included a
stamped envelope with the correct amount of postage to mail pians to Port
Engineering.
When the submission is all in place, route to the Health Secretary.
4Li �
Received Mar-09-00 12: 13 from 508 688 9542 -> G page 2
Mar-09-00 12:07 North Andover Com. Dev. 508 688 9542 P.02
CCK 1153
060
SEPTIC PLAN SUBMITTAL FORM ll.d
LOCATION:
NEW PLANS: YES $123.00/Plan
REVISED PLANS: <=-`� $ 60.00/Plan V
SITE EVALUATION FORMS INCLUDED: YES C�
DATE: 2i^ /D, o2mDo
DESIGN ENGINEER: h r sl-,CL VL6-e� F Se
c .
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three pians and included a
stamped envelope with the correct amount of postage to mail plans to Port
Engineering.
When the submission is all in place, route to the Health Secretary.
SEPTIC PLAN SUBMITTALS
LOCATION: /
NEW PLANS: YES $60.00/Plan
REVISED PLANS: (3YE $25.00/Plan\//
DATE:--,,I I
DESIGN ENGINEER:
When the submission is all in place, route to the Health Secretary
CHRISTIANSEN & SERGI, INC.
PROFESSIONAL ENGINEERS AND LAND SURVEYORS
160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372-3960
March 6, 1997
Ms . Sandra Starr
Board of Health
146 Main St .
No. Andover, MA 01845
RE: Long Pasture Road
Lot 4
Dear Ms . Starr:
In response to your letter of Feb 19, 1997, attached is
a revision to the above referenced Septic System Design Plan.
The following items have been added to the plan:
1 . Wetlands disclaimer
2 . D-box pipe statement
3 . Assessor' s map and parcel .
Ver tr y your p,
Phi p G. Christiansen
PGC;lc
Town of North Andover, Massachusetts Form No.2
NORTH BOARD OF HEALTH
• o+"u.e
++' DESIGN APPROVAL FOR
ii7ss�`HUSEt,�j SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant Test No.
e
Site Location
• Reference Plans and Specs. 7
ENGINEER DESIGN
Permission is granted for an individual soil absorption sewage disposal system to be installed
f in accordance with regulations of Board of Health. �y/dta
CHAIRh1AN,BOARD OF HEALTH
Fee Site System Permit No. �•
I
Town of North Andover f NORTH
OFFICE OF 3a �` 6,6 °
COMMUNITY DEVELOPMENT AND SERVICES - p
146 Main Street
North Andover,Massachusetts 01845 �,9"°•,.,o.•��ty
WILLIAM J.SCOTT SSACHUS�
Director
February 13, 1997
Christiansen & Sergi
160 Summer Street
Haverhill, MA 01830
Re: Lot #4 Long Pasture
Dear Phil:
This is to inform you that the proposed plans for the site referenced above have been
disapproved for the following reasons:
1. Wetlands disclaimer missing.
2. First two (2) feet of pipe out of D-box to be level.
3. Map & Parcel missing.
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
Sandra Starr, R.S.,
Health Administrator
SS/cjp
cc: Applicant _
William Scott, Director, P&CD
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
CHRISTIANSEN & SERGI, INC.
PROFESSIONAL ENGINEERS AND LAND SURVEYORS
160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 (508)373-0310 FAX: (508)372.3960
T0: Ms . Sandra Starr
Board of Health
North Andover
RE: Septic System Design Plans
Date .
9('
Attached are plans for
This ;de&ign is
a new submittal
a revision with the following changes
PLAN REVIEW CHECKLIST
ADDRESS 20/-1f 16V6 ENGINEER C��,(P/�7`T/moi 66�',O
GENERAL
3 COPIES `' STAMP C� LOCUS NORTH ARROW ��� SCALE
CONTOURS PROFILE Z,,— SECTION �-� BENCHMARK L--' SOIL &
PERCS c/ ELEVATIONS f WETS. DISCLAIMER„ W & WETS -
WATERSHED? U DRIVEWAY Elev) WATER LINEc/� FDN DRAINZ�
SCH40 v" TESTS CURRENT? SOIL EVAL D , O 'Caw,Ic—& -
SEPTIC TANK
MIN 150OG � . 17 INVERT DROP C-�" GARB. GRINDER J/0 comps +200)
10 ' TO FDN MANHOLE04 ELEV GW # COMPS. GB
D-BOX
SIZE 8 # LINES FIRST 2 ' LEVEL STATEMENT
INLET OUTLET / (2" OR . 17 FT) TEE REQ'D? Aleo
LEACHING //
MIN 440 GPD? RESERVE AREA`' 4 ' FROM PRIMARY?'y/ 20 SLOPE
100 ' TO WETLANDS L/ 100 ' TO WELLS - 4 ' TO S.H.GW f (5 ' >2M/IN)
20 ' TO FND & INTRCPTR DRAINS 400 ' TO SURFACE H2O SUPP L--�-
4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER (./ FILL? (15 ' )
BREAKOUT MET?
TRENCHES
MIN 440 gpd SLOPE (min .005 or 6"/100 ' ) SIDEWALL DIST. 3X EFF.
W OR D (MIN 6 ' ) L-- RESERVE BETWEEN TRENCHES? C-- IN FILL? L---- MUST
BE 10 ' MIN. l/ 4" PEA STONE? VENT? (>3 ' COVER; LINES >50 ' )
BOT .SQL` + SIDE -2-eO X LDNG i TOT 441- -?4k
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 0 1996 by S.L. Starr
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
6/14/01
This is to certify that
the individual subsurface disposal system
constructed (X) or repaired ()
by
Leo Virnel i
at
Lot 4 Long Pasture
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 satisfactorily.
Board of Health Inspector
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System 0"constructed;
( )repaired;
by /
located at f y ��o �c f� 7/ ��� 2 Z J
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit#_' dated with an approved design
flow of Y50gallons 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 epresentat've
Final inspection date: 1 2 2 Do
/ - ng' er epresentative
lnslalicr: 1C" Lic.#: _ Date:
Design Enginee . Date:
TO'J-VN OF NORTH ANDOVER/ )
BOARD OF HEALTH
ei
SAY 14 290
AS-BUILT CHECKLIST
LOT NUMBER, STREET NAME
1� ASSESSORS MAP & PARCEL NUMBER
1� LOT LINES & LOCATION OF DWELLINGS
LOCATIONS &DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
c/ TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES &PERC
TESTS
✓� ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK&D-BOX
ORIGINAL STAMP & SIGNATURE
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
✓'� NORTH ARROW
�~ LOCATION&ELEVATIONS OF BENCHMARK USED
�A
V
INSPECTION CHECKLIST FOR SEPTIC SYSTEMS �r /
Yes NO Initials_..-•-�/�
A. Bottom of Beds
1. Excavation to proper depth
2. With trenches,sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation,etc. 1 i
Comments: J ' '
p los
B. Retaining Wall
1. Wall height and width as specified
2. Waterproofed
3. Wall minimum 10'to leaching facility
4. Wall meets specifications of plan
Comments:
C. Building Sewer
1. Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Watertight joints
4. Inlet to tank cemented
5. Slope minimum 0.01 or 1/8"per foot minimum
6. Pipe properly set on compact firm base
7. Pipe laid on continuous grade in straight line
8. Cleanouts precede all change in alignment and grade
9. Manholes at any 90°change
10. 10' minimum offset to water line
Comments:
D. Septic Tank
1. Level
2. 1,500 gal minimum
3. Gas baffle present on outlet
4. Manhole to grade
5. Manholes over center and each tee
6. 3-20"manholes
7. Inlet tee minimum 12"under invert
8. Outlet tee minimum 14"under invert
9. Outlet line cemented
10. Air space 3"above tees
11. 2"-3"drop from inlet to outlet
12. Pipe set
13. Compact base with 6"of 3/4"crushed stone under tank
14. Tank is watertight
Comments:
h
. l
Yes NO
E. Pump Chamber
1. If separate from tank,compact base with 6"of/<"stone underneath
2. Minimum 2"pipe to d-box if gravity system
3. 20"access manhole
4. Tank level
5. Watertight
6. Tank size agrees with plan specification
7. Manhole to grade
8. Check valve and bleeder hole present
9. Alarm in building on separate circuit
10. Alarm functions
11. Manual operating switch
12. Pump delivers liquid to d-box
Comments:
F. Distribution Box
1. D-box level
2. Minimum 0.17"(2")drop from inlet to outlet
3. Minimum 6"sump
4. Outlet pipes show equal distribution
5. Compact base with 6"of stone beneath box
6. Box is watertight
7. All lines cemented with hydraulic cement
8. Schedule 40 pipe
Comments:
G. Soil Absorption system
I. All stone double-washed-'/. 1 %z" ✓
-pea stone
Bucket test done?
2. Minimum 2".of pea stone above distribution lines
3. Minimum 6"stone beneath pipe
4. Distribution lines capped or connected together
5. Grading meets 3:1 slope
6. Minimum of 9"of fill graded over system
7. Toe of slope stops minimum 5' from edge of property; if not,then swale.
Comments:
H. Leach Trenches
1. Minimum 2 trenches t/
2. Length of trenches agree with plan. (Max. length 100') �-
3. Width of trenches agree with plan-Minimum 2';maximum-4'.
4. Vent present if<50 feet or specified
5. Distance between trenches minimum 4'and maximum of 6'
6. Minimum distance between trenches 10'
7. Pipe slope minimum 0.005 or 6"per 100'
8. Depth of trenches below outlet invert minimum of 6".
Yes NO
9. Pipes set on stable base.
Comments:
I. Leach Field
1. Maximum length of field 100'
2. Pipe slope minimum 0.005 or 6"per 100'
3. Separation between pipe 6'maximum
4. Pipes connected at end
5. Separation between adjacent fields 10' minimum
6. Pipes set on stable base
7. Maximum 4'separation from edge of field to first line
8. Minimum two distribution lines
9. Maximum perc rate 20 mpi
Comments:
J. Leaching Pits
1. Minimum inlet pipe 4"
2. Pits of concrete
3. Sidewall between 12"and 48"wide
4. Access manholes on each pit
5. Pipes cemented with hydraulic cement
Comments:
K. Final Grade
1. Slope over soil absorption system minimum 0.02
2. All system components covered by at least 9"soil j
3. Cover soil free of stones larger than 6"
4. Grading slopes away from dwelling
5. No areas over system that may pond
Town of North Andover, Massachusetts
• t AORTH t � 1. BOARD OF HEALTH Form No.3
e�t
• O o a'�
+a 00
O
• h A
ACHU 'tom DISPOSAL WORKS CONSTRUCTION PERMIT
SACMUSE
Applicant
N ME AD RES S
Site Locatio TELEPHONE
Permission is hereby granted to Construct ( or Repair
Sewage Disposal System hn A Individual Soil Absorption
as sown on the Desi
r, g Approval S.S. No.- 2-0�
CH N BOARD OF HEALTH
Fee �a
D.W C. No. �1
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PE�1-C IIT
DATE: 1'45V/0U CURRENT D, 'STALLER'S LICENSE
LOCATION:
LICENSED D, +STULER: ,
SIGNATURE: TELEPHONEm ��� �Ooo�
CHE CK 0`+E:
REPAIR: NEW CONSTRUCTION: (/
IF NEW CONSTUCTION, PLEASE ATTACH FOUNT DATION AS-BLT LT.
Administrative Use Only
575.00 Fee Attached? Yes No
Foundation As-Built? Yes No
✓ i`i o
Fioor Plans? Yes
Approval Date:—
2z S�v
22
i
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the property
at relative to the application of �PU L,,/e// ,
dated z/g op for plans by 5'l 17 _W %4 and dated ( with
revisions dated 3 6 0
I understand and agree to the following obligations for management of this project:
1. As the installer I am obligated to 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 two shall be applicable .
2. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without completion
of the items in accordance with Title 5 and the Board of Health Regulations may result in a
$50.00 fine being levied against 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 BOH 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.
3. As the installer I understand that persons or companies not associated with my company may
not perform the work required by my company 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 in the Town of North Andover plus
significant fines to all persons involved.
4. 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.
d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components.
5. 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
edSe is Installer
sy% Date:
; 22
Town of North Andover, Massachusetts
Form No. 1
NORrM 9A. BOARD OF HEALTH
2°�,t LED 164 "YO
19
* j
APPLICATION FOR SITE TESTING/INSPECTION
��SSgcHLisE��y
Applicant ' �. �,�
NAME ADDRESS
TELEPHONE
Site Location
Engineer
NAME ADDRESS
TELEPHONE
Test/Inspection Date and Time
CHAIRMAN,BOARD OF HEALTH
Fee
Test No. �
S.S. Permit No. D.W.C. NO.
C.C. Date Plbg. Permit No.
Page I of 3
Date:
No.
Commonwealth of Massachusetts
lqo)zTjl ANI)OuerZ Massachusetts
age Disgosal
Soil Suitabilit Assessment y
Date: .......
Dnfita.4-,.....0-ClOriNELL.................................,.......
Performed By
.......................................................................................................................................................
wimessed By: ........
owwr's Ha= LUNG P"S TWeE VgW)0,-V&V?,coff-jo.
r
AddMu.Md
LOCRIM Addft&S Or OT
LAX I TemI P.
tl (/tip ain't
e
-STZ6�T
o j;-F
"
W Construction Repair
❑
Office Review
Published.d Soil Survey_Available: No Yes .........
Soil Map Unit
Year Published ...... Publication Scale
......................................................................................
...............
m
.fp.. Soil Limitations
itations
Dramage Class
�
Surficial, Geologic Report Available: No
'Yes .
❑
=Publication Scale
Year Published ........ ... .......................
............................................
G.eoiogic Material (Map Unit) ...........................................................
....................................................................
....................................................77....
Laridform
Flood Insurance Rate Map:
Above 500 year flood boundary No [Dyes
Within 500 year flood boundary No ❑Yes
Within too year flood boundary No [:]Yes
❑
W6tland Area: ..............................
.......................................................................
National. Wetland Inventory Map (Map unit) ....................................................................................................
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS): Month
Range :Above Normal ONormal OBeic-NNormal
❑
Other References Reviewed:
DEP APPROVED FORM 12/07195
rvxlvl 11 OWAAL A, >✓v va. •.
Page 2 of 3 j
Location Address or Lot IJo. fol 4 Loa1/6 PAST
On-site Review
Deep
Hole Number lb-1 T Date: rJ/ '�(v Time:. %h Weather $NN/V y 70
Location (identify on site plan)
Land Use .. l.J q U Slope (%)
3-8 Surface Stones
Vegetation ...AS19Wj Q140::�r M04 1 WdY.lzF--P/Aft
Landform
Position on landscape (sketch on the back)
Distances from:
Open Water Body feet Drainage way feet
Possible Wet Area feet Property Line Sb - feet
Drinking Water Well feet Other
DEEP OBSERVATION HOLE '—OG
Other
Depth from Soil Horizon Soil Texture Soil Color Soil
(USDA) (Munsell) Mottling (Structure, Stones,Boulders, Consistency,
Surface (inches)
o- s Iq Z. 4
FSC
X613 -
to4r4(o M�4SS( � Firwll��3(
3Z- 1Zlr✓ C� FSS Z'�4� C ZI) (FI-W-M IA) -Pua•Cefi SL,0[ I ►A
PL41 ce S
30" ffo pNLuLgrt SIDNr
ANO C.0135LOS.
F�LJ poo (b e5O
L t
MINIMUM U
?'/i DepthtoBedrock:
Parent Material•(geologic)
Weeping from Pit Face:
Depth to Groundwater: Standing Water in the Hole:
Estimated Seasonal High Ground Water:
3 11
DEP APPROVED FORld-12/07/95
FORM 11 - SOIL EVALUATOR FORM
Page Z of 3
Location Address or Lot No. LO t` 4 LQAJf'Y
On-site Review
Deep Hole Number
9f?-I S Date: 5-�Z¢��� Time: Weather 7oU
Location (identify on site plan)
...::..,::.:.....:.:.
Land Use .. WOO Y>S Slope (%) d"3 Surface Stones.
ti T swr' Q�4 AAWGf ( r'c.u. :�°� L,,p(rre P(Nf-
Vegetation :. .fNICK-�n-y 1 wI �1
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, Boulders, Consistency,
Surface (Inches)
D=� SSL' Z��l�3�Z MpSSr.v —vu�g
Z� —(ZS J�S (, Z,Stir�¢ 5K6 f 3 int tSuu� tea ►3
CZE
L cA
DepthtoBedrock.
Parent material-(geologic) Q
•� Weeping from Pit Face:
Depth to Groundwater: Standing Water in the Hole: 1,
Estimated Seasonal High Ground Water:
DEP APPROVED FORM-12/07/95 -
rvivYi �� - �viL L' Yt1Lu.t1J\Ji\ rvitlY.L
Page 3 of 3
Location Address or Lot No. -LO7 l,�N(r PrrfSiLf12
Determinatz'on for Seasonal High Water Table y
Method Used:
❑ Depth observed standing in observation hole inches
❑ Depth weeping from side of observation hole ........... .... inches
® Depth to soil mottles ...:.� inches
❑. Ground water adjustment .................:. feet
Index Well Number .................. Reading Date .................. Index well level ............. .. ..
Adjustment.factor ........:........:. Adjusted ground water level .........................................;........
:....
Depth of Naturally Occurring Pervious Material
Does at least four feet-of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? qS
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on IG 94 (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 444J AMd Date
DEP APPROVED FORM-12/07/95
FORM 12 - PERCOLATION TEST
Location Address or Lot No. L.OT 001-.Tu1:-E
COMMONWEALTH OF MASSACHUSETTS
/uor—lq fMiyOL)� , Massachusetts
Percolation Test`
Date: ..: Time:_....
Observation Hole #. _
Depth of Perc << 4¢ c
Start Pre-soak
End Pre-soak
Time at 12" °/ 0 f
Time at 9
/0;(1CS : Z7
Time at 6"
r0 ; .36 /Q � IZ
Time (9"-6") Z 4 SY
Rate Min./Inch -
0
* Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed 2�' Site Failed ❑
..............................................................................................:......................................_._.....__........
Performed By: G4f (S 111/VS6o -4 WC- 1
Witnessed By:
Comments: :::....:........
.:.. _.
DEP APPROVED FORM-12/07/95
FORM U - LOT RELEASE FORM
INSTRUCTICNS: Tnis farm 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/cr landowner `rom compliance with any applicable or.repuirements.
AFFLICA�NT FILLS OUT THIS SSECTICN
FHCNE
LOCATION: Assessors blan Nurcer FARCE_
SUBDIVISION WOr -1 3 L07 (S)
STREET (' �r1C� �Ca "� V� _ ST. NUbIHE:R(0
OFi-ILIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS: O
CGNSE:RVATION ADMINISTRATOR DATE APPROVED I OQ
I l DATE REJECTED
COMMENTS UAAI �✓/ �ok A. 4•%-) j,g+ _ a)4Sgs bwt�1
use dAJ b t,r t►.
TOW NER DATE APPROVED\
DATE REJECTED
COMMENTS
FOOD INSPECTOR4iEALTH DATI=.APPROVED
DATE REJECTED
SE= S ECTOR-HEALTH DATE APPROVED
CATE REJECTED
COMMENTS
PUELIC WORKS -SE'NErR/WA T ER CONNECTIONS iD
CRIVENAY PERMIT Gv /b -GrC7
FIRE DEPARTNIEliT
RECEIVED EY EUILCIlIG iiISPEC.TCR DATE
ReY iEed 9l9 im
��vt 1`i Cv �a � aoQ� 1 cs f 6+��vr►r� 0,J et,*,v- Coit
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT touk, e PHONE
ASSESSORS MAP NUMBER LOT NUMBER
SUBDIVISION 10P9 �/ Z-JA1.S LOT NUMBER }
STREET �a Nq Pis e STREET NUMBER L a
OFFICIAL USE ONLY I
RECONnv ENDATIONS OF TOWN AGENTS
DATE APPROVED
i
CONSERVATION ADMINISTRATOR
DATE REJECTED
COMMENTS
t
9
DATE APPROVED
TOWN PLANNER °
DATE REJECTED
I 1
CONMENTS
DATE APPROVED
s
FOOD INSPEOR TH DATE REJECTED
a
DATE APPROVED o
SEP ' IN9WCTOR-HEALTH DATE REJECTED
(/
A p
COMMENTS
I
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
4
FIRE DEPARTMENT
1
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
I
I