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HomeMy WebLinkAboutMiscellaneous - 717 FOSTER STREET 4/30/2018VA N_ O V V O T D 0. Il 4 X o m o m P m 0 o.; r Lot & Street /or 7DSyG,Z 5,7- Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# 6 - Plan Plan Approval: Date: 5 /i/cl Approved by: ry- Designer: -lvel-I /0 Plan Date: M Conditions: Water_ Supply- own Well C -_ Well t: _ ___.._.�_ Driller: ^ -~- - Well Tests: Chemical _ Date Approved Bacteria I Date Approved_ _ Bacteria II proved - Plumbing.Sign-Off Wiring Si �ff: Comments: Form "U" Approval: Approval to Issu LN -0 Date Issued By: - -- Conditions: - Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO - Septic System Construction Approval? YES NO Certification? _YES NO Other YES NO Any Variance Needed? YES NO ff l FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: y {h NO tl. SEPTIC SYSTEM INSTALLATION Is the installer licensed? _ NO Type of Construction: - W REPAIR New Construction: Certified Plot Plan Review YES _ NO Floor Plan Review NO Conditions of Approval from Form U _YES YES- NO - Issuance of DWC permit: NO DWC Permit Paid?YE --- NO DWC Permit # 9�7 --- Installer: J'v�,�= . Begin. Inspection: ES V NO Excavation Inspection: - Needed: - - Passed: _By- Construction Inspection: Needed: "Plan Satisfactory: YE Approval of Backfill: Date: / By: Final Grading Approval: Date: A - By.. Final Construction Approval: Date: Igz By: V� c Certificate of Compliance: Approval: Date: X, 4 �7_ v z 'TITLE V INSPECTIONS "Dean G. Luscomb II & Sons 135 Middleton, MA 01949 4`" 1_-508-7744065 ICENSED PLUMBER #20285 - V, a FILE # Xj/Q j;-%a'q i SUBEURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME: PG -Lt. I PROPERTY ADDRESS: 717 Fo s+, �J, f)ndoVer- ADDRESS OF OWNER: QMH, (if different) _ DATE OF INSPECTION: _ �u Iu �� , 2-0g0 NAME OF INSPECTOR:.—Dean G. I-WCO^� 0 J A L I T Y I S N J M B E R O N E T 0 J S Dean G. Luscomb II & Sons P.O. Box 135 Middleton, MA 01949 �.\ 1-978-774-4065 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 717 Fosfief_$'1-• N, n`a4°e�r_ Name of Owner � � T) ipI Uo Address of Owner: Sa-o -e zoo--> of y � grspection: Tu'� �'" / Name of Inspector: (Please Prim) man G. (.dtSilJt�� L I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000) company Name: Dean G Luscomb IT & (;()n.(; MaaingAddress: P.O. BOX 135 Talephone Number: Middleton MA 01949 CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: /Passes Passes _ Conditionally Passes _ Needs Further Evalu ion By the Local Approving Authority Fails Inspector's Signature: Date: X" I L The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department at'Environmentol Protection. The original should be sent to" system ownerand copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9'2/98 Page 1 of 11 0. Primed on Recycled Paper Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7/ 7 Fostv.— �tJ A. vver- owner: C),/0d/,, Date of Inspection: 7/Z l%Z®ac,? INSPECTION SUMMARY: Chech B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances.. if "not determined", explain why not. The septic tank is metal, unless the owner• or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 14) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than fourtfines a yeardue to broken or obstructed pipe(s). Thesyatem withpess-, inspection if (with approval of the Board of Heelth): broken pipe(s) are replaced obstruction is removed revised 9!2/98 Page 2of II Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7/ Z rOSq?x-- Sik N, A ex— Owner: zv p j //O Date of inspection: 7A11A006 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 the public health, safety and the environment. 1) SYSTM 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.YALL.PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. N Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE ENVIRONMENT: t_J 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER li revised 9,'2/98 1`2ge3of11 Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:! '717 7 Fvss,Cr 0, A nclew4 " Owner: bb l it v Date of Inspection: 7Ai boot/ D. SYSTEM FAILS[: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No. IsY) Backup of scwege intofecilitler-stem eotnponertt•dnego an overloaded orOhgged SAS or,ceaspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _ `�ii Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. /J Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. N Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. /v Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. /v Any portion of a 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 I of a public well. W 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 greeter than 50 feet from a private water supply well with no acceptable water quality analysis. If the well hes been analyzed to be acceptable, attach copy of well water analysis for --coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: Yust indicate either "Yes" or "No" to each of the following: following criteria apply to large systems in addition to the criteria above: The syste�endf h adesign flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health enonment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking r supply the system is -within 200 feet of a-twbiKerY toa aur "ing.wat y --. the system is located in a nitrogen hive area (Interim Wellhead Protection Area • I or a mapped Zone 11 of a public water supply well) The owner or operator of any yss^ system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult t cal regional office of the Department f,, rther information. revised 9112/98 Page 4 of 11 Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 T_-osj:wr $C. �j Owner: 1)% p i 110 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye No Pumping information was provided by the owner, occupant, or Board of Health. _✓ _ None of the system compoaants ham ~"n ptwnpedifor-atleast two we"a an&the rystem hasbewmecsiai ega nnoW clow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffle! or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: v Existing information. For example, Plan at B.O.H. _✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) t / 115.302(3)(b)1 V _ _ The facility owner land. ocuupants.if differe t from_owner).wardpmyidad.with iniotma2ionnn tha grope mint&a& Q -f SubSurface Disposal Systems. revised 9;2/98 Page 5 or I I Property Address: ? 1-7 Fos -6f owner: 'p i to, 110 Date of Inspection: 7/1 I &VO uedn u. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDMONS RESIDENTIAL: Design flow: J&) g.p.d./bedro m. Number of bedrooms (design l: Number of bedrooms (actual): Total DESIGN flow ll Number of current residents: Garbage grinder (yes o no .AID ,y� Laundry (separate system) (yes o o .fes"; If yes, separAte inspection. required Laundry system inspected� ((yes or o Seasonal use (yes o no : {v Water meter readings, if available (last two year's usage (gpd): —1WrN Sump Pump lyes 009): Last date of occupancy: ti[�/riE/r Type of estebT3h nt: Design flow:d (Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: lyes or no)_ Non -sanitary waste discharged to the Title 5 system: lyes or Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Last date of occupancy: PUMPING RECORDS and source of in System pumped as part of inspection: (yes oCn If yes, volume pumped: 1.500 g Ilons Reason for pumping: 194, GENERAL INFORMATION lq� K11 TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other PPROXIMATE AGE of all components, date installed4if known) -end source of-Warmation: -�►� Z� Ole) Sewage odors detected when arriving at the site: (yes o no XV revised 9/2/98 Page 6of11 Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C w SYSTEM INFORMATION (continued) Property Address: 7/7 FcoSfer st; A), 19"wr Owner: ,, Wig; 110 Dete of hu on: BUILDING SEWER: Yes (Locate on site plan'l r, Depth below grade:-/— Material of construction: j, cast iron Z40 PVC _ other (explain) Ty L� L �V Distance from /private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of Isakage SEPTIC TANK: Vov (locate on site plan) If Depth below grade: / Material of construction: ✓ concrete _metal Fiberglass _Polyethylene _other(explain) If tank is ►petal, list aget�A ls.age.confirmed by Certificate of ComplianceiW" Dimensions: s awlr k S f /� it k A 16'A62t� r 43Uro 4/ Sludge depth: rl Distance from top of sludge to bottom of outlet tee o►beffle� Scum thick nos s:< Z" W` Distance from top of scum to top of outlet tee or baffle:_ �ls Distance from bottom of scum to bottom of outlet tee or affle:_L How dimensions were determined: o. `+�eG �� �e N^a—aSurle- Comments: (recommendation for purr evidence of leakage, etc.) GREASE TRAP: PO (lo�aie on site plan) of inlet and outlet tees or -baffles, (Yes/No) P liquid level in relation to outlet invert, structureHnte S Gilt, e Y1 uerU stood wr iol rte! r14- 14-t AiQ Depth below gra Material of construction: _ ncrete _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 baffl Date of lest pumping: Comments: (recommendation for purr ' , ondition of inlet and outlet tees or baffles, depth of liquid level in relation to evidence of leakjye, c.) revised 9/2/98 Page 7oril structural integrity, Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / ` ySYSTEM INFORMATION (continued) Property Address: / r7 1? F0 f.w_- ' A' 1 Andov'er- O.nnee: 'D,p�{lo Date of Irupecbon: 7 /2 TIGHT OR HOLDING TANK: 00 (Tank must be pumped prior to, or at time of, inspection) (lo on site plan) Depth below grade Materiel o! construction _concr metal _Fiberglass _Polyethylene _other(explein) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments (condition of inlet tee, condition of.„alarrfidand float switches, etc.) DISTRIBUTION BOX:Ye$ (locate on site plan) /P Depth of liquid level above outlet invert: zero Comments' 1- f30k 15 �� rd�ua-rte' (note if level and distribution is equal, a idenee of solids carryover, evidence of leakage into or out of box, etc.) i + D -130X 65 I-inid ��'s rwivtj e-.- H$5 Cor.ec�- "or -k, Ili*7, fi..96Y fd C'�-er/. L�R�P42.[G 8l..ehd. "N 4A.`:•t C.1,Ae— — --1 1'�4.... P CHAMBER:M,I (locate on Ian) Pumps in working order: (Yes Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurt e •,: ; c e ' 2 / 7 8 Pune 8 of 11 Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 777 F.Sfe,,- Sr-. N, AnJOVer" Owner: 'D i (o i Ito Date of Inspection: 7/Z1/2000�/ SOIL ABSORPTION SYSTEM (SAS):rE5 (locate on site plan, if possible: excavation not required, location may be approximated by non intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ . leaching trenches, number, length:t '~' � �g ` a E, A L�`5 ddb Gt1 leeching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding � damp soil condition of vegeta on, etc.) It, Cis �. r 1 r,. ,wt -11 G GCDH4ri;+�3C "ZAJO 'Tics"V r2r'o lr-A s' SPOOLS: (loce site plan) Number and conflgurafi'Mm Depth top of liquid to inlet Depth of solids layer:_ Depth of scum layer: Dimensions of cesspool:_ Materiels of construction: Indication of groundwater: inflow (cesspDa� be pumped as part of inspetti Comments: (note condition of soil, signs of hydraulic failure, level of pe"ding, condition of -vegetation, etc.) PRIVY: Lo (locate on site plan) Materiels of construction: Depth of solids: Comments: (note condition of soil, signs of of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII Dimensions: Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I , jj `� SYSTEM INFORMATION (corrdnued) Prop" Address: 7/7 0sti;, sr Yv A Ver Owner:'zip; Ito Date of Impecdon:'7JZI Ae'v0 SKETCH OF SEWAGE DISPOSAL SYSTEM: �U s4; —'—"—mc u e ties to t least two p nent ref meerence landmarks or benchmarks locate all wells within 100' (, tate where public water supply comes into house) revised 9/2/98 F ", ArfWO U'er- v�Ac Ay& -se Page 10 of 11 � CI �t�[f 1 tfAc-T =M1 Dean G. Luscomb II & Sons Middleton, MA 01949 r 1-978-774-4065 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 717 Foji et-S�, P' �injavt-f Owner: 'Digi Uo Date of Inspection: r7l, / fZow NRCS Report nam Soil Type_ Typical dept USGS Date website visited %�Z1�2oraa Observation Wells checked1q/911aV16' 116 Z' 1 Groundwater depth: Shallows fi LG7 r Moderate + 1, Deep SITE EXAM Slope i+016 k Surface water A-45Wa7 Check Cellar :D f-4 A-�b Stt.'4�'P POVAtO Shallow wells y,,ytsrs�. r Estimated Depth to Groundwater> (= Feet Please indicate all the methods used to determine High Groundwater Elevation: _V/Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sum[[ p etc.) V - ''t`r�Y1 4� �4,,�d:'� .:i !�'t,(�, C`•Gdr f3{ �kt+�,� �i.L+ �V Determined from local conditions V Checked with local Board of health ✓Checked FEMA Maps V"'Checked pumping records _ Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11 of 11 O Nim O J m v0 m w ti�o E L E V A T l 0 N I N FEE T NCO Cb p I J a t. J oac� Il ooaD�� °ta tD F r C) I m 4 11 °Oo y II C CD W O O °O °�'. k �m Ppp ,�_ � �N 1 19 o mni m^3 Nn0 zn 0 �ANjIIIIj� W0 11 Fr D, <O tOch 0. II 00y J3o�au in ZpC U1. t4 � z A 0� 1 x 0� Pr � /,, (�1• vl F N o U g j- _ 1 a �p� a � i 1 0(b ? _ rV ±i 41 Q �1 3a T M W \` De �• o I N F E E T O s O , • f '-M14 Q O Nim O J m v0 m NCO Cb p I J J Il ooaD�� tD r I m 4 11 II C CD W O O °O °�'. k �m Ppp ,�_ �-C• toW o mni m^3 Nn0 r I L_j �ANjIIIIj� W0 c� .n�o�m 0� 0. II J3o�au in U1. t4 nOn o -D v 0 4 m _ rV ±i 41 Q �1 3a T M W E L E V A T l 0 N I N F E E T s Drawing Sanitary DisposalSys tem No. Designed For 7-1686-4 Travis & Tim Construction, Inc. TOWN OF NORTH ANDOVER BOARD OF HEALTH 10/9/98 CERTIFICATE OF COMPLIANCE This is to certify that the individual subsurface disposal system constructed ( x ) or repaired ( ) by North Andover Licensed Installer Peter Breen at 717 (Lot 4) Foster Street, North Andover, MA North Andover, MA 01845 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit# 1005, dated February 4, 1998. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector `rte rsse TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (a constructed-, ( ) repAi red; by T(S Q Ctc., 64 c 0- i Z Q. -t''(o,N Z VI, C, located at 7/7 was installed in conformance with the North Andover Board of Health approved plan, System Design Permit #�, dated -1 with an approved design flow of gallons per day. The materialA used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bed inspection date: Final inspection date: Engi eer Representative Engineer Representative Installer: PC.l_�' �e-�✓ Lic.#: Date: Design Engineer: ��Ur,, Date: (�% _0 y d C � d CA CM) Z ca CD O 'C y a� o m c o CD CD O CL Q CD CD o CD C CD y Q y —• o ca C S O CO) O 10 Z CD O co O C CD n . � C O 0 Z o• ON co O C CL _ m tom O CIO O a CA N z 0 N o w oT S- C) , Com" c° ` � 5 d o � dryTcvtzN. NO 4 Commonwealth of Massachusetts W City/Town of NORTH AN®OVER, MASSAC , G' U E= f System Pumping Record 41M S.a . Form 4 APR 0 5 2006 NOF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Theygt!',ki umpi=nKKR cord -must be submitted to the local Board of Health or other approving authority—"` A. Facility Information Important: When filling out 1. System Location: jn forms the computer, r, use only the tab key Address /l/6 to move your cursor - do not r use the return CitylTown State Zip Code key. 2. System Owner: U arch, Name - — Address (if different from location) City/Town State Zip C e Telephone Number B. Pumping Record 1. Date of Pum In /1)6 p g �3 Date I r 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes,/21-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sy 6. System Pumped By: "41? 4lt- N ame- 05�•6��/l�� Company 7. Location where contents were disposed: raa") "�') ')74 . ,A / Vehicle License Number a -d — _ gnature of H er Date http://www.mass-gov/dep/w ater/approvals/t5forms.htm#inspect t5form4.doc• 06/03 Ko System Pumping Record • Page 9 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION or� (example: left front of house) 9f 7 DATE OF PUMPING: QUANTITY PUMPED LS7d GALLONS CESSPOOL: NO !J YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: L _J i LUUI CONTENTS TRANSFERRED TO: 0 rn Q Q CD n 0 CD Q. G y M m 0 H i C M O � Q A v Q n O m o a 0 -^ D 4 D 0 QL, X co0 n� a 0 -n Pom v o (D 3 cn .� d � m � o o' o m D a � S. �I 0 rn Q Q CD n 0 CD Q. G y M m 0 H Town of North Andover, Massachusetts BOARD OF HEALTH /, DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant.+`�"�� ��'' �' Test No, Site Location Reference Plans and S ENGINEER Form No. 2 DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. & Q' Fee - — - 2 &� (5 A 0 1�?'q CHAIRMAN, BOARD OF HEALTH Site System Permit No. % 00Z— Y a APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: �or— LICENSED INSTALLER:. SIGNATURE: TELEPHONE# G �`% % CHECK ONE: REPAIR: NEW CONSTRUCTION: C/ IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes r/ No Yes No Floor Plans? Yes �' No A proval G Town of North Andover, Massachusetts Form No. 3 1 NORTH BOARD OF HEALTH O tt�a° �e1'ti �) .. f A / DISPOSAL WORKS CONSTRUCTION PERMIT 9SSACHUSE' Applicant --7zz _rte NAME ,ADDRESS TELEPHONE Site Location Z,/- ':X� Permission is hereby granted to Construct (;/) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. '' 0 0 5 �S� Fee CH'Al RMAN, BOARa OF HEALTH D.W.C. No. Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director March 18, 1998 Mr. John Morin Neve Associates 447 Old Boston Rd. Topsfield, MA 01983 Re: Lot 4 Foster St.. N. Andover, MA 01845 Dear John: 30 School Street North Andover, Massachusetts 01845 This is to inform you that the proposed plans for the site referenced above have been approved. 1, If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/rel cc: Travis & Tim Construction File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 DATE BOARD OF HEALTH TOWN OF NORTH ANDOVER Sheet of SUBSURFACE DISPOSAL DESIGN REVIEW FEE_ &to PERMIT # � DATE RECEIVED APPLICANT 7',egV/5 /Tiny (_.oV57.el)Gnak) ASSESSOR'S MAP 9,01,9 PARCEL # 7 - ADDRESS %,76z -o ccomo ST, LOT # 4- STREET # ENGINEER /%��///% ADDRESS 447 QZb 965T6,u Z -i) T PLAN DATE ,I A/J . a 7. M x' REVISION DATE CONDITIONS OF APPROVAL: APPROVED L� DISAPPROVED PLAN REVIEW CHECKLIST ADDRESS 41-0r4 s✓ ENGINEER AMC— L16 GENERAL 3 COPIES/ STAMPL/ LOCUST/ NORTH ARROW �� SCALE CONTOURSIi PROFILEL--(SC)SECTION L-- BENCHMARK &--' SOIL & PERCS ELEVATIONS WETS. DISCLAIMER L-- WELLS & WETS Lvc—a— lg(-5D 5NCX.c)N,/,,7 WATERSHED? A10 am DRIVEWAY L� WATER LINE L` FDN DRAIN Z-- M&P`� SCH40 TESTS CURRENT? L--' SOIL EVAL SEPTIC TANK MIN 150OG .17 INVERT DROPy GARB. GRINDER//6 (2 comps +200) 10' TO FDN MANHOLEO/<-" <_ELE_V GW # COMPS. GB -,eve ;,, e e f 5 Nle -7.0 4 D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT�� INLET 138.0 % - OUTLET/3;9. 50 =7 ( 2" OR .17 FT) TEE REQ'D?YO LEACHING MIN 440 GPD?c� RESERVE AREA!,-' 4' FROM PRIMARY?2% SLOPE 100' TO WETLANDS 100' TO WELLSZ! 4' TO S.H.GW `" (51>2M/IN) 20' TO FND & INTRCPTR DRAINS C/ 400' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY `� MIN 12" COVER � FILL) BREAKOUT MET? // TRENCHES MIN 440 gpd W OR D (MIN 6') BE 10' MIN. SLOPE (min .005 or 6"/1001)_ RESERVE BETWEEN TRENCHES? 4" PEA STONE? BOT + SIDE - (L x W x #) (DxLx2x#) Copyright Q 1996 by S.L. Starr SIDEWALL DIST. 3X EFF. IN FILL? MUST VENT? (>3' COVER; LINES >501) X LDNG = TOT (G/ft2) PITS MIN 440 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT+ SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 60') MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 440 GPDL---" 900 ft2 BED LI--, GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED?4" PEA STONE? 6-- DIST LINE SLOPE .005? >31COVER-VENT SCH 40 L--- MIN 12" COVER RATEa,o/ (_ }{) X = TOTAL L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X - L W D Vol. DISCHARGE SIZE DISCHARGE RATE PUMP CAPACITY gpm gpm DISCHARGE TIME MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. l' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ENUF STORAGE? Copyright (D 1996 by S.L. Starr w�..®...meY..._�� .fMµ. ._ _ .. • .A:�°!: 1•. 17 1 9 f� � is .5 Y.! {' �. ',.Sd t a4.,;; !.k .H�r:�t ti 3 c fr-}. y"� 'i'a' Kn ��:�tix.. i�.. :�{, �� :1� y.: ^i 1.�l., !s y .hru r. '`d . 3�•,t �:rM' a�!skj�-By-'rt.�w ,. f� S',t `1'). � r', .� M '�, tai! �{yA'w�' Sr„7 `" •� ;�..x »�(�.P+rs�,ytr �'.r .iS��iy_� 5+7 •:�. �`r�it�*Y+',*sr> , -� *Fr.4 &�'"Y;"4'r.�,.,,,lF X41.', �!. .bn .!• � , 5n t a ! Ih i.",x7 � int a �'. t.,'r 1 4 ,�'' .!! ) t .',{••�d .,�. .�7 i'. -.!' , I N ; a i 0 33 s r N \ V? C 6` O r o^ r 9 r0 J y 9 -r 010 1 ; \ 4 . r T t s -A 2 .. -p m P a n : t 'r 'A O O c 2 O O° p i t 1 r � 1 tii Ln 6 a d4o a s ' l o' ' O it R o 0 „i O O � O 2 lO ago O G SEE PLAT 105 A / N SEPTIC PLAN SUBMITTALS LOCATION: z:�— NEW PLANS: (2q) $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: 4 -zl'.3 /1'2 Fes' DESIGN ENGINEER: When the the submission is all in place, route to the Health Secretary Town of North Andover, Massachusetts Form No. 1 N°RTH BOARD OF HEALTH /f, 19 X-7 41 APPLICATION FOR SITE TESTING/INSPECTION 7 A�RATE� PpP �y �SSAGHUS�� Applicant --7�/ oAe��"'' NAME _ ADDRESS TELEPHONE Site Location 45 7- -JT�� 5.7 Engineer -/d NAME / ADDRESS TELEPHONE Test/Inspection Date and Time— BOARD OF H CTH Fee L 75— Test No. R/10 S.S. Permit No. ��� D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No -1 NORTH BOARD OF HEALTH / Y 19 ° lei" �ti4Ao°°° EwoP."APPLICATION FOR SITE TESTING/INSPECTION i Applicant — - NAME ADDRESS TELEPHONE Site Location r�eel J Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time �A / 7' _ CHAIRMAN, BOARD OF HEALTH Fee / Test No. S.S. Permit No. ���� D.W.C. No. C.C. Date Plbg. Permit No. DATE: 1 D - �J— T% LOCATION: % lt-� ENGINEER: BOH WITNESS: PERCOLATION TEST # 7 BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: (At least 15 minutes long) TIME AT 12" / b TIME AT 9" / b t 7 TIME AT 6" a OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: TIME AT 12" TIME AT 9" TIME AT 6" /o Mp / (At least 15 minutes) BOARD OF HEALTH 146 N4AIN STREET TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: 1706. 7 9 LOCATION OF S IL TESTS: Assessor's map & parcel number: OWNER: 'P�TE� 73,0�'4j TEL. NO.: w/ 9 7 %7%}' ADDRESS: 770 -BoXcoeA 57-. ENGINEER: 4556C - TEL. NO.: 8?7— CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Aug jQ9i THO ' 4 N3. NEVE ASS INCO s b August 8, 1997 Ms. Sandy Starr Board of Health 30 School Street North Andover, MA 01845 Re: Poster Street Soil Testing - Peter Breen Dear Sandy: Pursuant to our telephone discussion yesterday I have enclosed a site plan and assessors map showing the land which Peter Breen would like to test as soon as practically possible. He has informed me that he submitted $350 to your office to test for 2 lots. You mentioned that you would complete the application and have Peter sign it. Kindly call me at your earliest convenience to schedule these tests. If you should have any questions regarding this please let me know. Very truly yours, THOMAS E. NEVE ASSOCIATES, INC. 6±1-� Kathy Molina Personal Assistant cc: Peter Breen # 1686BREE. WPS • ENGINEERS • 447 Old Boston Road (508) 887-8586 • LAND SURVEYORS • U.S. Route #1 • LAND USE PLANNERS • Topsfield, MA 01983 FAX (508) 887-3480