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HomeMy WebLinkAboutMiscellaneous - 72 STERLING LANE 4/30/2018 (2)0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF E TITLE 5 TECTION CEIVED F'E8 2 2 2005 rOVVN p tV EAO H �� RTND VER NT OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 70- &- l -RNC Owner's Name: R IC K- in vN7 �rl A/ Owner's Address: '7 a .!5 �P�tAv 6-- LA-ve Date of Inspection: 2 / i g / 0 - Name of Inspector: (please print) Beniamin C. Osgood, Jr. Company Name: New England Engineering Services Inc. Mailing Address- 60 Beechwood Drive North Andov ., t�A �] X45 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I oetify 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 toSection15.340 of Title 5 (310 CMR 15.000 The system: — Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: r— Date: z- 1ki '� 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. Notes and Comments ""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, Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -7 ,�2, S}e.F? w ,g nrE Owner: _ e IC K ?M 0 AJ—)9q/V Date of Inspection: Z.I d 2�(os Inspection Summary: Check A B C D or E / ALWAYS complete all of Section D A. . System Passes: G 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: ,Z One or more system components as descr bed in the "Conditional Pass" section need to be replaced or Maim& The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (YAM) in the 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed p'npe(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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 tunes a year due to broken or obstructed pipes). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Vage 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 ,;7-f?, `1 �v � 1_6,) _ /V -?(2 (2 i t ��� � ov e 2 44 04 Owner: Q 1 c K iy1 v f�N Date of Inspection: 7-1 4 o5 - C. Farther Evaluation is Required by the Board of Health: NCondithons 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(l)(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 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 fee_ t of a surface water supply or tributary to a surface water suppler. _ 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 wellwater analysis, performed at a DEP certified laboratory, for cotifoM 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, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. Page 4 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address*, 7 2 sj(_,6_ R U ,v U _L6tiC Owner. --- ��c.)< Date of Ins a: Z.) o311 D. System Failure Criteria applicable to all systems: You must indicate `fires" or `Sno" to each of the following for aIl inspections: Ye$ 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 inthe distn-button box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than'/, day flow 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 fed 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 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, provided that no other failure criteria are triggered. A copy of the analysis most be attached to this corm.] (Yes/No)'Ile system fails. I have determined that one or more of the above failure criteria exist as descxiiW in 310 CMR 15303, 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 mast serve a facility with a design flow ofgpd. 10,000 god to 15,000 You must indicate either W or "no" to each of the following: (The %1104?"teria apply to large systems in addition to the criteria above) yes no — — the system is 400 feet of a surface drinking water y — the system is within 200 of a tri o a surface drinking water supply — the system is locat a nitrogen itive area (Interim Wellhead Protection Area — IWPA) or a mappe =answered lir water supply well If you hayes" to any question in Section a system is considered a significant threat, or answered —"yes' in Section D above the large system has failed. The o er or operator of any large system considered a significant threat under Section E or failed under Section D sh grade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional o Fe of the Department. Page 5 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _ -7 2 , , N U G-f#nAe– Owner; Date of Inspection: Check if the following have been done. You mast indicate `f res" or "nd' 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" 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 baffies 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 determimed based on: Yes no — — 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 d'tistanc ( is unacceptable) [3 10 CMR 15302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _-?a &T 7kl-1 c -An r� A,10 a rV( Atif DC?��e2 Owner: Ri�w btij9�/ Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example- 110 gpd x # of bedrooms): 1 Number of current residents: Z Does residence have a garbage grinder (yes or no): Is laundryon a separate sewage system (Yes or no): LO [if yes separate inspection required] Laundry system inspected (yes or no): = Seasonal use: (yes or no)t _[ Water meter readings, if available (last 2 years usage (gpd)): -2� w n Sump Pip (yes or no): /V O Last date of ocgancy: COIVII MICIAUINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): C"%d Basis of design flow (seats/persons/sq%etc): �P present (yes or no): _ Industrial waste holding tank present (yes or no) - Non -sanitary waste discharged to the Title 5 system (yes or no): — Water meter readings, if available: Last date of occupancy/use: 43THER (describe): GENERAL INFORMATION Pumping Records Source of information: - N e.le (Z - was Was system pumped as part of the inspection (yesor no):.� If yes, volume pumped; __,gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XSeptic tank, distribution box, soil absorption system — Single cesspool _ Overflow cesspool —Privy Shared system (yes or no) Of yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the cement operation and maintenance contract (to be obtained from system owner) — Tight tank _ Attach a copy of the DEP approval — Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): 0 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _7v; 516A 1-1 AY( A-1 Q.TN Owner. A-� y-. Date of Inspection: _ Z 1 i . .1 BUILDING SEWER (locate on site plan) Depth below grade: Materials of constnx;tiom: cast iron Z40 PVC other (explain): Distance from private water supply well or suction line: Comments (oa condition of joints, venting, evidence of leakage, etc.): ►P� ��vrl-S �n:op cti. r�AcE/�t�.U� SEPTIC TANK: _(locate on site plan) Depth below grade: i - i .a fil ( ecl els i G- P P r Material of construction: ✓. concrete metal fiberglass __jpolyethyleae if tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): certificate) —(attach a Dopy of Dimensions: C' C%f}!-LG .v S Sludge depth: Z :Distance from top of sludge to bottom of outlet tee or baffle: Z ? Salm thickness; l_ Distance from t of scum to . op top of outlet tee or baffle - Distance Distance from bottom of scum to bottom of outlet tee of baffle: i How were dimensions determined: 1,o r #5 X12 F 477611 - Comments 7Gi1Comments (ea pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc ); 7►��'K /nr Crevn �o ✓��710.✓ «/ oto ?at 7Ffs i lmo� — CJ ti l_7r7 N GREAStr TRAP.- / (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baM e. Date of last pumping Comments (on Pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pages of 11 OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7g Owner. N9 2 �1 t Atip ootx- Date of Inspection: 0 --'- TIGHT TIGHT or HOLDING TANK: k1k (tank must be pumped attune of kspection)(locate on site plan) Depth below grade: Material of coostrudion: concrete metal fiberglass __polyethylene Tother(explain): Dimensions: may. �aLlons Design Flow: ---gallons/day Alarm Pry (yes or no): Alarm level: Alarm in working order (yrs or no): Date of last pumping: Comments (condition of alarm and float switches, etc ). DLSTRiBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, ryover, any evidence of leakage into or out of box, etc.): 12) D no Lo c. -R-7 aX, 7-0 ee-L„p cc -3 PUMP CHAMBER: Al Pr (locate on site plan) Pumps in working order (yes or no): _Alarms in working order (yes or no): Comments (note condition of pump cumber, condition of pumps and appurtenances, etc.): Page 9 of ll OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 A ti�Q-�fFP Rti�� Owner: - fz lC-l< IW UA -Tj�-i4n! Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why. TS'Pe leaching pits, number. _ leaching cumbers, number: leaching galleries, number: leaching trenches, number, length: pTre •, i, f 6 ' �o �, leaching fields, number, dimensions: overflow cesspool, number: innovativetalternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): -Eio fi oNc/ig-5 "o/4s NERMA�- No 7)L-, i'ONDiN(r OR V1VU50A-L ,166-0 Al CESSPOOLS: X? A (cesspool must be pumped as part of inspec tionxlomte 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 constrnctiow -Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc ): PRIVY: N 0 (locate on site plan) Materials of cmstcuction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc): Page 10 of 11 OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -7 a Si 2U.v CT c RrLe Owner. p[c_I4, —ZVI UV —1 AN Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. � � h G Page 11 of 11 OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: - `7 2 5 i r x t. iti, (; ,4,j e Ivo27f /-iQ oyJI_ MA Owner: DIC -11. M vNi54n> Date of Inspection: ;21 fy ( as- SITE EXAM Slope --I, S`, Surface water ,vo,✓j� Check cellar Shallow wells N� ,,G D Estimated depth to ground water 6 feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within ISO feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: ELL 70,A . TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 11/27/00 This is to certify that the individual subsurface disposal system constructed ( X) or repaired ( ) by Dave Maynard at Lot 4 Sterling Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. -�` 'Board of Health Inspector TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (N constructed; ( ) repaired; by located at xoT *,&�l was installed in conformance with the North Andover Board of Health approved plan, System Design Permit #4 , dated -?la> /p E) , with an approved design flow of 9 / 0 gallons per day. The material sed 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: Z Final inspection date: Installer Design 1 Engineer Representative Engineer Representative Date: //-9 2-- dQ Date: // Z� O, 27 FA Vk G, INSPECTION CHECKLIST FOR SEPTIC SYSTEMS A. Bottom of Bed 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation, etc. Comments: B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: Yes t/ C. Building Sewer 1. Pipe diameter minimum 4" ✓r 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8" per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90° change 10. 10' minimum offset to water line Comments: 12. Pipe set 13. Compact base with 6" of 1/4" crushed stone under tank 14. Tank is watertight Comments: Z t- It, NO Initials D. Septic Tank 1. Level L� 2. 1,500 gal minimum 3. Gas baffle present on outlet ✓ 4. Manhole to grade ✓ 5. Manholes over center and each tee 6. 3-20" manholes ✓ 7. Inlet tee minimum 12" under invert t/ 8. Outlet tee minimum 14" under invert 9. 'Outlet line cemented 10. Air space 3" above tees 11. 2" - 3" drop from inlet to outlet y 12. Pipe set 13. Compact base with 6" of 1/4" crushed stone under tank 14. Tank is watertight Comments: Z t- It, NO Initials Yes NO E. Pump Chamber 1. If separate from tan compact base with 6" of 1/4" stone underneath 2. Minimum 2" pipe to - x if gravity system 3. 20" access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan speci tion 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d -box Comments: F. Distribution Box 1. D -box level i 2. Minimum 0. IT' (2") drop from inlet to outlet 3. Minimum 6" sump 4. Outlet pipes show equal distribution 5. Compact base with 6" of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement _ .8. Schedule 40 pipe IL Comments: G. Soil Absorption system 1. All stone double -washed - 3/4" = 1 %i" - pea stone LC/ Bucket test done? 2. Minimum 2" of pea stone above distribution lines 3. Minimum 6" stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9" of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not, then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan - Minimum 2'; maximum - 4'. 4. Vent present if <50 feet or specified 5. Distance between trenches minimum 4' and maximum of 6' t� 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6" per 100' 8. Depth of trenches below outlet invert minimum of 6". /' 9. Pipes set on stable base. Comments: 1. Leach Field 1. Maximum lengt\ea ld 100' 2. Pipe slope miniOS or 6" per 100' 3. Separation betwe 'maximum 4. Pipes connected5. Separation betwcent Ids 10' minimum6. Pipes set on stab7. Maximum 4' sefrom edg of field to first line 8. Minimum two don lines9. Maximum perc mpi Comments: J. Leaching Pits 1. Minimum inlet pipe \4"2. Pits of concrete 3. Sidewall between 124. Access manholes on 5. Pipes cemented with Comments: K. Final Grade 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9" soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond Yes NO AS -BUILT CHECKLIST v LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS ' ^ LOCATIONS & DIMENSIONS OF SYSTEM, CLUDING RESERVE - `' 9-e s e ri,/ t TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION i� LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED FORM I I - SOIL EVALUATOR FORM Page 1 of 3 No. Date: Commonwealth of Massachusetts AApc> , Massachusetts Performed By:� ., Date: Witnessed By: y I- �0- j2 r— > /Dfz9ZZZ adon Address or Owner's Name # _ Address an&- fl,, 11 -FA VE j E2AJ Telephone # � k'Z �Z4-Z New Construction Office Review Published Soil Survey Available: No Year Published Drainage Class Repair Yes a Publication Scale �—� _-/,/6 Al Soil Map Unit C� 7Z A) Soil Limitations /v�J vy Surficial Geologic Report Available: No Yes Year Published Publication Scale Geologic Material (Map Unit) Landform Flood Insurance Rate Map: Above 500 year flood boundary No Yes iC Within 500 year flood boundary No yC Yes Within 100 year flood boundary No Yes Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range: Above Normal Normal Below Normal Other References Reviewed: DFS APPROVED FORM - 12M7/95 �oilevdsrm FORM I I - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. Z07- On oT On - Site Review Deep Hole Number 97-1 Date/D Z9 9% Time ld; Lo(J Location (identify on site plan)Zt Land Use j��� Slope (%) Surface Stones Vegetation Z51A fil,,1-7 Landform 0%G jzAl .--v E�7 Position on landscape (sketch on the back) Weather 0Z,5A tZ Distances from: Open Water Body O -D feet Drainage way >10 U feet Possible Wet Area. /0 a feet. Property Line 7D feet Drinking Water Well feet Other DEEP OBSERVATION HOLE LOG* Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) 0-S, FS L- FS ZSj�S — /1 V Flp- 2Z (f S Z -s-/ Co 'MINIMUM OF 2 HOLES REQUIRED ATTVERY PROPOSED DISPOSAL AREA Parent Material (geologic) :n. /-- L Depth to Bedrock: Depth to Groundwater. Standing Water in the Hole: 1A/L/�1::— Weeping from Pit Face: Estimated Seasonal High Ground Water. -,ti DEP APPROVED FORM - 12/07/95 weevd,.m Location Address or Lot No. L07--14 Deep Hole Number z Date Location (identify on site plan) Land Use Slope (%) 12� Surface Stones Vegetation T�'UC7— f, 0 Nc Landform jjp2 t�)-! AU C FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 /b /29h,7 Time �� Weather G.e 9� Position on landscape (sketch on the back) Distances from: Open Water Body 7/� feet " Drainage way ikd feet Possible Wet Area % / feet. Property Line Drinking Water Well °A feet Other _feet DEEP OBSERVATION HOLE LOG* Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) ©- aJ Ap �S I g� 3Z �w FS L /d�2,% /y�� 1 eD-DC/�S L -MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) �(_ Depth to Bedrock: Doth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: 3z r'/ DEP APPROVED FORM -12/07/95 soilrnlsue FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address orLot No. - F -1 Depth observed standing in observation hole Depth weeping from side of observation hole Depthto soil mottles 3 inches. Ground water adjustment feet inches inches 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 occuring pervious material? Certification Icertify that. on (date) I have: passed. the soil evaluator examination approved by the Department of Environmental Protection and that. the above analysis was performed by me consistent with the required training, expertise and- experience nd experience described in 310 CMR 15.017. Signature �j - Date 77 V DFP APPROVED FORM -17/07/95 "Iriw..m FORM 12 - PERCOLATION TEST Location Address or Lot No. COMMONWEALTH OF MASSACHUSETTS , Massachusetts Percolation Test* Date: Time: Observation Hole# / z Depth of Perc5b (11PX� Start Pre-soak �O _' C/7 Z/'3 End Pre-soak / O Z Time at 12" Time at 9" Time at 6" ` Time (9"-6") -7 Rate Min./Inch I *Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed F� Site Failed a Performed By: Witnessed By: Comments: DEP APPROVED FORM - 12/07/95 PemmtsAM DATE: % 8 _J14 — 12 LOCATION: T ENGINEER: BOH WITNESS: PERCOLATION TEST #, '3 (� fL C BOTTOM DEPTH OF PERC TEST: s— TIME OF SOAK: % (At least 15 minutes long) TIME AT 12" l C TIME AT 9" �t TIME AT 6" t (� OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: TIME AT 12" TIME AT 9" TIME AT 6" (At least 15 minutes) Town of North Andover, Massachusetts Form No. 2 e MORTh BOARD OF HEALTH F p DESIGN APPROVAL FOR ACHusft� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant (geore Gr'Test No. Site Location_ Lj Reference Plans and Specs�� r I /�(i t "10 Ag ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee 96' � 0 —CHAIRMAN, BOARD OF HEALTH r Site System Permit No. X0914 SEPTIC PLAN SUBMITTALS LOCATION: o (rG a 5 -kr NEW PLANS: C/ $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: 411—c -.2d° F7 DESIGN ENGINEER: . --1 A When the submission is all in place, route to the Health Secretary SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan REVISED PLANS. YES ,./ $25.00/Plan DATE: 4� — DESIGN ENGINEER: When the submission is all in place, route to the Health Secretary NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: �� PERMIT #_ooz 7 DATE RECEIVED % ZZ APPLICANTMAP PARCEL ADDRESS LOT ## 4 ENG. ADD. PLAN DATE REV. DATE CONDITIONSOFAPPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: --- �4 �C' c A �� a -t r s s j,v � , (g16e- A�:e /L5"• aaGC�, )9 s !/9 --plo e -c5-6 ANG, STEVEN J. D'URS® Environmental Designs 22 Lilly Pond Road W. Boxford, MA 01921 (508) 352-9872 TO � 11 WE ARE SENDING YOU L)(Attached ❑ Under separate cover via_ ❑ Shop drawings Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ a L1 IEUTEM OF MUSEDUUL DATE ATTENTION /GJ - RE the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION hf re;W.�' G O� L-oT Z A4� ,< LST 3 e THESE ARE TRANSMITTED as checked below: or approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As "requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 124L M,42K COPY TO i ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US SIGNED: Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director February 3„ 1998 Mr. Steven D'Urso 22 Lilly Pond Dr. Boxford, MA 01921 Re: Lot #4 Sterling Lane. Dear Mr. D'Urso: 30 School Street North Andover, Massachusetts 01845 This is to inform you that the above referenced plans have been disapproved for the following reasons: 1. Elevations of peres and deeps missing (N.A.8.02n). 2. Benchmark missing (3 10 CMR 15.220(q)). 3. Assessor's map and parcel missing, also abutters. (N.A.8.02a). 4. Please show additional detail for retaining walls. If you have any questions, please do not hesitate to call the number below. Sincerely, Sandra Starr Health Administrator c.c.: George Farr William Scott -,File- 0 9 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 STEVEN J. D'URS® -- Environmental Designs �4_414a-4? S 22 Lilly Pond Road W. Boxford, MA 01921 (508) 352-9872 TO` !� > WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via_ ❑ Shop drawings ❑ Prints ❑ Plans ❑ Copy of letter ❑ Change order ❑ MEU 11 CEM (BEF �Ql>�aSEDUMU ATTENT Joe NO the following items: ❑ Samples ❑ Specifications COPIES DATE NO. DESCRIPTION Z aitd_� THESE ARE TRANSMITTED as checked below: For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE _ 19 REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: ZZQ� JPLAN REVIEW CHECKLIST ADDRESS 0 ENGINEER 5 - GENERAL 3 COPIES`' STAMP L-1 LOCUSy :NORTH ARROW SCALE CONTOURS `� PROFILE �Sc) SECTION V BENCHMARK SOIL & PERCS ELEVATIONS/ WETS. DISCLAIMER WELLS & WETS WATERSHED? 41D DRIVEWAY � WATER LINE FDN DRAIN � e-'� M&P SCH40 TESTS CURRENT? t/ SOIL EVAL SEPTIC TANK AA // MIN 1500G "' .17 INVERT DROP GARB. GRINDER./O (2 comps +200) 10' TO FDNC/ MANHOLE ELEV ,l./ GW # COMPS. GB `f - D -BOX -- SIZE # LINES I;�— FIRST 2' LEVEL STATEMENT— INLET IZ1 R9 - OUTLET 7 ( 2" OR .17 FT) TEE REQ.' D ) LEACHING MIN 440 GPD? RESERVE AREA L"�4' FROM. PRIMARY? L -"""2-a SLOPE_ 100' TO WETLANDS X100' TO WELLS L--' 4' TO S.H.GW ?(51>2M/IN) 20' TO FND & INTRCPTR DRAINS 400' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY MIN 12" COVER" FILL?!- 15') BREAKOUT MET?� to A-4 c 5 TRENCHES MIN 440 gpd ✓ SLOPE (min .005 or 6"/100') i--�SIDEWALL DIST. 3X EFF. W OR D (MIN 61) �' RESERVE BETWEEN TRENCHES?A�6 IN FILL? MUST BE 10' MIN. C/ "_PEA STONE? VENT? �� (>3' COVER; LINES >501) BOT �aZO + SIDE o2.�� - 7LIo� X LDNG '15 � = TOT -44,3;74 4-0 - (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1996 by S.L. Starr DATE: C. LOCATION: ENGINEER: BOH WITNESS: PERCOLATION TEST # 7 �-- BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: ���J �- (At least 15 minutes long) 6 TIME AT 12" TIME AT 9" ,r° f kvr/. TIME AT 6" r t OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: TIME AT 12" TIME AT 9" TIME AT 6" (At least 15 minutes) WILLIAM J. SCOTT Director Town of North Andover NORTH OFFICE OF f , 3�Ots,.eo ,e°e1OL COMMUNITY DEVELOPMENT AND SERVICES A 30 School Street . . North Andover, Massachusetts 01845 �'9� ^•° °���/ June 25, 1998 Steve D'Urso 22 Lilly Pond Road W. Boxford, MA 01921 RE: Lot 4 Sterling Lane - Dear Steve: This letter is to inform you that the proposed septic plan for Lot 4 Sterling Lane 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 Dave Zaloga File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 G. J. Bruno Associates r Architectural Designers 28 Berkeley Road N. Andover, MA 01845 " 978-683-1153 i Erne t��e�n �r�cros��� foie J .-....a ..e ..i .. .... .-f_�. _. _. G. J. Bruno Associates r Architectural Designers 28 Berkeley Road N. Andover, MA 01845 " 978-683-1153 i Erne t��e�n �r�cros��� foie 4e c? RA- QT I 14ALL � KICiNT ARNR TQ AffruCQx4TlkWnQN, A QOfW FOR THE RLrTKFM£D COMGRCT[ R£TAlffiNG WALL sHAUac' Svf#kmo f9 TH' :oma of hR•itJ,rH, rNt pm4v Of in +fE A"w • wALA SHALL- hftfT' TNf OOt.W*Ni: MCMA7104 AS FC)l aro OMP IAS.2WI) -AND Taft RVLrS AMD REGUiATlm w TMr WORTw Awvro 11 A" or HC Lm, A) THC RETAtNNNG WALL SNAU or CONST*VCfM of Arwrort'CCO. CONCRCM &M" HAYr NO WEA' HOM, AND SMALL K WAP;C1MWf. a) THE ftTAJM M- WALL $HALL SC DdY1WD ST • A REGISTERED rROfYS WWL - EMGIIME'ER. Wm ROU GERT►fT TMT TKC AWM CQNOITXN is NET Rr Mr 54109( TED am(OH. C) THE upoRw6T SIDE of WE RETAINING. WAU*SWU, PC WA TERPROOFrIL . A) CQPlSTnirCTlOr( of THC RUAItttMO WA U 3MLI, er SWC1tY = 81' TK ,=OK fMOtNCiR, E) AA AS -Amour PLAN sNALL RS PwL7ARlCA , !>'• G MtfLib Atr n�k, nrs ox AClyCJwEtR 'rwcr . THE WALL, W IM CONSTJtW= INACCOROM MU MM tK .AI">WYE'0 OWN Mm. . F) miE rtrvmoo of mr Top' of Tmr lifTAMIWWALL WiVA of hf* 1oh9¢rt rMN Me 'WIEAK0117 REM T", WHICW 1S THF ELV,ATION Or THC. Top -M 7W -FVJR INCH LAYER of 1/i INCH'ro •11,z 0YCM WASMO STOME•AG REGATF COYER. o) rHr O1SrAICC• " rHr wAu ro Tw • of TW VACW *AfifA..sxAU K AT LEAlr YEN s"r_ H) CONSTRNCT}oN or w scpho' sH TiF1A!!, 1MOf STAR' t1MITL TriIX Rf1'Atr p WAt� 1S t�ONS71HK'T1O. ftWWWO IY 77it` J?IFSJON 04MMCM,, •,ANO WSWCMCr•!AV'•TW WAAA OF MrAL•T _ L t e. .. ... �.. .... FORM U - LOT RELEASE FORM° INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having. jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *********'t***************'"*'"*APPLICANT FILLS OUT THIS SECT ION*********************** APPLICANT�D�J/rDGE �4,dO T PHONE1�7, %D)OI LOCATION: Assessor's Map Number Aa6c PARCEL SUBDIVISION qA/<.�4 F PES% 7%T LOT (S) STREET �2�4/NG ST. NUMBER Z USE RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED COMMENTS TOWN PLANNER COMMENTS DATE REJECTED DATE APPROVED DATE REJECTED CA FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED O L� DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS I W DRIVEWAY PERMIT �� W ! 2,7-77 FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm LOT 5 STERLING LANE �08 7'f L 0 T 3 LOT 4 \ EXIST. FND. \ EL. =132.3' \, \ \ EASEMENT \ a, 50' BUFFER \ A REFERENCE PLAN NO. 13035 FOUNDATION LOCATION PLAN CLIENT: COOLIDGE CONSTRUCTION CO., INC THIS CDMnCATION IS MADE AND UMITED TO THE ABOVE CLIENT. LOCATION: MIDDLETON, MA. f -/Y I COU" PMT 7W AMMMMr SIBUCIUME SHOWN COMP AW TO 9W HaNEWAR SEnMff AEDUNNOW M W nN: IMPAR APPl CA" ZA%W Br-UWS W EFFECT WEN Cd%STBUCYM (17E5 (.f1PnEIPAPMN DMFS AOT COMM ANY OPIEB AESflML71 SUCH As Commul Sr MROEt:s OF CG MnUW=) nlrs DMIWW SMU AOT BE UM W Off aOff FGR AW Pumaw m" PMN PMT ixmm fiD ABGYE;ExCEPr wm 7w wAFr1W PERVISSM aF aMUMIM t SUW NMA FUMERMW WX DMIWW IS PIE Ca MOM MFEW OF CINM MNSEN t 309 NMC. AAO Mr INWUPI UMV USE IS AGNM MCNWnUfSE7U t SEAGI TMES NO AESPOARSMWM FGR Pi' I MUPMOM USE OF 76 =WMO W Mr MW- IMnW WWANIM;G M B = SCALE: 1 " = 50' DATE: 8/11/00 CHRISTIANSEN & SERGI UW SUOr"M IMO S MIR ST. HAVE1WMI. M UFAW UL 978- 473-iUIO Q2= er aNmmNA r r SOW W- DWG.NO.:98024005 rA W O z U O cm ca O ;0 CD O �O G3 CD CD O imp. CD co O i O d CL cm< CO), =` CL o CD C Z CO)CL !c m • C _c �. E 0 U) crw W CEW U) v O� •\ W 4:c 0 C, ZW C H • O C s :cav 'Q ♦: : C O . 6 O v cz to �r O x r O G w O G O G Q O w cn w a cn cn U O cm ca O ;0 CD O �O G3 CD CD O imp. CD co O i O d CL cm< CO), =` CL o CD C Z CO)CL !c m • C _c �. E 0 U) crw W CEW U) v 4:c 0 C, C H • O C s :cav 'Q ♦: : C O . m C O m moi: E a m o c. N C C.3 c Oo C N N co as = C co m COS y Of V h O" CC420 m. O r' O C m « �= N p y+ N O C!) 12- CD W N *d=: C �E v a •N Z O LU C* = a O 'p A o H.= yp+ CLs- m i U O cm ca O ;0 CD O �O G3 CD CD O imp. CD co O i O d CL cm< CO), =` CL o CD C Z CO)CL !c m • C _c �. E 0 U) crw W CEW U) Appl ican Town of North Andover, Massachusetts BOARD OF HEALTH ? 19 Form No. 1 APPLICATION FOR SITE TESTING/INSPECTION Site Location e�QT If �r // �a Z�l Engineer Test/Inspection Date and Time Fee ' �- CHAIRMAN, B OF HEALTH Test No. M S.S. Permit No.IOAD.W.C. No. C.C. Date Plbg. Permit No. Cl) W C o Z O Z 2 a Cts E a L LU w p un � LL J \ 1 fJ 2 I- O i — D ce. c c m uj V z a _ J u _Q �w o o Q > LL 1� Q , 0 O --- Q p u G ce In Y -� L Q O O 3 v Q 3 o p �, CL !. N L W % l . •�• 0 O ' N �i •a.+ C (: . �, YW `f �..1 ii K� if V V p O rJ:i i � INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at Za / h, y relative to the application of Z!?4, dated-� r .2 cP --6 (3 for plans by-f/e c 4 ,6,s o and dated) - iyav /Z with revisions dated _? --p?0- %? I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed — generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to BOH, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. is 3. As the installer I understaiid that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer Date: --�d7 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PE'?I IIT DATE: �a a� LOCATION: LICENSED INSTALLER: CURRENT D, 'STALLER'S LICENSEr 74VE SIGNATURE: TELEPHONEm CHECK 0 NE : REP.: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only 575.00 Fee Attached? Yes No Foundation As -Built? Yes Ni o Floor Plans? Yes No Approval Date: