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North Andover Board of Assessors
vvu -. i ✓ V -W-X. VAW U A 1X lU 1
wner Name: VOKE, BRIAN P
LAURIE A VOKE
wner Address: 730 BOXFORD STREET
City: NORTH ANDOVER State: MA
Zip: 01845
eighborhood: 5 - 5 Land Area:
1.03 acres
se Code: 101-SNGIrFAM-RES Total Finished Area:
4445 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
otal Value: 735,300
763,600
uilding Value: 537,700
566,000
and Value: 197,600
197,600
larket Land Value: 197,600
hapter Land Value:
I IjCert Doc: 12145 Book: 00092 Page: 0185 �I I
i
http://csc-ma.us/PROPAPP/display.do?linkld=1464704&town=NandoverPubAcc 11/2/2009
1
.... .. ... ......
,rowN OF NORTH ANDOVEP, [JAN "0 6 j
A Il SYSTEM PUMPING RECOPD
SYSTEM Em vwNI~K & ADDRESS SYSTEM LOCATION
v6/�e,
13
OA I b VY PVWNIQ:—/
.._QUANTITY PLJNfPED:_._._
Sopuic Tank: NO. YB,s
NA run OF SERVICE:
ObSERVATION3:
GOOD CONDITIONVFULL-roeovER
HEAVY OVIA3BBAMES IN PLACL
ROOTS — LEACKFIELD RUNBACK ...
BXCUSNE SOLIDS --'FLOODED
SOLID CARR YOVER
OTIfER EXPLAIN
�Ystfm Pumpod by
2611. (5L
ograa�g& 102W.
VUMMENTS.
N,
Important:
When filling out
forms on the
computer, use
only the tab key'
to move your
cursor - do not
use the return
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ream
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSETTS
HUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health, Th System Pumping ng RRecor mu!
be submitted to the local Board of Health or other approving auth rity.
_ 11 II • A Anne
A. Facility Information
I TOWN Or NURTH ANDOVER I
1. System Location: HEALTH DEPARTMENT
Address --_"''v--- •
---. — -
1 _.y4
y own
- State --------
Zip Code
2. System Owner:
Name
Address (if different from location)
C ity/Town
'umping Record
ate of Pumping
ype of system: ❑
Other (describe):
Stat -------------- _
Zip od
Telephone Number"- -
�� 2.
Date Quantity Pumped:
Gallons
Cesspool(s) Septic Tank ❑ Tight Tank
`fluent Tee Filter present? ❑ Yes ❑ No
Dndition of System:
If yes, was it cleaned? ❑ Yes ❑ No
6. Sy em Pumped By:
-tel 2�1._� ` -
Name -------- ----- --
Vehicle License Number --
Company
7. Location where contents were disposed:
-- — — - W ,
Si ature of Haul
http:,//wvvw.mass.gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc- 06/03
Date
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Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Asses,,
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner's Name
N. Andover
City/Town
RECEIVED
NOV 5 2009 1 y -
HEALTH
MA 01845 10/26/2009
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Chad Jablonski
Name of Inspector
Jablonski & Sons Inc.
Company Name
167 Willow Ave.
Company Address
Haverhill
City/Town
978-360-9358
Telephone Number
B. Certification
MA 01835
State Zip Code
4574
License Number
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evalu ion by the Local Approving Authority
rZSigna DateThe sysector shall submit a copy of this inspection report to the Approving Authority (Board
of Healt) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
*"*This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 r'
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner's Name
N. Andover MA 01845 10/26/2009
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved -by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ® N ❑ ND (Explain below):
Gins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Commonwealth of Massachusetts
I
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner Owner's Name
information is
required for N. Andover MA 01845 10/26/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Distribution box is cracked and corroded.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 09/08 Title 5 Official Inspection Form, Subsurface Sewage Disposal System • Page 3 of 17
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w� 730 Boxford St.
Property Address
Brian & Laurie Voke
Owner Owner's Name
information is
required for N. Andover MA 01845 10/26/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Ya day flow
t5ins • 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
N 730 Boxford St.
Property Address
Brian & Laurie Voke
Owner Owner's Name
quine d fotifor is
eN. Andover MA 01845 10/26/2009
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El® 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 elevatio
E]® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El® Any portion of a cesspool or privy is within a Zone 1 of a public well.
El® Any portion of a cesspool or privy is within 50 feet of a private water supply w
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 fee
from a private water supply well with no acceptable water quality analysis. [Th
system passes If the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analys
and chain of custody must be attached to this form.]
El® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
i
r
e
n
equire
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
II.
t
is
is
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner Owner's Name
information is
required for N. Andover
every page. City/Town
MA 01845 10/26/2009
State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes
No
®
❑
Pumping information was provided by the owner, occupant, or Board of Health
❑
®
Were any of the system components pumped out in the previous two weeks?
®
❑
Has the system received normal flows in the previous two week period?
❑
®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
®
❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
®
❑
Was the facility or dwelling inspected for signs of sewage back up?
®
❑
Was the site inspected for signs of break out?
®
❑
Were all system components, excluding the SAS, located on site?
®
❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
®
❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
®
❑
Existing information. For example, a plan at the Board of Health.
®
❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 450 gpd
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner's Name
N. Andover MA 01845 10/26/2009
City[Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
6
Does residence have a garbage grinder?
❑
Yes
®
No
Is laundry on a separate sewage system? [if yes separate inspection required]
❑
Yes
®
No
Laundry system inspected?
®
Yes
❑
No
Seasonal use?
❑
Yes
®
No
Water meter readings, if available last 2 years usage d
Attached
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑ Yes ® No
Occupied
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
15ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M� 730 Boxford St.
Property Address
Brian & Laurie Voke
Owner
information is
required for
every page.
Owner's Name
N. Andover
CitylTown
D. System Information (cont.)
MA 01845
State Zip Code
Last date of occupancy/use: Date
Other (describe below):
10/26/2009
Date of Inspection
General Information
Pumping Records:
Source of information: North Andover BoH
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: na
gallons
How was quantity pumped determined? na
Reason for pumping: na
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)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
�, Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner Owner's Name
information is
required for N. Andover
every page. City[rown
MA 01845
State Zip Code
10/26/2009
Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
27 yrs old- As -Built plan dated July 14,1982
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
8"
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other (explain): —
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
5"
feet
❑ Yes ® No
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: na
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10.5' x 5.7' x 5.7'
Sludge depth: 3
t5ins • 09.!08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
�. Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
r� Property Address
Brian & Laurie Voke
Owner
information is
required for
every page.
t5ins - 09/08
Owner's Name
N. Andover
City/Town
D. System Information (cont.)
Septic Tank (cont.)
MA 01845 10/26/2009
state Zip Code Date of Inspection
Distance from top of sludge to bottom of outlet tee or baffle
30"
V.
Scum thickness
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measuring Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is structurally sound Tee's in good working condition
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System- Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w. 730 Boxford St.
Owner
information is
required for
every page.
Property Address
Brian & Laurie Voke
Owner's Name
N. Andover
Cityrrown
MA 01845 10/26/2009
State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity: gallons
D FI
eslgn OW. gallons per day
Alarm present: [:]Yes El No
Alarm level: Alarm in working order: EI Yes F-1No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner Owner's Name
information is
required for N. Andover MA 01845 10/26/2009
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)-
Distribution Boxj f pr� must be op��ene��d)-(1oc�
Depth.-of'liquid level above outlet invert
Comments (note if box is level and distribution to o
evidence of leakage into or out of box, etc.):
/Distribution box needs replacement
on site plan):
.Is
level below invert due to damaged box
Its equal, any evidence of solids carryover, any
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Owner
information is
required for
every page.
t5ins - 09/08
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner's Name
N. Andover
City/Town
D. System Information (cont.)
Type:
MA 01845
state Zip Code
10/26/2009
Date of Inspection
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
®
leaching fields
number, dimensions: 1
❑
overflow cesspool
number:
❑
innovativelalternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No sign
of hydraulic failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w. 730 Boxford St.
Property Address
Brian & Laurie Voke
Owner
information is
required for
every page.
Owner's Name
N. Andover
MA 01845
10/26/2009
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,h 36 Island Pond Rd.
Property Address
Robert Castanza
Owner Owner's Name
information is Dracut
required for
every page. City/Town
MA 01826 10/27/2009
State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
[hand -sketch in the area below
❑ drawing attached separately
136 o2V-
A , G 303
3 ' G Zz.�
_-r> K�
-5- -D 'I 7
t5ins - 09/08 Title 5 Official Inspection Form; Subsurface Sewage Disposal System- Page 15 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner's Name
N. Andover
Cityfrown
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
Estimated depth to high ground water:
State Zip Code
5'
10/26/2009
Date of Inspection
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: 4/14/78
Date
Observed site (abutting property/observation hole within 150 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:
Perc test performed by JJ Barbagall and witnessed by J Cushing
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System- Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
730 Boxford St.
Property Address
Brian & Laurie Voke
Owner Owner's Name
information is
required for N. Andover
every page. City/Town
MA 01845
State Zip Code
10/26/2009
Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
Summary Record Card generated on 10/26/200911:58:08 AM by Karen Hanlon
Town of North Andover
Tax Map # 210-105.A-0022-0000.0
Page 1
Parcel Id 16899
730 BOXFORD STREET
BRIAN VOKE
730 BOXFORD STREET
NORTH ANDOVER, MA 01845
Class 101 Single Family Property Type
Size Total 1.03 Acres 1 Residential
FY 2010
UB Mailing Index
Name/Address
BRIAN YOKE
730 BOXFORD STREET
NORTH ANDOVER, MA 01845
UB Account Maint.
Account No Cycle
Bldg Id. 22453.0 - 730 BOXFORD STREET
3170662 03 Cycle 03
UB Services Maint.
Account No. 3170662
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Account No. 3170662
Type Loan Number Active/Inact. From
Owner
Occupant Name Active/Inactive
Last Billing Date 10/7/2009
Active
Rate Charge Multiplier/Users
1 1 9.18 1/
01 ALL METER SIZE 49.40 1/1
Serial No
Status
Location
35352424
a Active
ERT HH
Date
Reading
Code
9/4/2009
29
a Actual
6/8/2009
16
a Actual
4/22/2009
0
n New Meter
3/16/2009
61
m Manual estimate
MSG
12/15/2008
35
a Actual
NEW METER TO BE INSTALLED.
9/10/2008
9
a Actual
6/9/2008
0
n New Meter
Brand
Type
b Badger
w Water
Consumption
Posted Date
13
10/15/2009
16
7/20/2009
0
7/20/2009
26
4/29/2009
26 1/20/2009
9 10/10/2008
7/16/2008
Until
Size YTD Cons
0.63 0.63 13
Variance
-57%
0%
0%
5%
180%
NORTH
OF tato ,61
0
- COPY
uy �
"q Q�R4 E o PPP`.'(
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
CYE127I(F1C4r1-(F OF'C09b1PGIA9VCrE
As of:
November 5, 2009
'This is to cert that the individuaCsu6surface disposaCsystem received a
SMS(ACZORTINSPEMOYof the:
Rpair/fpCacement of a
Septic Distribution Boal for a
Sewage D0 osaCSystem
By.
,john DiVincenzo
At:
730 Bo.-�Ford Street
Map -10.5.A; ParceC 22
NokthAndover, 9M 01845
The Issuance of this certificate shaC! not be construed as a guarantee that the system wilt
function satisfactorily.
4Wich. Grant
Public -VeaCth Inspector
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
TOWN OF NORTH ANDOVERNORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES ``t.��* "�+�
r e o
HEALTH DEPARTMENT p
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845 CH„Sk<{g
Susan Y. Sawyer, REHS/RS 978.688.9540 - Phone
Public Health Director —T 78.688.8476 - FAX
E WASTEWATER
LOCATION INFORMATION
ADDRESS: Q� _ AP:
INSTALLER:
DESIGNER: G% l
PLAN DAT .
BOH APP �VAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION.
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
ION NOTES
LOT:
r
❑Existing septic tank properly abandoned
[]Internal plumbing all to one building sewer
[]Topography not appreciably altered
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
❑ Inlet tee installed, centered under access port
❑ Outlet tee (gas baffle or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation— Feb 2006
Page 1 of 6
TOWN OF NORTH ANDOVER g NoRrH N
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845 "1 ACHUB�``h
.Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
Comments:
PUMP CHAMBER
❑
Bottom of tank hole has 6" stone base
❑
Weep hole plugged
❑
Combo Tank installed. Size:
❑
1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
❑
Inlet tee installed,.centered under access port
❑
Pump(s) installed on stable base
❑
Alarm float working
❑
Pump On/Off floats working
❑
Separate on/off floats
❑
Drain hole in pressure line
❑
24" inch cover to within 6" of final grade installed over
pump access port
❑
Water tightness of tank has been achieved
Visual testing
❑
Hydraulic cement around inlet & outlet
Comments:
ADVANCED TREATMENT TECHNOLOGY
❑ Type of treatment device:
Comments;
❑ Installed per manufacturers requirements
❑ All components working in accordance with
manufacturer's requirements
Wastewater System Documentation — Feb 2006
Page.2 of 6
TOWN OF NORTH. ANDOVER woRTti
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845 �1 SSgCHUg8t45
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
D-BOXEl,�/
�`°j
Installed on stable stone base / r
❑
Inlet tee (if pumped or >0.08'/foot)
F
Hydraulic cement around inlet & outlets
[�
Observed even distribution
[Y
Speed levelers provided (not.required)
Comments:
SOIL ABSORPTION SYSTEM
El
Comments:
Bottom of SAS excavated down to soil layer, as
provided on plan
Size of SAS excavated as per plan
Title 5 sand installed, if specified on plan
3/4-1 Y2" double washed stone installed
1/8-1/2" (peastone) double washed stone installed
Laterals installed and ends connected to header
Laterals vented if impervious material above
Orifices @ 5 & 7 o'clock positions
Gravel -less disposal systems: type, number and
location as per plan
Elevations of laterals installed as on approved plan
40 Mil HDPE barrier installed
Retaining wall (boulder / concrete / timber/ block)
Final cover as per plan
/dnnAOiliYl�3 �� � d"—
/Wastewater System Documentation — Feb 2006 �' Q/j�� 9 '
v l d ge 3 of
6,
)i i�l.v / l
�- 4&d
TOWN OF NORTH ANDOVER t µcATa
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36 w,q F`tyr
NORTH ANDOVER, MASSACHUSETTS 01845 C
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director., 978.688.8476 — FAX
PRESSURE DISTRIBUTION
Comments:
CONTROLPANEL
Comments:
INS
-- inch manifold
laterals installed with end sweeps
size:
material:
Squirt test ft in height
Equal distribution to all laterals
orifice size inch as per plan
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel:
❑ Rated for exterior if placed outside
Wastewater System Documentation — Feb 2006
Page 4 of 6
TOWN OF NORTH ANDOVER aoeT„
Office of COMMUNITY DEVELOPMENT AND SERVICES=ob`;4ao'a
HEALTH DEPARTMENT - p
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
' Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland
bylaws
Wastewater System Documentation — Feb 2006
. Page 5 of 6
Tank
SAS Sewer
❑
Property line
10
10 --
❑
Cellar wall
10
20 --
❑
Inground pool
10
20 --
❑
Slab foundation
10
10 --
❑
Deck, on footings, etc
5
10 --
❑
Waterline
10
10 101
❑
Private drinking well
75
1002 50
❑
Irrigation well
75
100
❑
Surface Water
25
50
❑
Bordering Vegetated Wetland ,
Salt Marsh, Inland / Coastal Bank'
75
100
❑
Wetlands bordering surface
water supply or trib. (in Watershed)
150
150
❑
Trib. to surface water supply
325
325
❑
Public well
400
400
❑
Interim Wellhead Prot. Area
❑
Reservoirs
400
400
❑
Drains (wat. supply/trib.)
50
100
❑
Drains (intercept g.w.)
25
50
❑
Drains (Other) Foundation
10 (5)
20 (10)
❑
Drywells
20
25
' Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland
bylaws
Wastewater System Documentation — Feb 2006
. Page 5 of 6
TOWN OF NORTH ANDOVER F NORTHov
q
Office of COMMUNITY DEVELOPMENT AND SERVICES
o
HEALTH DEPARTMENT A
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845CH'�t�y
acNus
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
SYSTEM ELEVATIONS
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 HIGH
Lateral 1 LOW
Lateral.2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Wastewater System Documentation— Feb 2006
Page 6 of 6
"o pri, Commonwealth of Massachusetts Map -Block -Lot
105.A0022
---------------------
Board of Health Permit No
h
North Andover BHP -2009-0692
FEE
ACWU*Ei $125.00
---------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John DiVincenzo
to (Repair -D -BOX ONLY) an Individual Sewage Disposal System.
at No 730 BOXFORD STREET
as shown on the application for Disposal Works Construction Permit No. BHP -2009-069 Date November 02, 2009
Issued On: Nov-02-2009of TTPalth
Application for Septic Disposal System
-'3a •`t'- �::�` p°o
=Construction Permit — TOWN OF TODAY'S DATE
°�'•'� ORTH ANDOVER MA 01845 $ 250.00 — Full Repair
$125.00 - Component
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer, use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your LV Repair or replace an existing system component — What? A
cursor - do not
use the return A. Facility I yor ation
key. jef® �� ✓�^
Address or Lot #
Opo . fid y 464,0,
City/Town
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information
Name
.736 � S
Address'(abif different from ve) (-�/
�o ; �-
City/Town State Zip Code
Telephone Number
3. Installer Information
TOW L � ViNPenon 5•��_'9 S�r-7C
Name C Name of Company
Address / 2_"l,G 11 Ld v
City/Town S ate Zip Code
Telephone Number (Cell Phone # if possible please)
4. Designer Information
Name Name of Company
Address
City/Town
_J_d�l /�, )
�,7K _S - lY 8
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
1
r_{ ,f "';T;,y Application for Septic Disposal System
3r •`s'°< TODAY'S DATE
Construction Permit - TOWN OF
$ 250.00 - Full Repair
$125.00 - Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: ['Residential Dwelling or ❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
df/ L V% !///V Q' c?
Name � � �� Date
Applicatio ��pproved By��I'd of Health Representative)
rIlzb 7
Name %l -6a —te
i
Application Disapproved for the following reasons:
For Office Use Only:
L
Fee Attached.
Yes
No
2.
Project Manager Obligation Form Attached?
Yes_
No
3.
Pump System? If so, Attach copv ofElectrical Permit
Yes
No
4.
Foundadon As -Built? (new construction ronly):
Yes
No
(Same scale as approved plan)
5.
Floor Plans? (hew construction only):
Yes
No
Application for Disposal System Construction Permit • Page 2 of 2
` COMMONWEALTH OF MASSACHUSETTS
J. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TC4 1 QF R1 C/R',H �?{{yggqrD0-,:_R
V•V wn. Ir ' .
9 i
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
�C'^E�RTIFICATION
Property Address: ,6Ox4q,,1 rYf
Owner's Name: /Ce -
Owner's Address:
Date of Inspection:
Name of Inspector: (please print)
Company Name: G(�
Mailing Address:
r t'11Q, C) lkas
Telephone Number: `1 �K— 372.' rl 4 `7l
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 the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
_ Conditionally Passes
Needs Fugher Eyaluation by the Local Approving Authority
Inspector's SignAture:
`� _.,.,f Date: / cl')for/ w
The system inspector shall bmit a copy of this inspection report t&4he Approving Authority (Board of Health or
DEP) within 30 days of c pleting this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspedfor 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.
1:
i?
Title 5 Inspection Form 6/15/2000 page I
�- -.: Page 2 of 11 7'
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: '1430 8-ak,'l�r�,�SL
r
�l 1 6.) {
Owner:
Date of Inspection: 71
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. %System Passes:
J I have not found any information which indicates that any;of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) 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:
x Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstrudfed pipe(s) or due to `broken; settled oriitmeven distribution box: System will-passinspectiori 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 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
' Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
~:. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7 1K 17jcd SL
Ill •
Owner:
Date of Inspection: 0
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. SystemAwill pass unless Board AHealtli determineg in' accord'dnce with,310 CMR 15:303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
_ The system has a -septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
r
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or.more from a
private water supply well**. Method used to determine distance
**This system;passes if the well water analysis, performed at a DEP certified laboratory, for coliform
_:bacteria and-vdiatile;organie'com;trounds ihdicates;that-the Avell4s free froth 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:
3
«!' Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner;
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
... , . _ Backup gf.sewage.into facility or system component due to overloaded or clogged SAS or cesspool
_
6isbhati6r ponding df effluent to the surfacepof thl grounAr' surface`waters due to'an overloaded or
clogged SAS or cesspool
_✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
Vcesspool
` Liquid depth in cesspool is less than 6" below invert or available volume is less than''/z 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 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compo®ds
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.]
t'lo (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
,..
-E. - Urge Systems:`'A
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd•
You must indicate either "yes" or "no" to_each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
11
R
Page 5 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
R PART B
CHECKLIST
Property Address:
Owner: ViAg
Date of Inspection: _,�• /
1
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Ye No
Nippin 1pformat on,)yas pr&idt�d>by the owrW,,=o�cupant, 40oard of Health
V/ Were any of the system components pumped out in the previous two weeks ?
_ Has the system received normal flows in the previous two week period ?
v 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)
V/ _ Was the facility or dwelling inspected for signs of sewage back up
V, _ Was the site inspected for signs of break out ?
_ Were all system components, excluding the SAS, located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems ?
ry The s, an; location of the §pil,AbsorptionSystem_(SAS) on,the site has been determined based on:
Ye 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 distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: " / "
i Car
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:_
Does residence have a.garbage grinder (des or n�): ftO �' k
Is laundry on al's'epar to sewage system (yes no):_Lvo [if yes' separatelnspectibr required) s
Laundry system inspected (yes or no): rid
Seasonal use: (yes or no): w
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): No
Last date of occupancy: ecu i
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap 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:
OTHER (describe):
GENERAL INFORMATION F
Pumping Records
Source of information:
Was system pumped as part of the inspection (yes or no): —
If yes, volume pumped: _gallons -- How was quantity pumped determined?
yy ,.Reason for purnpnng., + - "- -.1 ... ,, - .' - ► -m -rA
'P
TYKE 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)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
- Tight tank _ Attach a copy of the DEP approval
v 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): No
9 {�
'' * * * Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM
cc INFORMATION (continued)
Property Address:
Owner: l}1(
Date of Inspection:
Z -
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other (explain):
.
f ' Distance fromiva`te water suPPjywell�or s�
u tion line: a,
r, ,.1 .
Comments (on condition of joints venting, evidence of leakage etc.):
SEPTIC TANK: / (locate on site plan)
Depth below grade, I in '
Material of construction: _concrete _metal _fiberglass _polyethylene
—other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: '6'-5 X 57"G' X 10,
Sludge depth: N tri
Distance from top of sludge to bottom of outlet tee or baffle: go r-\•
Scum thickness: I i r
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or ba
How were dimensions determined: } a P° rhf?surfs
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
t�1s+ itt't s a -46 n IC CT005;( Car
.. ..... r� GREASE(lobate'onsitepl)...
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 baffle:
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.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ,
Owner:
Date of Inspection: Z
TIGHT or HOLDING TANK: ~ (tank must be pumped at time of inspection)(locate on site pian)
Depth below grade:
Material of ponstrugion: ,concrete m_ et l fib(
Y
Dimensions:
Capacity: gallons ,
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
A.olyethylene , other(explain):
DISTRIBUTION BOX: v (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
hn no 3orW curt
PUMP CHAMBER: (locate on site plan)
Pumps in working order (yes or no):
Alums in working order (yes,or:no)'. .,_� ;. ' F ; . #.t as r
Comments (note' condition of pump chamber, condition of pumps and appurtenances, etc.):
8
I r 16^ Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:j�—
o . A -rt l ex 5_4
Owner: v4ko
Date of Inspection: 4-7
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
I
Type `
leaching pits, number:
leaching chambers, number:
leaching
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions: , 4 t.► ; i W )
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
C�l� t.��'r+�inC� i1U �"�>i r'�►' a u I i �. f-GiY,�sre
M � ,
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: r
Depth — top of liquid to inlet invert:
Depth of solids layer: *'
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or a):. T—
�Cortiments (note condition;*of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
I ` r ,* Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEAINFORMATION (continued)
PropertyAddress:
Ally
Owner: ID
Date of Inspection: rf
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.
1 t
a
AC, 30
f+b y7
P
10
" Page 1 I of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE• DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: [J?['
Owner:
Date of Inspection: r71Z,r
SITE EXAM
Slope
Surface water
Check cellar .
Shallow wells`,
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
of Obtained from system design plans on record - If checked, date of design plan reviewed:
_ Observed site (abutting property/observation hole within 150 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:
a
DESIGN_ DATA � CALCULAT IONS
veL JPSERVATIONS 5y, UT ?AIzAG�LL WWITNE55# 7QJS4�INf
(D PERCOLAT 1oN -TEST hi0• 1 2 3
DTE g�2h7.
-TOP-ELEVATION IO�,S4'I 1
rBOTTOM - ELevA7IONor. 5a
SA-TURAT1oN -MINS. I lS
I t%
I2" s-9- DRO P - MIN5 /
G• D RoP - M I N5. %
T�;)SOIL PROFILE -DEEP PIT NO
DAT E
f
STOP- ELEVATION
TOPSOIL
r --
SUBSOIL
' PARE NT SOIL
WATER TABLE
CbMFltZMWq
I 2
L
5, 6
GF,1W R
t-, o Y�/i ATE R
WA*TER-TABLE ELEVATION 9S,o0
g5,3Q
t
y
l BOTTOM ELEVATION
J500
I
9S.3b I
I
BUILOINCTTYPE . 3„ZF
J
3 B.R.. OR
x
� 5Ca GAL. UNIT = 4 Zoo
GPD Flow
S�) GPD FLow x 15-C)7"= (-lS GPD USE—k000 GALS
EPTtC-TAl`1K
LEACHINCT AREA
4so GPD Flow x
�, SFfGAL.=
58S SF 8 E USE
goo
PITS :
_ _SF
0,Ata) QVEC` M (t4
TYP E mip R • (-TY f?
SIDEWALL AREA
_SF X_
-GALS.( SF =_
_ GPD
aCTTONA AREA
_SF x
GALs
GPD .
-TOTAL PIT LEAC+a+NG CAPACITY
_._
_ GPD PIT
_ GP D FLOW =
GPD/PIT =_
P11S REQ'D . USE _ _ —PITS
TFZ E.1J C H ES
SIDEWALL AREA _
_S FILFx_
_CALS(SF = -___
GAL JUN FT
80TrOM AREA
SF/LF x
GALS/SF =
�GAL.� LIN.FT.
-TOTAL-RENiCH LF -ACHING-
CAPACITY
_
GAL LIN.FT.
GPD PLOW -=_
�c\L.1b)4PT =
L.F TRF NCHE5 REQ'D.
USE •F
NOTES -11"IT *-1
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of
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ell
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SAG --v 4 OF S
TO: �oav� n ,1%���� NORTH ANDOVER, MASS. J l 19
BOARD OF HEALTH
s
FROM: /�a��h�/���vas S�ssoG.1��_ DESIGN ENGINEER Re: Soil Absorption
Sewage Disposal.
!, System
This is to certify that I have ins ected the construction materials of
said disposal system at L o -r 4� o,/, -Co�icl Z�, as d Mo. And—
Site
nd.Site Location
North Andover, Mass.
The grades and construction materials"ar p if ied in my plans and
specifications dated aJo ,M 19'7 ,Ai $s i It
�o� ' A 1K
C. n
Reg.Prof anitarian
ft. 2273 Q'
o9o�Fc�STEP
FSS/GNAT. E��
Board-ofHealth
No.rtb AnctovarI�`.aas,
SFM C STSTEK
%NSTALUTICK Com$ LIST
eaqonsi
VL�2-
C__`i�,
LOT , 2.
AVATI ON Ob M L�
1. Distance To:
a. Wetlands
b.. Drains •
c. Well 7tU4)
e •
$. Septic Tank -
a. Tees -_Length k To Clean Ont Covers.
b. Cement Pipe to Tank - Cu Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flo-Ang Equal Amount�,,,,�
C. No Back Flow
b. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped ids "
d. Clean Double Washed Stone'
7. LeAi Pits
a. Dil ns ns
b. Sion epth -- -
C. SP1 Pads
d. T
e. C.Pipe to Pit - Both Sides
f. "I_2Do,,ble Washed Stone
8. No Garbage Dii spo sal
9. Final Grading Inspection \
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location -with Regard -to Pere Test
d. 'Elevations
e: Water Table
P,oa,:•d of Health
APPNOVED DATE DISAPPROVED
ALZ L
ea ins t
BF.MC STSTM
INSTALLATION CHFrK LI M
7'7
� OK ''�y►IJ 1 �r'1y
t
i
I. Distance To:
V a. Wetlands
! {� b. Drains
�✓ c. WeI1
LOT #-
AQATZCK OK FYtI.L
a '
I �
3
septic Tank - --
a.. _Tess -_Length do To Clean Out Covers.
b. Cement Pipe to Tank On Both Sides of Tank A.a
L
5. Distribution Box
a. Covers &: Box - No Cracks
b. All Lines Flowing Equal Amounts
C. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Eads
d. Clean Double Washed Stone'
7, ch Pit
a.Yean
ons
b.epth
c.padsd. peto Pit - Both Sides
f.ou a Washed Stone
8. No Garbage Disposal
i
MBarricading
Grading Inspection %-tl A +'te-7.9_'- k "O'.0 -c
Covered System U
11. As Built Submitted -
_ a. Lot Location
r✓ b. Dimensions of System
�-� c. Location -with Regard -to Pere Test
d. Elevations
✓ e. Water Table
WAP OVr` PROVIDED
q.q_9
Reg. 2.5
Reg. 6.1
Reg. 6.7
Reg. 6.$
Reg. 6.9
Reg. 6.1
Reg. 6.1
Reg 3.7
Reg: 9:1
Reg. 9.6
NORTH ]MOVER .BOARD OF HEALTH
SUBSURFACE DISPOSAL SYSTF..P'I CHLCK LIST
DISAPPROVED
2 �# Y rajtD ST-.
General Information � JOS
The submitted plan must show as a minimum:
---(a) the lot to be served (area,dimensions, lot #, abutters)
; (- " location and dimensions of system (including reserve area)
,(e) design calculations
.(d) calculations showing reouired leaching area
:,--(-e)--existing and proposed contours
,-fT)-location and log of deep observation holes -distance to ties
..()- location and results of percolation tests -distance to ties
.(h). location of any wet areas within 100' of the sewage disposal
system or disclaimer
(i) surface and subsurface drains within 1.00' of sewage disposal
system or disclaimer
--(-j)-"37cication of any drainage easements within 100' of sewage
disposal system or disclaimer
�( c) oTtifii sources of .;Tater supply within 200' of sewage disposal
system or disclaimer
.location of any proposed well to serve the l.ot(100' from leaching facility,
)-TS' tion of zrater lines on property (10' from leaching facilities)
maxzi mum ground zrater elevation in -irea of se nge disposal system
{e) location of benchmark
plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
_driveways
__(_4 --garbage disposers
.._._W_a profile of the system (elevations of basement, plumbers pipe
septic tank) distribution box i.nlets.�.nd outlets, distribution
field piping and any other elevations)
4 -t -)-no PVC 'is to be used in construction
Septic
(a) Ca, �acities - 150% of.flow
(b) W6ter table
(c��Tces
(d) Depth of tees
(e) Access
( f) Punping
(g) Cleanout
(h) 10from cellar v:!all or inground swimming pool
(i) 25' from subsurface drains
I Piz. s •
Approval
(b) Stand -.by poT.:er
I
Board of Health
North Andover,Mass'
APPROVED DATE I&, Z- v
Provided: , 1
d2jZIA1Avte
SUBM-FACE DISP iOSAL DESICIN CHECK LIST
DISAPPROVED DATE
Reasons
LOT # 2
Title Q FAIL OK
Reg 2.5 The submitted plan must show as a minimums
a) the lot to be served-area,dimensime lot #,abutters
b location and log deep observation holes -distance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
v,' -'(e) location and dimensions of system -including reserve area
✓(f) existing and proposed contours
(g) location any wet areas within loot of sewage disposal system or
disclaimer -check wetlands mapping
✓ (h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
✓ (i) location anv drainage easements within 1001 of sewage disposal
system or sclainr�Planning Board files
(j)
known source of hater supply within 2001 of sewage disposal r
system ori
./ (k) location of W proposed well to serve lot -1001 from leaching facility
(1) location of water Lines on property -101 from leaching facility
(m) location of benchmark
(n) driveways J'__
(o) garbage. dispoSala tl ea eucr fit. /�" 0
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 I ( S22tic Tanks
(a) capac t es- 50� of flow, imter table, tees, depth of tees,
access, pumping
(b) cleanout
✓ (c) 101 Brom cellar wall or inground swimming pool _
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
Y/ (a) Slope greater th 0.08
Reg 10.4 b) suug
esiSM Check
FAn I °�
Reg 11.2
11.41
11.20
11.11
Reg 15.1
15.4
15.8
3.7
beaching pits are preferred where the installation is possible
a) cal tons of leaching area -minium 500 sq ft
jb) spac
c) aarf ce drainage 2%
d) material
e) 80 tx4" splash pad
P) to at elbow
g) no bends in pipe from d -box to pipe
Leaching Fields
a} no greater than 20 minutes/inch
b) area -minimum 900 sq ft
c) construction of field
d) surface drainage 2 %
e) 201 From cellar wall or inground swimming pool
✓
v
Reg 14.1
14.3
14.4
14.6
14.7
14.10
Reg 9.1
9.6
ns'Ieaching area -min 500 Bq ft
ft min 6 ft with reserve between
G
ej sLon
f) sur ace drainage 2$
hfll Slope
a) ope y x =-C-to be shown)
b) x X 150 (to be shown)
a) app vel
b) s d -by power
III
Ncrih Andover Subsurface disposal system check list -Pape 2
ai ll ' stribution Boxe's ���
Reg.10.2
Reg. 10.4
Reg.11.2
Reg -11-4
Reg.11.10
Reg.11.11
Reg.15.1
Reg.15.1
Reg.15. 4
Reg.15 8
Ref.3.1
,,(/a) Slope greater than 0.08
(b) Su%o
eaching Pits
Leaching pits are preferred where the installation is possible
(a) Calculations of leaching area (minimum 500 S. F.)
(b) Spata,n g
(c) ,Surnce drainage 2%
(d) Cgv/er material
ac ung Fti olds
(a) Greater than 20 minutes/inch
(b) Area (minimum 900 S.F.)
(c) Construction of field
OSurface drainage Oct
Y) Surface
from cellar t,* 11 or inground swimming pool
I'dwill Slope
(a) Slope y/x = (to be shovm)
(b) y/x X 150 = (to be shovm)
v SOIL PROFILE & PERCOLATION TEST DATA
Town/C ty No.&Street ,qx o ULot No.
Loc./Subdiv. z5:1fJf ����� Plan Owner r,
Investigator Gtr- G-// D Observer
SOIL PROFILES -DATE
1' E ev. �' Elev. 3' Elev. 4'Elev.
77 0 3 ��� 7 0 0
I�
2
V 3
�4
6
7
E:3
9
Benchmark Location
Elevation Datum
Percol5tign Tests -Date
2'
3
4
S
6
7
8
9
10
ait Number 1 2 3 4 S
Start Saturation
Soak -Mins.
Start Test -Time
Dro-P of 3" -Time
RDro2 of 6" -Time
Mins.lst 311Dro
Mins.2nd 3"Dro
Notes & Sketches on Back `� Frank C. Gelinas & Associates, North And.
Y
46,
1�
r_
r
6Jf
1
R
Form
DEQE File No.
Commonwealth (To be provided by DEQE)
of Massachusetts
City/Town
�\• c + Applicant
Notice of Intent
Under the
Massachusetts Wetlands Protection Act, G.L. c. 131, §40
and
Application for a Department of the Army Permit
Part I: General Information
1. Location: Street Address #730 Boxford St., North Andover, MA
Lot Number 2 (Town Map #105A, Tdwh Lot #22)
2. Project: Type Buffer Description _
an existing house in the buffer zone.
Construction of a garage addition to
3. Registry: County Essex North Current Book - & Page
Certificate (If Registered Land) 9659 - 1985
4. Applicant Frank Buco Tel 638-7060
Address #730 Boxford Street, North Andover, MA 01845
5. Property Owner Frank Buco Tel 683-7060
Address #730 Boxford Street, North Andover, MA 01845
6. Representative Merrimack Engineering Services Tel.475-3555
Address §6 Park Street, Andover, MA 01810
7. Have the Conservation Commission and the DEOE Regional Office each been sent, by certified mail or
hand delivery, 2 copies of completed Notice of Intent, with supporting plans and documents?
Yes 6 No O
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Effective 11 /1 /87
MAK.
8. Have all obtainable permits, variances and approvals required by local by-law been obtained?
Yes ❑ No M� eo-
Obtained: Applied For: Not Applied For:
Building Permit
9. Is any portion of the site subject to a Wetlands Restriction Order pursuant to G.L. c. 131, §40A or G.L.
c. 130, § 105? Yes ❑ No a
10. List all plans and supporting documents submitted with this Notice of Intent.
Identifying
Number/Letter Title, Date
A Topographic and Site Development Plan of Land
in North Andover, Mass. drawn for Frank Buco,
#730 Boxford Street, No. Andover, Mass. 1"=40',
July 1988, Merrimack Engineering Services
66 Park St., Andover, MA 01810
11. Check those resource areas within which work is proposed:
(a) ,Gk Buffer Zone
(b) Inland:
❑ Bank'
Land
Subject to Flooding,
❑ Bordering Vegetated Wetland,
❑
Bordering
❑ Land Under Water Body & Waterway*
❑
Isolated
(c) Coastal:
❑ Land Under the Ocean •
❑
Designated Port Area•
❑ Coastal Beach*
❑
Coastal Dune
❑ Barrier Beach
❑
Coastal Bank
❑ Rocky Intertidal Shore
❑
Salt Marsh*
❑ Land Under Salt Pond*
❑
Land Containing Shellfish*
❑ Fish Run*
*Likely to involve U.S. Army Corps of Engineers concurrent
jurisdiction. See General Instructions for
Completing Notice of Intent. .
3.2
12. Is the wettand resource area to be altered by the proposed work located on the most recent
Estimated Habitat Map (if any) of rare, "state -listed" vertebrate and invertebrate animal species
occurrences provided to the conservation commission by the Natural Heritage and Endangered
Species Program?
YES [ j NO [XI Date printed on the Estimated Habitat Map issued
NO MAP AVAILABLE [ j (if any)
If yes, have you completed an Appendix A and a Notice of Intent and filed them, along with
supporting documentation with the Natural Heritage and Endangered Species Program by
certified mail or hand delivery, so that the Program shall have received Appendix A prior to the
filing of this Notice of Intent?
YES [ j NO [ j
3.3
Part II: Site Description_ . .
Indicate which of the following information has been provided (on a plan, in narrative description or calcula-
tions) to clearly, completely and accurately describe existing site conditions.
Identifying
Number/Letter
(of plan, narrative
or calculations)
Natural Features:
A
Soils
�_
Vegetation
Topography
AOpen
water bodies (including ponds and lakes)
AFlowing
APublic
water bodies (including streams and rivers)
and private surface water and ground water supplies on or within 100 feet of site
A
Maximum annual ground water elevations with dates and location of test
Boundaries of resource areas checked under Part I, item 11 above
Other
A
Man-made Features:
Structures (such as buildings, piers, towers and headwalls)
Drainage and flood control facilities at the site and immediately off the site, including
culverts and open channels (with inverts), dams and dikes
—AA.—_
Subsurface sewage disposal systems
Underground utilities
A
Roadways and parking areas
_
Property boundaries, easements and rights-of-way
Other
Part III: Work Description
Indicate which of the following information has been provided (on a plan, in narrative description or calcula-
'MP tions) to clearly, completely and accurately describe work proposed within each of the resource areas
checked in Part I, item 11 above.
Identifying
Number/Letter
(of plan, narrative
or calculations)
A
_.A
A
A
A
Q
e
Planview and Cross Section of:
Structures (such as buildings, piers, towers and headwalls)
Drainage and flood control facilities, including culverts and open channels (with inverts),
dams and dikes
Subsurface sewage disposal systems d underground utilities
Filling, dredging and excavating, indicating volume and composition of material
Compensatory storage areas, where required in accordance with Part III, Section 10:57
(4) of the regulations
Wildlife habitat restoration or replication areas
Other
Point Source Discharge
Description of characteristics of discharge from point source (both closed and open
channel), when point of discharge falls within resource area checked under Part I, item
11 above, as supported by standard engineering calculations, data and plans, including
but not limited to the following:
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1. Delineation of the drainage area contributing to the point of discharge;
2. 'Pre- and post -development peak run-off from the drainage area, at the point of discharge, for at least the
10 -year and 100 -year frequency storm;
3. Pre- and post -development rate of infiltration contributing to the resource area checked under Part I, item
11 above;
4. Estimated water quality characteristics of pre- and post -development run-off at the point of discharge.
Part IV: Mitigating Measures
1. Clearly, completely and accurately describe, with reference to supporting plans and calculations where
necessary:
(a) Ail measures and designs proposed to meet the performance standards set forth under each re-
source area specified in Part II or Part III of the regulations; or
(b) why the presumptions set forth under each resource area specified in Part II or Part III of the regula-
tions do not apply.
❑ coastal Rom- a Area Type:
❑ Intend
Identifying number or fetter
of support documents
11 coastal Resource Area Type
❑ Inland
Identifying number or letter
of support documents
3.5
C Coastal Resource Area Type:
C Inland,;.
Identifying number or letter
of support documents
Work involves the construction of a 24'x22' garage
A
2. Clearly, completely and accurately describe, with reference to supporting plans and calculations where
necessary:
(a) all measures and designs to regulate work within the Buffer Zone so as to ensure that said work
does not alter an area specified in Part 1, Section 10.02(1) (a) of these regulations; or
(b) if work in the Buffer Zone will alter such an area, all measures and designs proposed to meet the
performance standards established for the adjacent resource area specified in Part II or
Part III of these regulations.
Coastal Resource Area Type Bordered By 100 -Foot Discretionary Zone:
)LX Inland Bordering Vegetated Wetlands
Identifying number or letter
of support documents
Work involves the construction of a 24'x22' garage
A
addition to an existing garage and relocation of the
--"'-`driveway servicing the garage.
All disturbed areas will'be loamed and seeded or paved.
Erosion control during construction is to be provided.
3.6
e,
Part V: AddHImi Information for a Department of the Army Permit
_ 1. COE Application No. 2.
(to be provided by COE) (Name of waterway)
3. Names and addresses of property owners adjoining your property:
4. Document other project alternatives (i.e., other locations and/or construction methods, particularly those
.that would eliminate the discharge of dredged or fill material into waters or wetlands.
5. 81/2" x 11 " drawings in planview and cross-section, showing the resource area and the proposed activ-
ity within the resource area. Drawings must be to scale and should be clear enough for photocopying.
r : Certification is required from.the Division of Water Pollution Control before .the .Federal permit,can be r ,
issued. Certification may be obtained by contacting the Division of Water Pollution Control,1 Winter Street,
Boston, Massachusetts 02108.
Where the activity will take place within the area under the Massachusetts approved Coastal Zone
Management Program, the applicant certifies that his proposed activity complies with and will be conducted
in a manner that is consistent with the approved program.
Information provided will be used in evaluating the application for a permit and is made a matter public
record through issuance of a public notice. Disclosure of this information is voluntary, however, if necessary
information"Is not provided, the application cannot be processed nor can a permit be Issued.
I hereby certify under the pains and penalties of perjury that the foregoing Notice of Intent and accompanying
plans, documents and supporting data are true and,complete, to the best of my knowledge.
9/19/88
Signature of Applicant Frank B'Uco fy Date
�r 9-1888
Signature of Applicant's Representative S S ipa ski Date
FORM "Exception to ENG rates 4345 approved by NQUSACE• 6 May 1064".
NID 100 (TEST),
1 MAY 82 'This document coataias a pint Department •1 the Army and State of Massachusetts application
for a permit to obtain permission to perform activities in United Stairs utters The Office
of Management and Budget fOMB1 Ms approved those questions required by the US Army Corps
of Eogineera. 01149 Number 0104-0076 avid aspiration date of 30 September 1663 applies". This
stgtemegt will be got IN 6 poigt type.
3.7
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