Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 706 FOSTER STREET 4/30/2018
K) SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: NEW REPAI NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT PAID? YES NO DWC PERMIT NO. INSTALLER: BEGIN INSPECTION YES NO:. EXCAVATION INSPECTION: NEEDED: PASSED CONSTRUCTION INSPECTION: AS BUILT PLAN SATISFACTORY: YES: �-=� APPROVAL TO BACKFILL: DATE: /Or FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: 7 BY BY DATE: /G BY of NORrN qj LIE COPYti 41 v ��SSA C H USS �y PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 5/26/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box By: Daniel Giard At: 706 Foster Street Map 090.A Lot 0034 North Andover, MA 01845 The IsAapce of this c�t'ficare ll not be t onstrued as a guarantee that the system will function satisfactorily. Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster ❑ Food Service - Type: ❑ Funeral Directors ❑ Massage Establishment ❑ Massage Practice ❑ Offal (Septic) Hauler ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco ❑ Trash/Solid Waste Hauler ❑ Well Construction SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector ly, Title 5 Report ❑ Other: (Indicate) 11 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 7223 Gf MORT :,y Town of North Andover HEALTH DEPARTMENT CHUSE4 CHECK #: 16W /+ n DATE: / LOCATION: i H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal ❑ Body Art Establishment ❑ Body Art Practitioner ❑ Dumpster ❑ Food Service - Type: ❑ Funeral Directors ❑ Massage Establishment ❑ Massage Practice ❑ Offal (Septic) Hauler ❑ Recreational Camp ❑ Sun tanning ❑ Swimming Pool ❑ Tobacco ❑ Trash/Solid Waste Hauler ❑ Well Construction SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector ly, Title 5 Report ❑ Other: (Indicate) 11 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer r. ,,r.i 7 223 Of 1���o •�,q0 r+t' F? ��r • 09 Town of North Andover `�'•�;, ;; �. HEALTH DEPARTMENT cNust� CHECK #: 1 + 'hql<64 DATE: LOCATION:q0b+VSqf( S-1, H/O NAME: ch!i, & . CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ �, Title 5 Report $Sol �V ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 'sl Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab renun L Commonwealth of Massachusetts <27 RECEIVED Title 5 Official Inspection F m MAY 142015 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NORTH AN�O 706 Foster Street HEALTH DEPARTIN! Property Address V L, - Yuri Yuri Bachilov & Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in way. Please see completeness checklist at the end of the form.io t �y A. General Informationt� 6� 1. Inspector: Jonathan Granz Name of Inspector Preventative Septi Company Name 327 Asbury Street Company Address South Hamilton Cityrrown 978-468-9001 and Drain L.L.C. LN State S113405 Telephone Number License Number B. Certification 01982 Zip Code 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: P— 60X ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9,1" (�� 5/11/15 Insp ors ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov &Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 iti „— Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 City[Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Distribution box is in very poor condition, corroded, cracked, structually un -sound and needs to be replaced. 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 l5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover CityrFown B. Certification (cont.) MA 01845 5/4/15 State Zip Code Date of Inspection 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 'h day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'c ,M 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner Owner's Name information is required for North Andover MA 01845 5/4/15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover City/Town C. Checklist MA 01845 State Zip Code 5/4/15 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 City/Town State Zip Code Date of Inspection D. System Information Description: System is composed of 1500 Gallon septic tank, distribution box and a 25'x40' leaching field. A Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: Private non -metered well. Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No n/a ® Yes ❑ No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 ' Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 706 Foster Street Owner information is required for every page. Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 5/4/15 Date of Inspection Last pumped 9/4/12, per BOH records. gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 706 Foster Street Owner information is required for every page. Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Certificate of compliance is date 10/16/97, per BOH records. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): M t nce from rivate water su I well or suction line 13" feet 80'+/- ❑ Yes ® No �s a p pp y feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition with no signs of leakage, backup or any other problems. Septic Tank (locate on site plan): 4" Depth below grade: 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: 101 x 5'W x 4'D effective Sludge depth: 5" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover City/Town D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 31" <11, 6" 14" 5/4/15 Date of Inspection How were dimensions determined? SludgeJudge/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.): Tank is in good condition, structually sound, no signs of leakage or infiltration, liquid at outlet invert. Both inlet and outlet T's are present and in good condition. **this tank does not require pumping at this time** Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form PE Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street M Owner information is required for every page. Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 5/4/15 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert a 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.): The distribution box is in poor condition, cracked, corroded and is in need of replacement. Liquid level is at the outlet inverts, slight solids carryover. speed levelers present. D -box is 12" below grade, outlet inverts are 23" below grade. 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 N w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner Owner's Name information is required for North Andover MA 01845 5/4/15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 @ 25'x40' 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 over system is dry,grassy and consistant with surounding yard with no signs of ponding, breakout or abnormal veaetation. 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 ' 706 Foster Street Owner information is required for every page. Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner's Name North Andover MA 01845 5/4/15 City/Town 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' Below SAS feet Please indicate all methods used to determine the high ground water elevation: ►/ 0 // C FEK Obtained from system design plans on record If checked, date of design plan reviewed: 4/30/97 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Plan on file for the design of this system. Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: Soil testing was performed for the design of this system on 3/18/97 by William Dufresne and witnessed by Sandra Starr, ESHGW was found 36" in TP1 and 48" in TP2. This system was installed with a 4' seperation from ESHGW per Title 5 requirements, it is not interfacing with aroundwater. 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 706 Foster Street Property Address Yuri Bachilov & Olga Bachilova Owner Owner's Name information is North Andover MA 01845 required for every page. City/Town State Zip Code E. Report Completeness Checklist 5/4/15 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Q N S m ➢ ^ D t9 � FF'�. S11350�9 1 u �U]OWmc, opx�7r z rT�—SG7'nmuoDD�0 Z 0-3 zzc Co d4�z�tJ XX 0 y�0 c —I Av�Oz fTl 0 W m j M < D N N N N N N N N N N N N N N N —I -L --4 14 -j 00 00 — �� WNWWW�P(I��U�CIiJvO� O co NOOOO-P-ANOO�I-f,0-P-00 Z N O m N�N�N�N-N-'N-• (n 000000000000 O�C�(7WOJ>>0U5I-i D I I zzZ 0 0 C7 X X r7 410N-P,UI-P-tlML4Ln�� -PNNcDPplO:;,--WA. w()�(nOv-rnrnowrn� North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 706 Foster St. INSTALLER: Dan Giard DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: MAP: LOT: INSPECTIONS TANK INSPECTION: D -Box 5/26/15 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port Comments: (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX nstalled on stable stone base VIH-20 D -Box ❑ / Inlet tee (if pumped or >0.08'/foot) - rau cement around inlet & outlets Ob ed even distribution peed levelers provided (not required) Q Schedule 40 PVC Pipe Comments: Commonwealth of Massachusetts Map -Block -Lot 090.A0034 ----------------------- BOARD OF HEALTH Permit No North Andover BHP -2015-0209 ----------------------- P.I. FEE F I $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Daniel -A. -Giard ---------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 706 FOSTER STREET as shown on the application for Disposal Works Construction Permit No. 1311P-2015-02.0 Dated May 26,-2015 PY --------------------------------------- Issued On: May -26-2015 `F BOARD OF HEALTH NORTH r 7235 Of ��•o i•�1'O . of Town of North Andover �,�'• '' HEALTH DEPARTMENT CMUSt4 CHECK #:PATE; LOCATION: q 0 T 6 31 e'0 H/O NAME: CONTRACTOR NAME: $ Type of Permit or License: (Check box) Septic Disposal Works Construction (DWC) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ Septic Disposal Works Construction (DWC) $ rl"J • ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ D Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer I Of NORTH , $ ! 2 5 • Town of North Andover HEALTH DEPARTMENT ,SSACHU`+�t CHECK #:a i ATE - LOCATION: H/O NAME: CONTRACTOR NAME: Q Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ /Septic - Design Approval $ ) L1 Septic Disposal Works Construction (DWC) $�iC/ 13�/ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ U'D Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer F p10 RTI} q 3 ommom 0 S4CHUSE � 1 ' Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. I—I iaam Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* .�&-/s' TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component ❑ Repair or replace an existing on-site sewage disposal system* © Repair or replace an existing system component — What? X A. Facility Information C—_ P%C 4.' S;; L �T l Address or Lot # �l� � )LC— � ✓' �P /Z. �' �'L LAS S City/Town 2, *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ➢ ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. / ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info, needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information Name % d C d S i e.z— ' Address (if different from above) 4 City/Town State Email address Telephone Number 3. Installer Information Fes- ,iiow, 4 A f Name Name of Company Zip Code Addressv Nb 4- vc.2— City/Town State Zip Code 4. Designer Information Name Address City/Town Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 ' 6 �•Application for Septic Disposal System TODAY'S DATE lqWConstruction Permit -TOWN OF $ 250.00 - Full Repair NORTH ANDOVER, MA 01845 $125.00 - Component 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. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the""tailed system is not approved. A o6 Name Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: L FeeAttached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Sys tem? Ifso, Attach coQK of Electrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approvalletter, all paperwork received. Yes No 5. Foundation As -Built? (new construction only): Yes No (Same scale as approved plan) 6. 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: $f'" A)% 14 h d o ;x 2 mass (Address of septic system) For plans by Relative to the application of e..t 4 (Installer's name) Dated - 3(, -- / S— o ay s ate And dated With revisions dated I understand the following obligations for management of this project: (Engineer) ngin ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and allinspections. 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 (VS 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 aappr�plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer:-, R (Today's Date) `�7DAIV i E-1 A , is t R r� (Name - rint—(Name - Signe SOIL PROFILE & PERCOLATION TEST DATA Town/City No.&Street OS,��,..- Lot No.� � 1 Loc. /Subdiv. ^Plan- Owner lewe_v_ ✓OG Investigator Gc:'V" �;L a Observer_ SOIL PROFILES -DATE �1 2Elev. ?• Elev. 3, Elev. 4'Elev. o 76 0 0 0 0 -4 2 3 4 \5 0 2 3 4 G, C. 7 0 9 2 3 4 5 M 7 No 9 2 3 4 5 7 91 10___-----) 10 �� 10 �.�� 10--�--J Benchmark Location Elevation Datum P-e--rcc�ojattion Tests -Date 37 g 9/'n // ll 172 71710t z Pit Number 1 2 3 4 5 Start Saturation 21LO Soak-Mins. / S Start Test -Time 'DO Drop of 3" -Time prop of 6" -Time Mins.lst "Dro Mins.2nd 3"Dro .'4uLc5 « Skezc es/ on bac. Frank C. Gelinas & Associates, North And. k j 'o Town of North Andover MORTIS , OFFICE OF•`"164, c COMMUNITY DEVELOPMENT AND SERVICES 30 School Street North Andover, Massachusetts 01845 �q`°•,•° •°' qty WILLIAM J. SCOTT SSACNUSE Director August 12, 1997 Merrimack Engineering Services 66 Park Street Andover, MA 01810 RE: 706 Foster Street Dear Les: This letter is to inform you that with the variances granted by the Board of Health on June 26, 1997 to 310 CMR 15.14.405(d) to allow a 25% reduction in the required leaching area and N.A. 4.18 to allow 52 feet to wetlands, the proposed septic plan for 706 Foster Street has been approved. 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 cc: Wm. Scott, Dir. CD&S Geraldine Lemoine File CONSFRVATION 688-95n HEALTH 688-9440 PLANNING 688-9535 Town of North Andover, Massachusetts Form No. 2 f N°RTh BOARD OF HEALTH o - � � M F DESIGN APPROVAL FOR INU SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant— �r� ' JTest No Site Location `� n G -d-pr-Q-� . S2-�— Reference Plans and Specs %/10/97 Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. % CHAIRMAN, BOARD OF HEALTH Fee Site System Permit No. 94(- Town of North Andover, Massachusetts Form No. 1 ORTM A BOARD OF HEALTH. ` j `ED �bq,v0 �}V' L- I 1 '` I 19 Cil 6 O/ O ._�Y A .°Aoe` APPLICATION FOR SITE TESTING/INSPECTION Applicant 4--wolv, L/-- NAME ADDRESS TELEPHONE Site Location�- Engineer ZCS NAME ADDRESS TELEPHONE 1� r Test/Inspection Date and Time ANA7,11 A7,1 CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. ���i D.W.C. No. C.C. Date Plbg. Permit No. I t .1 4 ��1Y No. FORM 11 - SOIL EVALUATOR FORM Page 1 Date.. 5'11797 Commonwealth of Massachusetts woviii Amwvez , Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By:...... W.11Li.A.t-.`j....... ..... QVF1269-- it. ....................... Witnessed By:.. $ ........................................................................................................................................................................................................I...................... Location Address or `10& `o 1-15 f ST Lot X I,. H , —1 0 A PAIz . 3q New construction ❑ Repair LQ' Office Review 0—,'s Name. �,EQ/� jr D 1 JlS E L,Or M O l kj Address. and —70(D IG- �OSTf-0 Sr, Telephone X QMZZT KiJDOVF-e , MA - o184S Published Soil Survey Available: No ❑ Yes LJ Year Published ... Publication Scale .J. -I... 15$y0 Drainage Class _..8.... Soil Limitations ........HODCRATIS, ... Surficial Geologic Report Available: No Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) .............—..- .............................................. .Landform ... .....:......... .:...... .... ............... .... ....... ................ .......... .......... ................. .......... ........... Flood Insurance Rate Map: 'Zsao48 -aao7G 6-Z-93 Soil Map Unit .....0 C. QHA R[. Tori ................................................................... Above 500 year flood boundary No ❑ Yes Within 500 year flood boundary No Yes ❑ Within 100 year flood boundary No Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ........... 00....$1.T�.....DE.G..i.u44A- j.Q.�......1�P Wetlands Conservancy Program Map (map unit)................................................................................................... Current Water Resource Conditions (USGS): Month .0.8.P. t4 Range : Above Normal ❑ ormal V Below Normal ❑ Other References Reviewed: v *I #2 FORM 11 - SOIL EVALUATOR FORM Page 2 On-site Review Deep Hole Number Date:. "�. 17 Time:. ....3.Q Weather S.?i. A4A 4 y.......Z1.A.5..... Location (identify on site plan) .. ....... F�.jul....YA.RD................................................................................................................................. Land Use Slope M ..... ...... Surface Stones ...... 1Q.Qi.�....................................................... Vegetation....... 1,A�✓. ................................. ..................... ..................................................... .......................... ............................................... ....... I............... Landform..........1".99AJA..�................................................................................................................................................................................................. Position on landscape (sketch on the back) .....Zig....... K9.ti.1.................................................................................................................. Distances from: Open Water Body .....1.00.t. feet Drainage way.....s. {" feet Possible Wet Area .....Sb.t feet Property Line ....10..+.. feet Drinking Water Well ...J!P :t. feet Other ......... ............ ......... DEEP OBSERVATION HOLE LOG Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (Inches) (USDA) (Munsell) (Structure, Stones, Boulders, Consistency, % Gravel) O�Aui cs '30"-3� 3G"- 1(," GV� RAEU. v5ji Y 2,Sv S-14 GvN+-to�-c S o�sru�� o s io C�&-,eS 5 �R �Rt'l rtorilES Sig STbuES 7SyesJg 2,sy �f I e 3�" 8" FA SA�coy Fri, la(oRGA/.I�C S SICT- 4,ANX 2,5-y sly CortNoi c S �toC IGy r4o- e+ s sy �t3 L �S„ Parent Material (geologic) ........TIC.l...................................................... Depth to Bedrock: . PtA................ Depth to Groundwater: Standing Water in the Hole: ................. .. Weeping from Pit Face: 3 �A.L($� (Wectieb) P Estimated Seasonal High Ground Water: 36�'. f Ll$ FORM 11 - SOIL EVALUATOR FORM Page 3 Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole inches ffDepth weeping from side of observation hole 3(e,46. inches Depth to soil mottlesinches ❑ 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? �— If not, what is the depth of naturally occurring pervious material? Certification I certify that on (date) I have passed the 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 Oub.'�(�ate y FORAT 12 - PERCOLATION TEST , COMMONWEALTH OF MASSACHUSETTS I,loM ALsoovf5V_ , Massachusetts Percolation Test 3-(f� .. Time: Date: �............. Observation Hole # p Depth of Perc ,.-r I `Z Start Pre-soak 12, q5� End Pre-soak I 0100 Time at 12" O Time at 9" 1' 3Z Time at 6" 3.01 Time (9"-6") Rate Min./Inch Site Passed LJ Site Failed ❑ leg..! ................. ................................ Performed By: LIFE 60bi IJ Witnessed By: 5:R Wb P_ A S7A 2bZ Comments: _._......................... _._......._........._................- .._ ......................................................................... p TO DATfE1 TIME AM H OM VAS n AREA CODE 2 NO. � � J 4 r EXT. E M / S E w �� 0 E SI ED PHONED ❑ BACK E] CALL RETURNED ❑ SEE VOUO ❑ AGAIN ALL [:] WAS IN ❑ URGENT ❑ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C G" SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 706 Fast 5�- C FILE# f, r-34, buT = /-?i p t"D w DoT = u, MoD = qg, DEPTH OF Depth to gi �. method of i NATER feet on or approximation: I oAt- 5�- , (revised 8/15/95) 9 ;3.)d Ot ttORTPI tt��o ,e 1ti O A K 1� .'44T.D At�`y.� SsACHUSEt Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 ��� 3 19-2 7 DISPOSAL WORKS CONSTRUCTION PERMIT Applicant /3" OS Oo�j NAME ADDRESS Site Location %® TELEPHONE Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH Fee / J �. D.W.C. No.9_�/ APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: ql Z, 3 /1-7 CURRENT INSTALLER'S LICENSE# %` Y LOCATION: 70Cs IVA- LICENSED INSTALLER: �c--t Ogg SIGNATURE: TELEPHONE# CHECK ONE: REPAIR: (/ NEW CONSTRUCTION: 6 86-!76 9 IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes Vl--Z No Foundation As -Built? Yes No Approval f% �' Date: MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL. (508) 475-3555, 373-5721 • FAX (508) 475-1448 June 16, 1997 Town of North Andover Board of Health 30 School Street North Andover, MA 01845 RE: 706 Foster Street - Title V Upgrade Owner: Geraldine Lemoine Dear Board Members: In regard to the design of a subsurface disposal system upgrade for the subject property, we request the following waivers: 1. Local upgrade approval waiver to C.M.R.14.405(d) for a 25% reduction in required leaching area. 2. Waiver to Town of North Andover Regulation 4.18 for a 52 foot setback from leaching area to wetland. Please schedule these items for action at the next available meeting of the Board of Health and feel free to contact me at this office should you have any questions or comments regarding the above. Very truly yours, MERRIMACK ENGINEERING SERVICES Les Godin Project Manager cd cc: Ms. Geraldine Lemoine r (n -a O CD Z n a r+ cn M —j o��:3 < -0 U) � n•- O ° BOO (�'0 . 0 acn O)o c CD �• Co Q O O D 0 O- n � :3 ���a-��a�C: M0 cD cD o : (D_.�(D �rn�(D x� NCD O O ,� _ cn w `G \ O D .CD CD 0 c0 cc r -r O '� c0 -D �� �6(D Wa O r oo��Z I7 x x o Z7 Cz> 0z� z FTI - F z FTl --------------- D N N N N N N N N N N N N N N N -i Ili VVVJVvv�vVVV0000 O W N W W W ��tnUnLnUl 4:,J6 N00—OO��NOO�I-;�,cD-P 00 z U) -a --j -a -j --j -j -j -i* -i -a -j -A 000000000000 OOoowWDDOO-�V D I i zz Z 00 n xx m �C7N�U -P--?N WU»� -PN�(D�-POS- L-4 Ln M 0o 00 Ut 0o �4 b) in O u b) cn (n K: -0 0 (D Z 0 0_ r' U) M --j :3- (D (D— -1 — O rr T (D :30 0 (D C<D -1 CD �_ (D n � — CD � _.0 M (D x n (D (D (D D t0 00 00 z F1 OZCZD -o z FT1 F- z JJJJJJJJJJJJJODOD O (AN)(AW(A P PC3i(3tC3tU�JJOj NOD—OO��NOOJ P(D�OO Z -i -1 -1 -j -i -1 -1 -1 -, -1 -, - v ) 000000000000 � OOC?CDQJ�DDOO—I -I D o CO zz Z 00 xx F1 �mN-r-Ut�-PNCrIUt--P� �N�(D��O P— (Acnm Oo OoCP 0o J C) Q) O CA Q) J M.. Town of North Andover, Massachusetts Form No. 3 NORTII BOARD OF HEALTH (� � OOT I- A DISPOSAL WORKS CONSTRUCTION PERMIT SSCHUSEt t Applicant U&&4J 6—Glk—� D/Y1�0 LANA _- NAME ADDRESS TELEPHONE Site Location LS14 T�0 �- A S �— Permission is hereby granted to Construct ( ) or Repair (w� an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee CHAIRMAN, BOARD OF HEALTH D.W.C. No. 2 -7 --�- 17 7 I i✓ A/0 i E �` !�✓� RQ �} / i Nom,=�•'•a+SH to ',\ r p� ..4. x .M . I i✓ t i i � x 31' N r� >"� BTW:.... W. ! .'r• ;� Commonwealth of Massachusetts City/Town of North Andover RECEIVED W° System Pumping Record OCT '1 8'1G12 ^M Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other form , UU1 111C 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. City/Town Ma State State Telephone Number Zip Code Zip Code B. Pumping Record ?ICV q 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System.- 6. ystem: 6. System Pumped By: Name Stewart's Septic Service Company If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 ture o Date S1 re of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms 1. System Location: on the computer, VC use only the tab 70(o key to move your Address cursor - do not North Andover use the return key. City/Town 2. System Owner: Name rehan Address (if different from location) City/Town Ma State State Telephone Number Zip Code Zip Code B. Pumping Record ?ICV q 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System.- 6. ystem: 6. System Pumped By: Name Stewart's Septic Service Company If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 ture o Date S1 re of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1