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Miscellaneous - 649 FOREST STREET 4/30/2018
0 FOREST STREETU� 21-0/105-1-0171-0000.0 C� �L { N SUMMARY OF INVERTS BUILDING TIES SEWER 0 FDTN. 99.62 . BLDG. CORNER A B C _NO THIS PLAN & CERTIFICATION IS NOT SEPTIC TANK IN 95.63 SEPTIC TANK OUT 43.0 45.7 A WARRANTY OF THE SUBSURFACE DISPOSAL SEPTIC TANK OUT 95.40 DIST. BOX 61.5 71.2 SYSTEM. IT IS A RECORD OF THE LOCATION DIST. BOX IN 95.03 AND ELEVATION OF THE EXISTING SYSTEM DIST. BOX. OUT 94.85 COMPONENTS. INV.. IN CHAM. 94.79 BOTT. CHAM. 94.47 LOT A-1 AREA-123,049 S.F. -2.8248 AC. z 0 G s "gym ^,1 {L B t Y C. �IX � d x „yyRnenwcemm. �%s 10, �ro 15-A1 IhA Fp4 Oak 17-A d 4 r g 1 12-A 18-A 10-A W-A A �. to NOM DA1R019MAL y - .;•-...w.. 1 ' x ': SERVICED.AME 30100 !-7t'+ ��y IN. ;: to Sn � FA (CE MED VBW&POOL) p} �'SL-ANIG r 20-A pwT r t VIEMT j OAL 4 i J, w, LfaCM ElLDw IWO GALA rA i-A 40 EIRIURA J qA/ D-em S S83'15 44 _ FOREST STRUT AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NORTH ANDOVER, MASS./649 FOREST STREET AS PREPARED FOR �H OF Mgss9c GREENSCAPE PROPERTY & BUILDING VLADIMIR L ti� DATE: 3—31-11 NEMCHENOK m „ , C4 ALE: TM: 105D. vtl 1 =40 NTL: 171 0 20 40 so o: NAL EN MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 Commonwealth of Massachusetts ... .U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 649 Forest Street 44 Property Address It Hernan Panzavecchia Owner Owner's Name Information Is required for North Andover MA 01845 10/21/2015 every page. City/Town 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: When filling out A. General Information RECEIVEU forms on the computer,use 1. Inspector: OCT 2 6 2015 only the tab key to move your Neil J. Bateson cursor-do not TpWN OF NORTH —I-r use the return Name of Inspector HEALTH �� key. Bateson Enterprises Inc. / Company Name ffi 111 Argilla Road Company Address Andover MA 01810 Cityrrown 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 ❑ Need 2Fuirthe Evaluation by the Local Approving Authority 10/21/2015 Inspector's tignaftr 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. i t5ins•3113 Title 5 Official Inspection Form: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 649 Forest Street Property Address Heman Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 649 Forest Street Property Address Heman Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 every page. City1rown 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 649 Forest Street Property Address Hernan Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 every page. Cityfrown 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 '/day flow t5ins•3/13 Title 6 ficial 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 649 Forest Street Property Address Hernan Panzavecchia Owner owner's Name information is required for North Andover MA 01845 10/21/2015 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•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 Foam-Not for Voluntary Assessments 649 Forest Street Property Address Heman Panzavecchia Owner Owner's Name information is North Andover MA 01845 10/21/2015 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 649 Forest Street Property Address Hernan Panzavecchia' Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 every page. City/Town State Zip Code Date of Inspection D. System Information Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): On well water 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts rA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 649 Forest Street Property Address Hernan Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 every page. CitylTown 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 two years ago,owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool P ❑ 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 649 Forest Street Property Address Heman Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 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: 4 years old, 3/31/2011, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No I Building Sewer(locate on site plan): Depth below grade: e 6 Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3" PVC in house, no leaks visible I Septic Tank(locate on site plan): Depth below grade: 2.6 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'x5'x4' Sludge depth: 2" 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 649 Forest Street Property Address Hernan Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 ' every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 2" j Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 13" 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.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Outlet filter clogged, clean same. Depth of liquid at outlet invert. No evidence of leakage. Inlet cover has riser 8"deep, outlet cover 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 649 Forest Street Property Address Hernan Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 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.): I i 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 I Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 649 Forest Street Property Address Hernan Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 every page. Cityfrown 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 leakage. Evidence of light carryover 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 649 Forest Street Property Address Heman Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 40 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil Ok. Vegetation ok. No sign of ponding to surface. Four rows of ten infiltrator chambers per row Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection 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 649 Forest Street Property Address Hernan Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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 M 649 Forest Street Property Address Hernan Panzavecchia Owner Owner's Name information is required for North Andover MA 01845 10/21/2015 every page. Cityrrowtf 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 9 P Y 9 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 "Ct)w z1( A4V Ll I 'Ll I 1. = 4 +--14 L4 1 , 3'_7 DA 3o7c .- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 649 Forest Street Property Address Heman Panzavecchia Owner Owners Name information is required for North Andover MA 01845 10/21/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont) Site-Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 10/26/2010Date ❑ 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-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 649 Forest Street Property Address Heman Panzavecchia Owner Owners-Name information is required for North Andover MA 01845 10/21/2015 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 Forth:Subsurface Sewage Disposal System•Page 17 of 17 : Commonwealth of Massachusetts IQ jp Cl'ty/Town of . ' System Pumping.Record Form 4 DEP has provided this form for use-by local Boards of Health. Other forms maybe•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: Lefti h nt of housl, Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town state - Zip Code 2. System Owner. Name Address(if different from location) City/Town state Zip Code ; ' _ -(v�"? •, (�0 5 � X13"�_ .� Telephone Number • ,r•. .B. Pumping Record �. 1. Date of Pumping O`�� l 5 2 Quantity Pumped: ©D '-_T Date Gallons 3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter resent? Yes ❑ No If es, was it cleaned? Yes No P Y ❑ 5. Condition of System: ff t) ii�Ctl 1rt'i it 6. System Pumped By: Neil.Bateson - F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents-were disposed: Lowell Waste Water Sign a Haul Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 • �r PUBLIC HEALTH DEPARTMENT Town of North Andover (ommunity Development Division f9? rlFICA�IE OF C0M(Lff--.,-,T.14JLjrVCE As of: Aril6, 2011 This is to cert that the individuaCsu6surface disposaf system received a SA` IS FAC`"ORT INS(ECYIION of the: Instadation of a New Inarividuaf On Site SewageIDisposaCSystem Wifliam 2: ,Sawyer At: 649nab~Lot.A-1 Forest Street Wap"l 05.0^AParcel-01 71 %orthAndover, 9WA. 01845 die Issuance o this certificate shaff not be construedas a guarantee that the system u4 ffunction satisfactorify. us n�Sa �'u Cu�[eaCtfi Director 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 918.688.8476 Web www.townofnorthandover.com µORTft p'1�tso.•'SMO O A� �1SSACNUS t� PUBLIC HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System(v4onstructed;( )repaired; By: I o 1-1 , A\,A-4 (Print Name) Located at: �o �d Kl Sr TYLE (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan,originally dated p '/UP—I'o and last revised on 1 `2-— 51 — 1 10 ,with a design flow of 1 4'10 gallons per day. T'he 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. Bottom of Bed Inspection Date: Engineer Represent tive(Signature) And—Print Name Final Construction Inspection Date: — Engineer Repr entative(Signature) LL �u�►/LG�E And—Print Name Insta (Signature) Date: And—Print Name Enginer: ��.9D/ /1`2r�t Glff � ignature) Date: 0 V44,011109 41�n140tieVok� - And—Print Name 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com Commonwealth of Massachusetts Map-Block-Lot 105.D0171 ----------------------- Q Board of Health Permit No North Andover BHP-2011-0563 P.I. FEE �S3CMUi F.I. $250.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted William Sawyer______________ ________________ to(Construct)an Individual Sewage Disposal System. at No 649 aka LOT A-1 (MAP l OS.D-PARCEL 171)FOREST STREET as shown on the application for Disposal Works Construction Permit No. BHP-2011-056 Dated __March-22,2011______ --------- Fil r: , -- Issued On:Mar-22-2011 na£lth Commonwealth of Massachusetts Map-Block-Lot 105.D0171 ar 4°f Board of Health --- ---- -- x North Andover . CERTIFICATE OF COMPLIANCE S��►c wu4# THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Construct) by ---William_Sawyer------------------------------------------------------------------------ -------------------------------------------- Installer at No 649 aka LOT A-1 (MAP 105.D-PARCEL 171)FOREST STREET has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-201.1-056 Dated March 22,2011 -------------------- ------------------------------ Printed On:Mar-21-2011 --------------------------- ------------------------------------------------ Board of Health e °Rrp Ij Application for Septic Disposal System 3/20/2011 ,tr• " ` °� TODAY'S DATE - T pConstruction P rmit — TOWN OF $250.00-Full Repair ;•b,,,,o., ORTH ANDOVER, MA 01845 $125.00-Component 1SSACM18�t Important: Application is hereby made for a permit to: When filling out ❑■ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your ❑ Repair or replace an existing system component-What? cursor-do not use the return key. A. Facility Information rat Address or Lot# j ST< City/Town /u de r 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump EgDravity(choose one) ***If pump system,attach copy of electrical permit to application*** ❑ Conventional System(pipe and stone system) ainfiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information ().r6tijSCa e A rej> e rel Name I I (� 6 b �j<<� (60 �aGY Address(if di erent om above) l D .- er rrl 0,50,'r-S City own `State Zip Code Telephone Number 3. Installer Information. t�l)L1Llam Sa".4P(- Name I Name of Company Addres City/ToW�— st�l�.. Zip Code Tela one umbel G'Cll Phone#!I possible p B�i9) 'pipone N (.. I 4. Q Name ' T' Name of Cornpany; Co ' S r, At to Eta cl(yrr41Mn Slow , Zip code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1.of 2 s �aerk Application for Septic Disposal System T—Zo —ZO i c 'Construction Permit — TOWN OF TODAY'S DATE $250.00 ORTH ANDOVER -Full Repair � MA 01845 $725.00-Component �SSACNUSt{ PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ❑Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. �(, SG4er 2,0 —ZDi Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Ssy tem? Ifso,Attach copy ofElectrical Permit Yes NoT/-� 4. Foundation As-Built. (new construction ronly): Yes No , (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: �6z A-/ notesi Sr --- (Address of septic system) For plans by e rri t/9lRG (Engineer) Relative to the application of_4 !"/lam t+ er (Installer's name) And dated -4 l o (Original ate Dated �I okay's ate With revisions dated (Last revised date) 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 approved121ans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer,I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or My company a. Bottom of Bed—Generally, this is the first(15) inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK(or e-mail to:healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work(other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board 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: .7-2-0 (Today's Date) am — runt ame— igne3) • SST PIED y6gG . • North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 649 Forest St. (a.k.a.) Lot 1-A MAP: 105D LOT: 171 INSTALLER: Tom Sawyer DESIGNER: Vladimir Nemchenok PLAN DATE: 10/26/10 rev. 12/9/10 BOH APPROVAL DATE ON PLAN: 12/15/10 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: 3/31/11 DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ® Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned Z Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: New construction (no existing tank) SEPTIC TANK ® Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan N/A ❑ Bottom of tank hole has 6" stone base °® Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ® Monolithic tank construction ® Water tightness of tank has been achieved by visual testing ® Inlet tee installed, centered under access port Z Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ® Hydraulic cement around inlet & outlet DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan ® 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ® Brand and Model of Chamber: Low Profile ® Number of chambers per row: 10 ® Number of rows (trenches): 4 Comments: Total Chambers = 40 SYSTEM ELEVATIONS AS-BLT INVERT DESIGN INVERT ELEV ELEV Benchmark Building Sewer OUT 98.00 99.56 Septic Tank IN 95.50 95.66 Septic Tank OUT 95.25 95.43 Distribution Box IN 95.00 95.05 Distribution Box OUT 94.83 94.87 Lateral 1 INVERT 94.78 94.78 Lateral 2 INVERT 94.78 94.79 Lateral 3 INVERT 94.78 94.78 Lateral 4 INVERT 94.78 94.80 CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh,Inland/Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib.to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot.Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other)Foundation 10(5) 20(10) ❑ Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws 0 i North Andover Health Department CommunityDevelopment Divi p Sion December 15, 2010 Greenscape Property&Building Attn: George Haseltine 66 Gilcrest Road Londonderry,NH 03053 Re: Subsurface Sewage Disposal System Plan for Forest Street,Map 105D, Lot 171, aka 649 Forest Street Dear Mr. Haseltine: The North Andover Board of Health has completed the review of the septic system design plans for the above referenced property. These plans dated October 26, 2010, final revision date of December 7, 2010,have been approved for a four(4) bedroom,maximum nine-room home. In accordance with 310 CMR 105. 020(2) " Construction of all systems for which a Disposal System Construction Permit application has been approved by the local Approving Authority and/or the Department shall be completed, and the Certificate of Compliance (COC) obtained within three years of issuance of the final approval."During this time a licensed septic system installer must obtain a permit and complete this work. Other items to be submitted prior to a COC is issued by the Town of North Andover are; an as-built of the system and an installation certification form endorsed by the installer, designer. This approval is subject to the following conditions: 1. Prior to receiving a building permit,the applicant must provide complete floor plans of the new home. Please include all living spaces. 2. Prior to receiving a Disposal Works Construction permit,the applicant must provide a foundation plan in 1"=20' scale to overlay on the septic plan. 3. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Page 1 of 2 North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Forest Street Map 105D Lot 171, aka, 649 Forest Street Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 4. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector,Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you might have. Sincerel. f J/'wJ Susan Sawyer;REHS/R Public Health Director cc: Vladimir Nemchenok, Merrimack Engineering, c/o: Bill Dufresne File Page 2 of 2 North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 � 4 TOWN OF NORTH ANDOVER E KCR*h Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT40 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 •---- ,. NORTH ANDOVER, MASSACHUSETTS 01845 40 hone Susan Y.Sawyer,REHS/RS 978.688.847 AX Public Health Director E-MAIL:he lthde t townoftro' ' dove om WEBSITE:h :// ` wrlo andover. om SEPTIC PLAN SUBMITTAL FORM Date of Submission. It —t- 10 Site Location: enur'r -rm 10-4 TI O?1 fz% 1 Engineer: HEW0 AC-k, X1.9610eWA New Plans? Yes ✓ $225/Plan Check# 6te®(includes lst submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes No V/ Telephone#:6 Fax#:6'75 L4 E-mail: 13 fA.R4 r-12.6*pFg-co h 4 if&5`r;L2 E� Homeowners r Name: OFFICE USE ONLY When the submission is complete(including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt ➢ Copy File;Forward to Consultant ➢ Enter on Lok Sheet and Database Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F i A. Facility Information Owner Name yT �KmT 1 b b I I Lo� Ma Street AOL & City �K••t State Zip Code B. Site Information 1. (Check one) [ New Construction ❑ Upgrade ❑ Repair 26,0 2. Published Soil Survey Available? YeS ❑ NO If yes: Year Published Publicati n Scale Soil Map Unit Soil Name — Soil Limitations 3. Surficial Geological Report Available? ❑ Yes ff No If yes: Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map Above the 500-year flood boundary? 2eYes ❑ No Within the 100-year flood boundary? ❑ Yes [?--No Within the 500-year flood boundary? ❑ Yes No Within a velocity zone? ❑ Yes LNo 5. Wetland Area: National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit -Name 6. Current Water Resource Conditions (USGS): ° SOI Range: ❑ Above Normal Normal ❑ Below Normal Moth/Year 7. Other references reviewed: t5form11.doc•rev.1/10 Form 11–Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Dee Observation Hole Number: � 6 Z! -!O 10 �OD+dC�t 7�`° �z r Deep Date Time Weather 1. Location Ground Elevation at Surface of Hole: 19 Location (identify on plan): E 2. Land UseIf"LAOr ope(% (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones ) Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body >16w, Drainage Way �—� ` Possible Wet Area feet feet Drinking � t Property Line fee Drinking Water Well �ee� Other ��feet 4. Parent Material: Unsuitable Materials Present: ❑ Yes 2 No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock :�2 Z_°� QLI I! 5. Groundwater Observed: [ Yes ❑ N(O�, If yes: Depth'Weeping from Pit Depth Standing Water in Hole Q®s� �e9 �l - 1 Estimated Depth to High Groundwater: inches elevation t5form1l.doc-rev.1/10 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal -Page 2 of 8 &\ Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) Dee Observation Hole Number: �Z LIZ }O 1 3 � 79 IJA��►� P Date Time Weather 1. Location Ground Elevation at Surface of Hole: Location (identify on plan): 2. Land Use ��L,,A (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%)T 6J422 W[2 epa. WQ *Igo 45;!!49PC Vegetation Landform Position on Landscape(attach sheet) 3. Distances from: Oen Water Bod DrainageWay Possible Wet Area �Ili g p y feet y feet t feet e Property Line fee Drinking Water Well Other feet 4. Parent Material: �L Unsuitable Materials Present: ❑ Yes r Nio If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock pyn if I is 5. Groundwater Observed: Yes ❑ No If If yes: Depth Weeping from Pit Depth Stanjii g Water in Hole Estimated Depth to High Groundwater: inches•, elevation t5form11.doc-rev.1/10 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal -Page 2 of 8 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Dee Observation Hole Number: T�3 �' P ate Time Weather 1. Location LL d. Ground Elevation at Surface of Hole: Location (identify on plan): 7 E 2. Land Use ,`AQ21�L'&k n-,> 3,I% �� (e.g.,woodland,agricultural fief,vacant lot,etc.) Surface Stones Slope(%) �A-1 � t 1 �!� Vegetation` ���� Landform Position o�cape(attach sheet) 3. Distances from: Open Water Body 'feet Drainage Way e-� Possible Wet Area feet Property Line feet Drinking Water Well fe Other feet 4. Parent Material: �--I 1 t Unsuitable Materials Present: ❑ Yes 9�-No If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock of 7D o. 5. Groundwater Observed: VIYes ❑ No If yes: 11155 Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 3 +! P 9 inches elevation t5form11.doc-rev. 1/10 Form 11 —Soil Suitability Assessment for on-Site Sewage Disposal -Page 4 of 8 Commonwealth of Massachusetts City/Town of d• Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) a `z _ —1�e Ly Dee Observation Hole Number: Dte Time Weather � 1. Location Ground Elevation at Surface of Hole. Location (identify on plan): 2. Land Use lA.�w rte..&Nb Slope(%) (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Vegetation landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body feet— Drainage Way feet Possible Wet Area feet 18 Property Line fecl_rlet feet Drinking Water Well feet Other feet 4. Parent Material: Unsuitable Materials Present: ❑ Yes [ IQo If Yes: ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: Yes ❑ No If yes: Depth Weeping from Pit Depth Standing Water in Hole 7i0:1 Qi101 1 Estimated Depth to High Groundwater: inches elevati n t5form11.doc•rev.1/10 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8 <C\ Commonwealth of Massachusetts luCity/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: T Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Co(Depth(in.) Layer Moist(Munsell) (USDA) Cobbles& Structure (Moist) Other Depth Color Percent Gravel Stones Le 7'S Additional Notes: t5form11.doc•rev.1/10 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) (USDA Structure Consistence Other Layer Moist(Munsell) DepthColor Percent ) Gravel Cobbles& (Moist) Stones o V, A vcgiz/%, r-°5.L. Additional Notes: t5form11.doc•rev.1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review, (continued) Deep Observation Hole Number: 3 Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) USDA Structure Consistence Other Layer Moist(Munsell) (USDA) Cobbles& (Moist) Depth Color Percent ravel Stones 11-42 0 10 nth-`�� � 5-� ��►��-� �.►'•J��► (I lI f e�/j Additional Notes: t5form11.doc•rev.1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City/Town of d Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: T Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA Structure Consistence Other Cobbles 8 (Moist) Depth Color Percent ravel Stones ate. Fni&15,100 Z,5;Y 5Y !Z �' rle Z,La�o-i5;(v -Ue Ftrr.wl Additional Notes: t5form11.doc•rev.1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: A. B. ❑ Depth observed standing water in observation hole inches inches A. B. ❑ Depth weeping from side of observation hole inches inches [.Depth to soil redoximorphic features (mottles) A. �� I B. 2!S inches inches B. ❑ Groundwater adjustment(USGS methodology) A. inches inches 2 Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? '�t �T- Z' Yes ❑ No +� k�` ,� 41Jet al b. If yes, at what depth was it observed? Upper boundary: inches boundary: inches t5form11.doc•rev.1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal 0` D. Determination of High Groundwater Elevation 1. Method Used: B• ' El Depth Depth observed standing water in observation hole inches inches A. B. ❑ Depth weeping from side of observation hole inches 2 ,t inches ,e �epth to soil redoximorphic features (mottles) in / B. inches inches ❑ Groundwater adjustment(USGS methodology) in inches inches 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil 7abso ion system? � Yes ❑ No • a �^• �np b. If yes, at what depth was it observed? Upper boundary: inches Lower boundary: inches t5form1l.doc•rev.1110 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. 0_:�• C 2_e e�� — —l0 Signature of Soil Evaluator I Date Lx.1ILUAI-1 [2U�5,47 �Ev� 'ICO Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam Name of Board of ealth Witness BoarA of 116iltli In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. t5form11.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8 Commonwealth of Massachusetts City/Town of Percolation Test Form 12 M !v Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. Important: When filling out A. Site Information forms on the �� — r 1�.��L► �SLA computer,use only the tab key Owner Name to move your cursor-do not use the return Street A dress or Lol# key. Dal`fo �fIJIE {� CitylTown State Zip Code (�Aa9) 7&6 Anact Person(if different om Owner) Telephone Number B. Test Results Date Time Date Time Observation Hole# ` -) 2, Depth of Perc Start Pre-Soak A ' End Pre-Soak Time at 12" II ! II 5*0 Time at 9" ' t Time at 6" Time(9"-6") 2160 Rate(Min./Inch) L Test Passed: [ Test Passed:. Roe", o . Test Failed: ❑ Test Failed: ❑ Test Performed � By: � - Witnessed By: Comments: t5form 1 2.doc-06/03 Perc Test•Page 1 of 1 NUMBER D FEE THE COMMONWEALTH OF MASSWAC USETTS Gown of �./J D/� .. f_ ............ at ----------- -- ---- This is to Certify that --------------- --------------------- ............... ----- DM GRANTED A LICENSE For .....A'. ... ---------------------------------------------- ---------------------------------------------------------------- ------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- This licis granted in conformity w ith the Statutes and ordinances relating thereto, and expires— .zya-- ---//------------- unless sooner suspended or revoked. Pfj r-F-------------------- ---------------- ----------- -------.--- - re- --- ---------- ................................... ............. ----------------------0----------------------------------------------------------------- ---------------------------------------------------------------------------------------- FORM 488 H&W HoBBs 8 WARREN TM TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y.Sawyer,REHS/RS 978.688.9540—Phone RECEIVED Public Health Director 978.688.8476—FAX healthde t townofnorthandF o_p. _ �� www.townofnorthandover.coWell and/or Pump Application ��`N°Rewzu�D°18ALIN DEPARTMENT (Please print) DATE: -- LOCATION to Drill Well or install a pump:_ �(�I (We 5} ;/y Or q— i_1n(lc7Je t-, VVXA O C Licensed Well Contractor Name and Company Name: e�l.i���Rg �, S6rnS w'C: Contact Phone Numbers: Homeowner: tpe.0(tq 2�,-A ki Address: fu. U"gti"�Vi ' JV th�J��3 Contact Phone Numbers: COa 3`78��' So E3 WELLS(to be completed at time of pump test) Type of well: Use: Diameter of well: Size of Casing: Depth of bedrock: Depth of casing into bedrock: Seal been tested? Yes( ) No( ) Date of test: Depth of well: Water-bearing rock: Depth of water: Delivers: GPM for: (how long) Drawdown: feet after pumping: hours at: GPM Date of Completion: Signature of Well Contractor PUMPS(To be filled in before installation) Name&size of Pump: Type: Size of Tank: Pump delivers: GPM Pipe used in well: Cast Iron_ Galvanized Plastic Sleeve used to protect pipe? Yes No Type of well seal: Date: Signature of Pump Installer Date water analysis report submitted to Health Department: Plumbing Wiring Inspector Health Department Representative C:\DOCUME—1\bcurran\LOCALS—1\Temp\Well Application.doc �iPROP. WELL50 i L r� j 7 0 DECK _ t PROPS f 4 BDRM. :- DWELLING �1 # N /G.F.=100.0 :F.=108.0 N c r� F.-100.4 o r,.,. cv P ' cO PORCH `' V 00 — 14 _ f 0 - jr Ql ' 0 98 -Q r` EXIST, VvF:, PROPP/ 1},500 GAL. ` �� L�\� DEPTIC � �O� = FY4 TANK \ 1_3 PROP. D—BOX PROP."LIMIT C 00 cyl `. 1 — r� v ' r _ (160 L.I EVai r FOREST T 772-WVr,1115 'IA/// /% ymc/deY11'/ InIC Zso, ; -- 71-14 } r 3 I i-, _ _ p3,hnC e-2-5 ., r. F <Y I . cRr r _ CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND S20 CMR 7.00 et seq. (as amended) By signing the application,the applicant understands and agrees to comply with the following: is No trench may,be excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including,but not limited to,the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164(DIG SAFE); ii. Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws,an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry, Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational.Safety and Health Administration on excavations:29 CFR 1926.650 et.seq.,entitled Subpart P"Excavations". iv. Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety; (2)that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CNa 1926.650 eLseq.,entitled Subpart P"Excavations"as well as any other excavation requirements established by this municipality;and(3)that he is aware of and has,with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way drat forms the basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www.mass.eov/dns 3IPage TOWN OF NORTH ANDOVER Permit Number 4�WOfltq NORTH ANDOVER,MASSACHUSETTS 01845 Date Issued }�0a;,, .,,•b ooh Expiration Date Jackie's Law — Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant C ' Phone Cell Street ress dd Q Cityffown MA 1-23P Name of Excavator(if different from applicant) "one Cell Street Address City/Town MA I ZIP Name of Owner(s)of Property �v R_0 E �-jQ LAI 0E Phone Ce lova (n$ Street Address &(9 614L-(-0--F--5T Q-V City/Town MA ZIP Other Contact Permit Fee Received No Yes Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. Insurance Certificate#!: Name and Contact Information of Insurer: (� t -Policy Expiration Date: —zl Q Dig Safe#: ` 0Z C�C5g�\� Name of Competent Person(as defined by 520 CMR 7.02): JLeu Massachusetts Hoisting License# License Grade: `Lk Eg iration Date: BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L.c.82A,520 CMR 7.00 et seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. AP CANT SIGNAT DATE 46Wf EXCAVATCa SIGNATURE(IF DIFFERENT) DATE !� f O NER'S SIGNATURE(IF DIFFERENT) DATE: 2JPage C.� TOWN OF NORTH ANDOVER aDRTy Office of COMMUNITY DEVELOPMENT AND SERVICES 3�D```j •y ;"�� HEALTH DEPARTMENT 1600 OS GOOD STREET; BUILDING 20; SUITE 2-36 NORTH A - -TTS 01845 R35gcNusE` S€2saii Y.Sawyer, REHS, RS 978.688.9540-Phone Public llealth Director 7ECEIV u�Q 78.688.8476- 1-AX calthdept@L townofnorthandover.com TOWN OF NORTH ANDOVER ww.townofnorthandover.com HEALTH DEPARTMENT APPLICATION FOR SOIL r DATE: MAP&PARCEL: 105 r�P 1 -71 LOCATION OF SOIL TESTS: r'OVL_1e7`rr Ie7. : r OWNER: PA t1 L/ &d't6 Contact#: C:�!CP , APPLICANT: 6 MM 6 �,(� [� Contact#: ADDRESS: ld�� ENGINEER: CERTIFIED SOIL EVALUATOR: Intended Use of Land: Residential Subdivision Sin a Family Home Commercial Is This: Repair Testing: Undeveloped Lot Testing: Upgrade for Addition: In the Lake Cochichewick Watershed? Yes No tr THE FOLLOWING MUST BE INCLUDED WITH THIS FORM ➢ Proof of land ownership(Tax bill,or letter from owner permitting test) ➢ 8.5"x 11"Plot plan&Location of Testing-(please indicate test nit sites on the plan) ➢ 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$360.00 per lot for repairs or upgrades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. ➢ Only Mass.Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test,at the discretion of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. ➢ 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). ➢ Within 60 days of testing soil evaluation forms shall be submitted. �S Please Do Not Write Below This Line F c� N.A. Conservation Commission Approval Date: 4 j� '` ��� ✓�'� �^� P ' Signature of Conservation Agent. ef)k 'S\ 00" Date back to Health Department: (stamp in): �'� �►�117W 95,33 PLAN OF LAND LOCATED/N NGWTHANDOVER,MASS OWNED BY KENNETHM9DOROTHYA.RASS SL'ALE/'4o' MAR0123,/959 scorr/.OIL SRL NO.Y/NSS a .fie �o P� �\ Sar, �` • a..,.4., n I �j� f YTa PL IY 'cr.gq f, / ' e N n d � o f ° f 94,Dat S.F ' S 2.212 Ac. j r 4 R..- as aaflw `""aiea2� S.ea�Act,_` B24¢ t% eaiso 1. 2egmmr sue l.ev<i�•�a Psgo es r CV VO �-C—} S.,.geS µA�l�ga _'_ a �4• yy,�is /fif /a.'�r9�r '. t 0 ?.4.. 11=da w May 19, 2010 To Whom it May Concern: Regarding property located at 0 Forest St, North Andover, MA, Parcel ID:210/105.D-0171-0000.0,OL- Al: I, Paul Rabs, the.owner of the referenced lot above,give permission to.George Haseltine and contracted resources hired by him,to perform tests,execute permits,and other means of action for the purpose of acquiring a building permit of a single family residence on the property referenced above. If you have any questions please feel free to call me. Regards, Paul Rabs Owner of 0 Forest St, North Andover MA, Parcel ID: 210/105.D-0171-0000.0,OL-A1. t Forest Street ,^. s Cert Vernal Pools NHESP Certified Vernal Pools Fej U5G5 Color Ortho Imagery 2008 30cm Fv] Massachusetts Town Boundaries f 70 m (1:3113) Sowoe:AFM-r.FG1S(www.mw-Y.gov1N i-r).Maps � 5(Y MRANNG:Fhvs map does Trot meef national and plrotos are rarplanriv pwposes only. map accwaayr standards,and cannot be rased \\ fvrerrQineeft purposes.Please cortsuk 00"MOrrs of use at �,i`-" ` lattpf/rrrrrr.state.flea.usf�gisf 38'-0' 24'-4' v] 21'-10' NOTE, E- CONTRACTOR TO LOCATE n B'COW FOUNDATION BASEMENT WINDOWS e m ON I'-4'x8'CONTINUOUS PER SITE CONDITIONS _ CONCRETE FOOTING STEP FND.t FTGS. a z AS NEEDED NY ———— ----------------------------- Z- v� o I I 2x4 STUD WALL I I BASEMENT I I rn m I I o y I 1 4' CONCRETE COMPACTED SLAB�B ON GARAGE i i 8'CCNC.FROST WALL ON 1'-4'XB'CONT. O I I 4'CONCRETE SLAB ON _ o O COMPACTED FILL h` I I CONC.FOOTING o ari FT. I I v FIRERATED 9 4 o — DOOR SLAB 4 I I o 1 I & 3 II I 6 v 20-10' � I I I 6'-II' b'-9" 3'-6' 6'-9" 6'-97'-4" I I _ o --- ------- I I Q I I 4-2X12 _ 4-2X12 _ 4-2X12 4-7X12 , 4-2X12 I I I v N J I ==_ - --- I - --- z 1L -- — Q I I 3 1/2'LALLY COL I 1 N W BEAM POCKET ON 24"x12'xC0NT. I I [�-- f-Q I I AS REQUIRED CONC.FTG. I I O Z N I I I I uLu uj SHEETROCK L! FIRERATED Q I I o o m O BE X ED o i I i 'tel (J)lry CANTILEVER I G RAGE — Q W FIREPLACE 3 2x4 STUD WALL I O I ----------------- -----j 1 4-2X12 r 4-2X12 r---- -- I ;TI ===fie ___ 7'-0' _ _ L J I r-----------------------STEP FWD.t F7G5 I I I 7'-0' I I I I AS NEEDED I I I bxb P.T.WD.POST I ON 10'CONC.FILLED I o I I PORCH SONO TUBE®A MIN. a CUSTOr ER I I I 4B'BELOW F.G.(TYP PCCNIAE- I LOT 171 L---------- I 1 ------------------ 1------- -- ------- ------� 8'-9' 6'-9' 6'-6" 0 FOREST 57 N ANDOVER DATE- 14-0 24--l' 12-21-10 xAi.E NOTE, SEE SWEET A-5 FORA-4 ADDITIONAL FND.NOTES. SWEET 0. 40F6 38'-0' 5i_bu I0_4' I0'_3' 5'-11' � NOTE: FINAL KITCHEN LAYOUT �.-.-.-. -.-.-.� �.I E M TO BE CUSTOMER VERIFIED I 8' x 4' 6ECK N m I PER CONTRACTOR � a z I I41 Nl 6068 S.G.D.TEMP. I � 'Z DW � ro rn a� F o SAMPLE O 0 2828 D.H. 2-2828 D.H. DINETTE - DINING_ EXTERIOR DOOR R/O SCHEDULE j j u� I� FR3N SDOCOR 64 1/2' x 82 1/2' Li-L068 ry 9-LITEi w 0 2' 2868 S.C. 34 1/2 x 82 1/2 pgY v z o o ' STRLIC SLIDER 72' % SOu 40_OPG_ SHELVES ^ m _HDRT – --BEAM ABOVE 6068 S.C. _--- - - - -_=2801-=- -_ - 7,_4u 0-4, ® o - Q 0 o _ � m m Q--. v 111 Z WOOD BURNING W PERKBUILDER MECN. 0 2828 D.N. O L Q WINDOW R/O SCHEDULE �' c1usE O E m 2828 DH 34' x 65' FAMILY u0 LIVING ILL w 2416 DH 30' x 41' 1� OM m ry� a 2-2828 DH 67 1/2' x 65' 4 1 13'_8' 3'-b° 4'16'—'? 2'-4° 3'-0'1I' II'-b' Cv 3 3036 39 I/2° x 42' ' IIS `� SLIDER BEAM ABOVE ►L N Q 2ND F.. n `o 6x(,P.T. CUSTOMER Q PORCH OVERHANG P.T.WOOD WOOD PANZAVE- ``T RAILING POSTS BEAM BEAM CCHIA LOT 171 NOTE: _ = 0 FOREST ST WINDOWS AT SLEEPING ROOMS TO COMPLY WITH CODE REQ-5 ri Ci N ANDOVER FOR EMERGENCY EGRESS SILL HT'S NOT TO EXCEED 44', NET CLEAR AT 2ND FLO(SR WINDOWS 15 5.7 S.F. MIN. NET DATE, CLEAR AT IST FLOOR WINDOW5 15 5.0 S.F. MIN. NE7e CLEAR n OPENING HT.SHALL BE 24', MIN.NET CLEAR OPENING WIDTH 12-21-IO SHALL BE 20'. 3'-I0' b'-4' 3'-IO' 5'-b' I2'-0' SCALE NOTE: 14'-0' 24'-0' ALL EXTERIOR DOOR AND WINDOW HEADERS TO BE 2.10 U.O.N. NOTE: A-2 SEE SECTION SHEETS FOR BEAM AND HEADER DETAIL. SHEET II. 20F6 J S4 E- ER ER N °i r c�P �Z I 13'-2' I n 3m BEDROOM 1 :civ 1'-2' 2'-0" I o 0 LINEN °® ? LINEN I o r-4 3i a- 3'_8• 3'-b' '^ b'-4' 14'-6' 2828 D.N. 0 6068 N BI-FOLDm K c •`+ v o Yq UTILITY o CLOSINK BEAM ABOVE �9 Z z m N r S!P a LAUNDRY STRUCT. POST :T (� ' , ----------- ;c, Q L— N m N CLO r p Jr W W,� _ ^,6068 W BI-FOL o L==A tJ MASTER W w MEN ' E BEDROOM w o Q 10'-0' 3'-b' T CHASE c, LL Q CHIMNEY b PER BUILDER in U)� -v_ O 6EDROOM ti 2828 D.N. O F 3 13'-8' � 3'-65o5TRUCT. v v PO5T m BEAM ABOVE 1= ==_3B02A _ Lu In 3802 - ------------- -- __--- I BEAM ABOVE i STRUCT.F05T Q o I 2828 D.N. II i r 0 0 ci G19TOMER. PANZAVE- in PORCH I CCNIA --- ------- ------- -------- LOT 171 0 FOREST 5T N ANDOVER NOTE o 0 WINDOWS AT SLEEPING ROOMS TO COMPLY WITH CODE REQ'S DATE- NETEMERGENCY EGRESS, SILL WT'S NOT TO EXCEED 44", NET CLEAR AT 2ND FLOOR WINDOWS 15 5.7 S.F. MIN., NET CLEAR AT 15T FLOOR WINDOWS 15 5.0 5.F. MIN. NET CLEAR 12-21-10 OPENING HT, SWALL BE 24', MIN.NET CLEAR OPENING WIDTH 3'-10" b'-4' 3'-10' S'-6' 6'-0' b'-0' SMALL BE 20'. SCALE, 12-0 3/104-0" NOTE= 38'_0• ALL EXTERIOR DOOR AND WINDOW HEADERS TO BE 2x10 U.O.N. NOTE: A-3 SEE SECTION SHEETS FOR BEAM AND HEADER DETAIL. �- SHEET n. 3OFG RECEIVED Commonwealth of Massachusetts 2013 City/Town of TOWN OF NORTH ANDOVER r System Pumping Record HEALTH DEPARTMENT Form 4 DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: LeftIghtTront of ho se�Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address PSS <;a+ Cityrrown State Zip Code 2. System Owner. 1 - ����,V•2C�.v\�ct Name Address(if different from location) City/Town Stat Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? es ❑ No Conditi�Of.Sy : 6+- �P 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio contents were disposed: GLS. Lowell Waste Water SignAtufe ct Haule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Nash Oba Analytical, LLC Tel:978-391-4428 Fax:978-391-4643 LabNumber: 118585 31A Willow Road,Ayer MA 01432 Website:http://www.NashobaAnalytical.com Use this number with all correspondence Client: Skillings and Sons, Inc. Report e: 12/20/2010 9 Columbia Drive Amherst, NH 03031 Certificate of Analysis 21719 Parameter Method Result MCL MRL Date of Analysis Analyst -George HaseltiW, 49 Forest Street North AndoxerllA Sampled:12115/2010 1:30:00 PM by J. Gove Total Coliform Bacteria,/100ML MF-SM9222B Absent 0/Absent Absent 12/15/2010 5:00:00 PM M-MA1118 Arsenic,Total, MG/L SM 3113B 0.003 0.01 0.002 12/17/2010 M-MA1118 Calcium,MG/L EPA 200.7 20.3 Not Spec 1 12/16/2010 M-MA1118 Copper,MG/L EPA 200.7 ND 1.3 0.01 12/16/2010 M-MA1118 Iron,MG/L EPA 200.7 0.23 0.3 0.01 12/16/2010 M-MAI118 Lead,MG/L SM 3113B ND 0.015 0.001 12/17/2010 M-MA1118 Magnesium,MG/L EPA 200.7 4.3 Not Spec 1 12/16/2010 M-MA1118 Manganese,MG/L EPA 200.7 0.009 0.05 0.005 12/16/2010 M-MA1118 Potassium,MG/L EPA 200.7 ND Not Spec 1 12/16/2010 M-MAI118 Sodium,MG/L EPA 200.7 33.6 See Note 1 12/16/2010 M-MA1118 Alkalinity,MG/L SM 2320B 102 Not Spec 1 12/15/2010 M-MA1118 Ammonia,MG/L SM 4500-NH3-D 0.1 Not Spec 0.1 12/15/2010 M-MAI118 Chloride,MG/L EPA 300.0 17.9 250 1 12/15/2010 M-MA1118 Chlorine,Free Residual,MG/L SM 4500-CL-G ND Not Spec 0.02 12/15/2010 M-MAI118 Color Apparent,CU SM 2120B 10 15 1 12/15/2010 M-MA1118 Conductivity,UMHOS/CM SM 2510B 340 Not Spec 1 12/15/2010 M-MA1118 Fluoride,MG/L EPA 300.0 1.9 4 0.1 12/15/2010 M-MA1118 Hardness,Total,MG/L SM 23406 68 Not Spec 2 12/16/2010 M-MA1118 Nitrate as N,MG/L EPA 300.0 ND 10 0.05 12/15/2010 M-MA1118 Nitrite as N,MG/L EPA 300.0 ND 1 0.01 12/15/2010 M-MA1118 Odor,TON SM 2150B 0 3 0 12/15/2010 M-MA1118 pH,PH AT 25C SM 4500-H-B # 6.4 6.5-8.5 NA 12/15/2010 M-MA1118 Sediment,pos/neg --------------- NEG ------ NEG 12/15/2010 M-MA1118 Sulfate,MG/L EPA 300.0 22.5 250 1 12/15/2010 M-MA1118 Total Dissolved Solids,MG/L SM 2540C 176 500 1 12/16/2010 M-MA1118 Turbidity,NTU EPA 180.1 4.6 Not Spec 0.1 12/15/2010 M-MA1118 MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline ND=None Detected(<MRL), *=Background Bacteria Noted Massachusetts Certified David L.Knowlton Laboratory#MA1118 Laboratory Director Page 1 of 1 Nashoba Analytical, LLC Tel:978-391-4428 Fax:978-391-4643 LabNumber: 118585 3 1 A Willow Road,Ayer MA 01432 Website:http://www.NashobaAnalytical.com Use this number with all correspondence Client: Skillings and Sons, Inc. ReportDate: 12/20/2010 9 Columbia Drive Amherst, NH 03031 RECEIVEp Certificate of Analysis �' TOWN OF NORTH ANDOVER 21719 WEALTH DEPARTMENT Parameter Method Result MCL MRL Date of Analysis Analyst -George Haseltine,649 Forest Street, North Andover MA Sampled:12/15/2010 1:30:00 PM by J. Gove Total Coliform Bacteria,/100ML MF-SM9222B Absent 0/Absent Absent 12/15/2010 5:00:00 PM M-MA1118 Arsenic,Total,MG/L SM 3113B 0.003 0.01 0.002 12/17/2010 M-MA1118 Calcium,MG/L EPA 200.7 20.3 Not Spec 1 12/16/2010 M-MA1118 Copper,MG/L EPA 200.7 ND 1.3 0.01 12/16/2010 M-MA1118 Iron,MG/L EPA 200.7 0.23 0.3 0.01 12/16/2010 M-MA1118 Lead,MG/L SM 3113B ND 0.015 0.001 12/17/2010 M-MA1118 Magnesium,MG/L EPA 200.7 4.3 Not Spec 1 12/16/2010 M-MA1118 Manganese,MG/L EPA 200.7 0.009 0.05 0.005 12/16/2010 M-MA1118 Potassium,MG/L EPA 200.7 ND Not Spec 1 12/16/2010 M-MA1118 Sodium,MG/L EPA 200.7 33.6 See Note 1 12/16/2010 M-MA1118 Alkalinity,MG/L SM 2320B 102 Not Spec 1 12/15/2010 M-MA1118 Ammonia,MG/L SM 4500-NH3-D 0.1 Not Spec 0.1 12/15/2010 M-MA1118 Chloride,MG/L EPA 300.0 17.9 250 1 12/15/2010 M-MA1118 Chlorine,Free Residual,MG/L SM 4500-CL-G ND Not Spec 0.02 12/15/2010 M-MA1118 Color Apparent,CU SM 2120B 10 15 1 12/15/2010 M-MA1118 Conductivity,UMHOS/CM SM 2510B 340 Not Spec 1 12/15/2010 M-MA1118 Fluoride,MG/L EPA 300.0 1.9 4 0.1 12/15/2010 M-MA1118 Hardness,Total,MG/L SM 23408 68 Not Spec 2 12/16/2010 M-MA1118 Nitrate as N,MG/L EPA 300.0 ND 1.0 0.05 12/15/2010 M-MA1118 Nitrite as N,MG/L EPA 300.0 ND 1 0.01 12/15/2010 M-MAI118 Odor,TON SM 2150B 0 3 0 12/15/2010 M-MA1118 pH,PH AT 25C SM 4500-H-B # 6.4 6.5-8.5 NA 12/15/2010 M-MA1118 Sediment,pos/neg ------ -- NEG ------ NEG 12/15/2010 M-MA1118 Sulfate,MG/L EPA 300.0 22.5 250 1 12/15/2010 M-MA1118 Total Dissolved Solids,MG/L SM 2540C 176 500 1 12/16/2010 M-MA1118 Turbidity,NTLI EPA 180.1 4.6 Not Spec 0.1 12/15/2010 M-MA1118 MCL=Maximum Contaminant Level(EPA Limit),MRL=Minimum Reporting Level Sodium Guidelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline ND=None Detected(<MRL), *=Background Bacteria Noted Massachusetts Certified David L.Knowlton Laboratory#MA1118 Laboratory Director Page 1 of 1 State Analytical, LLC Granite Main Office/Laboratory 22 Manchester Rd./Rt.28 Derry,NH 03038 (603)432-3044 ` Contact.Donald A. D'Anjou,Ph. D., Laboratory (rector DATE PRI 4/7/2011 CLIENT NAME: Greenscape Property & Building T '�OWNOF pEp�R�QOVER CLIENT ADDRESS: 66 Gilcreast Road Attn:Joe S. RrMENT Londonderry, NH, 03053 CERTIFICATE OF ANALYSIS FOR DRINKING WATER SAMPLE ID#: 1104-00054-001 DATE&TIME COLLECTED: 4/5/11 6:50 am SAMPLED BY: Mattus, Daniel by GSA QCM App. I DATE&TIME RECEIVED: 4/5/11 2:58 pm SAMPLE LOCATION• orest St.,No Andover,MA ANALYSIS PACKAGE: No.Andover RECEIPT TEMPERATURE: ON ICE 8.9 CELSIUS Test Description Results Test Units Test Falls Analysis Method Analyst Date&Time Analyzed MCL Sediment Absent WL 4/5/11 15:33 Turbidity* 3.4 NTU EPA 180.1 WL 4/5/11 15:33 5 NTU Calcium* 29.1 mg/L EPA 200.7 WL 4/6/11 15:04 Copper* <0.01 mg/L EPA 200.7 WL 4/6/11 15:04 1.30 mg/L Hardness(talc)* 104 mg CaCO3/L EPA 200.7 WL 4/6/11 15:04 Iron* 0.280 mg/L EPA 200.7 WL: 4/6/11 15:04 0.300 mg/L Magnesium* 7.6 mg/L EPA 200.7 WL 4/6/11 15:04 Manganese* 0.024 mg/L EPA 200.7 WL 4/6/11 15:04 0.050 mg/L Phosphorus* mg/L EPA 200.7 WL 4/6/11 15:04 Potassium* <1 mg/L EPA 200.7 WL 4/6/11 15:04 Sodium* 15.3 mg/L EPA 200.7 WL 4/6/11 15:04 Arsenic* <0.002 mg/L EPA 200.9 WL 4/6/11 14:51 0.010 mg/L Lead* <0.005 mg/L EPA 200.9 WL 4/6/11 11:54 0.015 mg/L Chloride* 29 mg/L EPA 300.0 WL 4/5/11 17:16. 250 mg/L Fluoride* 0.31 mg/L EPA 300.0 WL 4/5/11 17:16 4.0 mg/L Nitrate as N* <0.2 mg/L EPA 300.0 WL 4/5/11 17:16 10 mg/L Sulfate* 18 mg/L EPA 300.0 WL 4/5/11 17:16 250 mg/L Color 25 CPU Fails EPA Secondary SM 21208 WL 4/5/11 15:33 15 CPU Odor ND T.O.N. SM 21508 WL 4/5/11 15:33 3 T.O.N. Total Alkalinity* mg CaCO3/L SM 23206 Total Dissolved Solids* mg/L SM 2540C 500 mg/L PH* 8.02 SU SM 4500 H B WL 4/5/11 15:30 6.5 - 8.5 SU Nitrite as N* <0.01 mg/L SM 4500 NO2 B WL 4/6/11 13:15 1.0 mg/L Coliform Bacteria* Absent P-A/100ml- SM 9223B WL 4/5/11 16:30 Absent E. coli Bacteria* Absent P-A/100ml- SM 9223B WL 4/5/11 16:30 Absent The results presented in this report relate to the samples listed above in the condition in which they were received. MCL = Maximum Contaminant Level - * MA Certified Analysis Donald A. D'Anjou, Ph.D. A list of our certifications is available upon Laboratory Director request. This certificate shall not be reproduced,except in full,without the written approval of Granite State Analytical,LLC Page 1 of 1 Pitcherville Sand& Gravel 36 Brown Drive Greenville, NH 03048 603-878-0035 (fax) 603-878-0025 Sieve Analysis C-33 CONCRETE SAND TO: ARCO EXCAVATING JOB: 648 FOREST ST. N. ANDOVER Source Wilton Date 3/25/2011 SIEVE SCREEN CUMLATIVE CUMLATIVE TOTAL% C-33 SIZE WGT. WGT. %RETAINED PASSING SPEC 3/8" 0 0.00 0.00 100.0 100 #4 18.99 3.70 96.3 95--100 #8 48.44 9.43 90.6 #16 110.60 21.53 78.5 45--80 #30 223.89 43.59 56.4 #50 384.69 74.89 25.1 10--30 , #100 476.82 92.82 7.2 2--10 7 #200 505.23 98.36 1.64 0--3 PAN 513.68 100.00 0.0 ti