HomeMy WebLinkAboutMiscellaneous - 717 FOSTER STREET 4/30/2018VA
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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
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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: (�%
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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:
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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
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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