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HomeMy WebLinkAboutMiscellaneous - 759 DALE STREET 4/30/20181 i w� ,JAMN F.).'Z aO 4 Tt SIP Y I C I STRIVE TO BE #1 IN THE #2 BUSINESSI 46 CENTRAL ST. NORTH READING, MA 01864 978-794-2006 781.334-5100 SOLD BY I CASH I C.O.D.. I CHARGE I ON ACC i 'CUSTOMER'S ORDER NO. PHONE DATE }' NAME, ADDRESS T. I MDSE. REM I PAID OUT 2��(- e r' ;% BOARD OF HEALTH 1600 Osgood Street, Suite 2035 North Andover, MA 01845 978-688-9540 APPLICATION FOR ABANDONMENT OF SUBSURFACE DISPOSAL SYSTEM (SEPTIC SYSTEM) Pursuant to Section 310 CMR 15.354 Of the State Environmental Code, Title V Name Phone Address Contractor hir d for work: Name % Phone gzo Address Date for scheduled abandonment The septic ste at e a e address has been abandoned according to Title V specifications. S gnature of Contrddor Method of septic tank abandonment (check one). O removal O sandfill rush O other Name of Offal Hauler This form must be returned to the North Andover Board of Health. 1N -THE SPACE BELOW SENTATIVES ONLY I Y, d Date Commonwealth of Massachusetts W Title 5 Official Inspectio Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner Owner's Name information is required for every North Andover MA 01886 June 3,2015 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms ma not be altered in any way. Please see completeness checklist at the end of the form. ma At Important: When filling out forms A. General Information JUN 1 b 2015 on the computer, use only the tab 1. Inspector: TOWN OF NORTH ANDOVER key to move your HEALTH DEPARTMENT cursor - do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive VP r� Company Name 58 South Kimball street Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Signature Date Trsystem inspector shall submit a copy of this inspection report to the Approving Authority (Board o Health or DEP) within 30 days of completing this inspection. If the system is a shared system or h s 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 H Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner's Name North Andover MA 01886 June 3,2015 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: ❑ 1 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: needs Dist box recommend removal of aarbaae arinder. B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner's Name North Andover City/Town B. Certification (cont.) RAA niRRA QLOLV 4-111 %.vuc June 3,2015 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Box needs replacing coraded around outlet inverts. ❑ 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner's Name North Andover MA 01886 June 3,2015 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins • 3113 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 w, 759 Dale street Property Address John Depippo Owner Owner's Name nformatiis North Andover MA 01886 June 3 2015 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ i Area — IWPA) or a mapped Zone II of a public water supply well ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 759 Dale street Property Address John Depippo Owner Owner's Name nformationis required for every North Andover MA 01886 June 3,2015 for page. City/Town 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 been determined based on: this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not approximation of distance is unacceptable) [310 CMR 15.302(5)] available note as N/A) ® i 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? 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 been determined based on: this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not approximation of distance is unacceptable) [310 CMR 15.302(5)] available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 l5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner Owner's Name information is required for every North Andover MA 01886 June 3 2015 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Water meter readings, if available (last 2 years usage (gpd)): Detail: recommended removal of garbage grinder. 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: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No "❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 3 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: recommended removal of garbage grinder. 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: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No "❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner Owner's Name information is North Andover MA 01886 June 3 2015 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Stewarts 1500 gallons Site guage on truck Inspect tank 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 - 3113 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 759 Dale street Property Address John Depippo Owner Owner's Name information is required for every North Andover MA 01886 June 3,2015 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1997 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 26" feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): ❑ Yes ® No Septic Tank (locate on site plan): 6" Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts -q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) State 01886 June 3,2015 Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 26" 0 6" 16" How were dimensions determined? Sludge Judge & Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles good no leakage liquid level good. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3/13 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 759 Dale street Property Address John Depippo Owner Owner's Name information is required for every North Andover MA 01886 June 3 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 759 Dale street Property Address John Depippo Owner Owner's Name information is required for every North Andover MA 01886 June 3 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (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.): Box needs replacing holes around outlet inverts no solids carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street D. System Information (cont.) Type:El Property Address El John Depippo Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Type:El El El El El overflow cesspool leaching pits leaching chambers leaching galleries leaching trenches leaching fields MA 01886 State Zip Code number: number: number: June 3,2015 Date of Inspection number, length: number, dimensions: number: 3-54' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding, no damp soils. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner Owner's Name information is required for every North Andover MA 01886 June 3,2015 page. 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 • 3113 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 759 Dale street Property Address John Depippo Owner Owner's Name information is required for every North Andover MA 01886 June 3,2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch. Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner Owner's Name information is required for every North Andover MA 01886 June 3 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water a 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• 11-30-96 ' Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Pulled files ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Water at elevation 98.3 bottom of bed at elevation 104.3 system raised 4'+ above water table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 759 Dale street Property Address John Depippo Owner Owner's Name information is North Andover required for every page. Cityrrown State Zip Code E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked June 3,2015 Date of Inspection ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 SCOTT L. GILES, ]t.P.L.S. FRANKS. GILES I HEREBY CERTIFY THAT I HAVE INSPECTED THE, SYSTEM AND. NORTH ANDOVER,NIA. CONSTRUCTION OF THIS DISPOSAL.. THAT THE CONSTRUCTION WITH THE DESIGNERSTHE RRADI G HAS BEEN IN ACCORDANCE INTENT AND THAT THE MATERIALS US D.W. - � - I TO THE PLAN SPECIFICATION AND 180.00' PARCEL C 6/16/97 00 , rn N M TABLE OF ELEVATIONS Invert out of house =107.05 in tank =106.15 + It out tank =105.94 11 1 in d. box 105.81 it 11 out d. box / 3x=105.66 end pipe #1=105.33 end pipe #2=105.35 ++ ++ ++ , It 43=105.36 EXISTING FOUNDATION T.O.W.=108.14 v _ 4-�-rr--� 24' ®l tank "PARCEL D". 89,512 S.F. R,g2,. oo D) S. 7s000 L,l Commonwealth of Massachusetts = CityTTown of -North Andover astem Pumping Record Form 4 wy DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before this must check h submitted to local Board of Health to determine the form they use. The System Pumping to in pP 9 Y Y l�OM the local Board of Health or other a rovin authority within 14 days fro accordance with 310 CMR 15.351. UN I A. Facility Information Important When 1. System Location; filling out forms on the computer, use only the tab key to move your Address cursor - do not North Andover use the return City/Town key. 2. System Owner: a Name TO HNEp,LTH DEPARTMENT ANDOVER Ma 01886 State Zip Code Address (if different from location) State City/Town Telephone Number B. Pumping Record Q, S 2. Quantity Pumped: 1. Date of Pumping Date ❑ Cesspool(s) Septic Tank ❑ Tight T 3. Type of system: ❑ Other (describe): if yes, was it cleaned? ❑ Yes ❑ No Zip Code Gallons ❑ Grease 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: t5form4.doc• 03/06 Vehicle License Number Company Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Date Signature of Hauler Date Signature of Receiving Facil'Ry System Pumping Record - Page 1 SEPTIC SYSTEM ASBUILT LOCATION DALE STREET SCALE: V= 40' DATE: 6/16/97 0' 40' 80' 120' SCOTT L GILES R P L S FRANKS. GILES NORTH ANDOVER,1VIA. I HEREBY CERTIFY THAT I HAVE INSPECTED THE A CONSTRUCTION OF THIS DISPOSAL SYSTEM AND.. THAT THE CONSTRUCTION AND THE FINAL GRADING HAS BEEN IN ACCORDANCE WITH THE DESIGNERS` INTENT AND THAT THE MATERIALS USED CONFORM. TO THE PLAN SPECIFICATION AND 310 CMR.15.00. f7 412.7p, 180.00' TABLE OF ELEVATIONS Invert out of house = 107.05 in tank =106.15 out tank =105.94 " in d. box -105.81 out d. box / 3x=105.66 end pipe #1=105.33 end pipe #2=105.35 #3=105.36 rn M 48.' S8' 44.' EXISTING M h FOUNDATION T.O.W.=108.14 48' 48.51 _ -- EXIST. GARAGE �=\ PARCEL C ;43.5' 24' --9 tank X28' "PARCEL D" /ese�i 5Q 89,512 S.F. \j R,82 s p p, L� p, S a;► , T- ?, 6/16/97 lD /7q .:. I PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 10/29/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box By: John DiVincenzo At: 759 Dale Street Map 104.0 Lot 0162 �_ dower, MA 01845 this certific , on t be construed as a guarantee that the system will function satisfactorily. Mkheli Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS -.I -,!5'q 6-Lc—:�7 ► MAP: LOT: INSTALLER: n j� DESIGNER: PLAN DATE: BOH APPROVAL 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 ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Installed on stable stone base H-20 D. -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) • l t�°� •. Application for Septic Disposal System 1c) OL, Construction Permit - TOWN OF TODAY'S DATE NORTH 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 n to move your Repair or replace an existing system component— What? 0'sr. . 9k cursor - do not use the return A. Facility Information key. 2� Address or Lot # rah D 1—Tt, U�0 City/Town 2.- *TYPE OF SER7fC SYSTEM*: ➢ ❑ Pump MGravity (choose one) ***If pump system, attach copy of electrical permit to application*** ➢ ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) ��CEIVED What is the Make? [khat is the Model. � 2. Owner Information OCT G � 2015 Name I OWN OF NORTH ANDOVER Dg IQ— I HEALTH DEPART„tENT Address (if different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information ' d b l I/ I r cc 5� ,crd a 5 ES4".a / 6 Name Name of Company A,� ddress �/Q j` J City/Town State Zip Cqe, ql? Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 • 4„, •. Application for Septic Disposal System Construction Permit -TOWN OF TODAY'S DATE $ 250.00 — Full Repair NORTH ANDOVER, MA 01845 $125.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Vesidential 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 44ndove . I u derstand that until a final Certificate of Compliance has been issued by th'k abar of a h, the installed system is not approved. 4 e Date v Application Disapproved for the following reasons: For Office Use Only: Z Fee Attached.? 2. Project Manager Obligation Form Attached? 3. Pump S sy tem? If so, Attach copy of Electrical Permit Applicant received copy of "Electrical Inspection Notes for Septic Systems” Handout? 4. Reviewed approval letter, all paperwork received.? 5. Foundation As -Built? (new construction only): (Same scale as approved plan) 6. Floor Plans? (new construction only): Date Yes L/ No Yes 1// No Yes No Yes No Yes No Yes No Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: f & 4e (Ad�septic system) Relative to the application o f (Installer's name) Dated zq! o ay s ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans Prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdep &townofnorthandover.coin) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done bothers unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by thdhomeovMer.e ral contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: t (To ay' ate) Al L 10 IV/ u ��Nlti — t ame —Print) igne ..wog Commonwealth of Massachusetts Map -Block -Lot 104.00162 BOARD OF HEALTH •"r Permit No North Andover BHP -2015-0880 P•1• FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John-DiVincenzo to (Repair) an Individual Sewage Disposal System. at No 759 DALE STREET as shown on the application for Disposal Works Construction Permit No. BHP -2015-088 Dated October 09, 2015 Issued On: Oct -09-2015 1���A OF HEALTH ---------------------------------------------------------------------------------- • �GgTLFoy Commonwealth of Massachusetts a Lot Co162 t BOA OF HEALTH 104. O16 --------- ` No h ndover >.. �w fi CE NTT—h TE"90M PLI NC S IS TO CE Individ al Sewa Disposal Sys m (Repair) by ohn Di incenz at No 7 DA E STREE has been installe ' accordance with the provisions of TITL f the State Enviro tal Code as described in the application for Disposal Works Construction Pen -nit No. -BH-P-2015-----09$--Dated __ October 09,_2015 --------------- ------------------- -------------------------------------------- Printed On: Oct -09-2015 BOARD OF HEALTH • 5t�:F�,. , Commonwealth of Massachusetts Map -Block -Lot 104.00162 • BOARD OF HEALTH----------------------- Permit No North Andover BHP -2015-0880 FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John DiVincenzo to (Repair) an Individual Sewage Disposal System. at No 759 DALE STREET as shown on the application for Disposal Works Construction Permit No. BHP -2015-088 Dated October 09, 2015 ----------------------- -------------------------- ------------------------------ - _�-� '�------------- Issued On: Oct -09-2015 LBOARD-OF ML�H Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH OF SLED �ti o m it — r_- -..."-1 *0'°A0RATEO°°°° Ew°° ^'0'` APPLICATION FOR SITE TESTING/INSPECTION F SA US r r F Applicant < V. Ae--, NAME ADDRESS TELEPHONE Site Location Engineer�� i Test/Inspection Date and Time 'CHAIRMAN, BOARD OF HEALTH Fee I Test No. �& Z S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. V ---- o 2 � E o 1 73 .N a� 3 U- (1) p rn r N L O y s L ro N M � ro O = ro � w C> p � � �o ro s U Z < U ro ro [ aj vv b JCL.r J b � ro }� a Q LU O "' z o L > rd w F y n 0 LL 0U LL OQ "w U c Q p w o V Q rno o w Q, H tn p z nw a s L O Q O /; e/ L O O Z °o iy H 3 m _ o f- � �' b ce 3 O w V o O �4 o 41 Z N IA Q � (J) C ro _ ro _U o N N vL w n b Q r{ O y vL1- i U E Ln 4 L O (n 4- U O N a — Q) > cu o o U N Q ro 0- U -C -c Q H Town of North Andover, Massachusetts Form No. 2 AORTh BOARD OF HEALTH /° F / t s ' °••�---•+DESIGN APPROVAL FOR SSS C14 S � SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM ApplicantTest No. Site Location U-) 1 ate_ Reference Plans and Specs. GINEER t Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. —0. Fee CHAIRMAN, BOARD OF HEALTH Site System Permit No. Town of North gORt BOARD ndover, Massachusetts OF HEALTH Form No. 3 M _ 9 « � „ o NUEt� 1 19 CSQ' DISPOSAL WORKS CONSTRUCTION PERMIT Applicant VY o &— _ _ Site Location_ ( �.-r— k 9— Permission permission is hereby granted to Sewage Disposal System as shown on the Re ( ) an Individual ( or pair Design Approval S.S. No Ideal Soil Absorption J0 CHAIRMAN Fee 5 ' BOARS �F HEALTH D.W.C. No. F t? uj z - � o �° ,..�� w x Q zw W x � z z w a a o ` C H O G1 Q as C/) Q O T .cz v C C w Q ai v O v w C/) � p O C C �2° C04 U w a :j, C 04 w w OC C r�G w OC C c4 w" C as cn cn uj z O \O 4 W — -"�v I J .W a z U4a0 z O U C OVAM N W 2 O O OM I O 'fl CD .� h O O 'E m m CD 0 CD t O.a 3� Oci O O O d CL CMQ CoZ O •-' Cc 3 �o Cl 0 CD C z � V V! cd C C C _� a CA - � o m c c � o ` C H O C � O V V CL C MM 7 m C t O CF 0 m .3 0 cm I:i . m c CL= m m CO h y m zip W = y y C=G C O : � y Em o c m co CM ;acs m mom V H ZCD O ♦.: C O � C H � y m C •O Q = m all—Ww y call- CO) G co�'flt10 •y C �+ � F. oc = ui E v -o v•y CD o W CL m� O� O 2 =team7s O \O 4 W — -"�v I J .W a z U4a0 z O U C OVAM N W 2 O O OM I O 'fl CD .� h O O 'E m m CD 0 CD t O.a 3� Oci O O O d CL CMQ CoZ O •-' Cc 3 �o Cl 0 CD C z � V V! cd C C C _� a CA 100 90 e0 T Q Z_ 0360 CL 5t) c0 z W 40 U m 0- 30 IN (J A plot of the sieve analyses of the portion of the sample passing the 94 sieve shall fall on or between the lines.on the following graph: PARTICLE SIZE DISTRIBUTION 12/1/95 (Effective 11/3/95) - corrected 310 CNa - 531 M OP 0 -AI t; ';,� 17��q D'&/ (a) The retairune wall shall be constructed of reinforced concrete, shall have no be waterproof. and shall .�,. (b) The retaining wall shall be designed by a Registered Professional Engineq� certify that the above condition is met by the submitted design. (e) The upgradient side of the retaining wall shall be waterproofed. `§ (d) Construction of the retaining wall shall be supervised by the design engineer. ^� = (e) An as -built plan shall be prepared and certified by the design engineer that the lin constructed in accordance with his approved design plan. irV (f) Ileelevation of the top of the retaining wall shall be no lower than the "breal•. elevation, which is the elevation of the top of the two inch layer of 'A inch to '/z inch wasW „ w stone aggregate cover. , The distance from the wall to the edge of the leaching area should be at least ten feet (3) Fill material for systems constructed in fill shall consist of select on-site or imported soil . 4 material. Tice 611 shall be comprised of clean granular sand, free from organic matter and deleterious substances. Mixtures and layers of different classes of soil shall not be used. The fill shall not contain any material larger than two inches. A sieve analysis, using a #4 sieve, shall be performed on a representative sample of the fill. Up to 45% by weight of the fill sample may be retained on the #4 sieve. Sieve analyses also shall be performed on the fraction of the fill sample passing the #4 sieve, such analyses must demonstrate that the material meets each of the following specifications: SIEVE SIZE EFFECTIVE % THAT MUST PARTICLE SIZE PASS SIEVE # 4 4.75 mm 100% # 50 0.30 mm 10%_100% #100 0.15 mm 0%- 20% #200 0.075 mm 0%- '5% 100 90 e0 T Q Z_ 0360 CL 5t) c0 z W 40 U m 0- 30 IN (J A plot of the sieve analyses of the portion of the sample passing the 94 sieve shall fall on or between the lines.on the following graph: PARTICLE SIZE DISTRIBUTION 12/1/95 (Effective 11/3/95) - corrected 310 CNa - 531 M OP 0 -AI t; ';,� 17��q D'&/ PLAN REVIEW CHECKLIST ADDRESS �lj7- ENGINEER GENERAL 3 COPIESy STAMP L`� C--' v SCALE LOCUS NORTH ARROW t,---' CONTOURS PROFILES/ SECTION c/ BENCHMARK--L—,-�SOIL & PERCS ^/ ELEVATIONS ;/� WETS. DISCLAIMER WELLS & WETS ✓/ WATERSHED?DRIVEWAY (Eley) WATER LINE FDN DRAINI� SCH40 ✓ TESTS CURRENT? y SOIL EVAL j,. STh'.e..�f SEPTIC TANK MIN 150OG L, .17 INVERT DROP GARB. GRINDER(+200% EDF) 2 5' TO CELLAR r_/MANHOLEXL-� ELEV GW # COMPS. D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET ,�, 407, - OUTLET 164, 6_ ,/ 7 (2" OR .17 FT) TEE REQ 'D?A�a 16,6-, 77 /0s; 6 t 7 LEACHING b �L MIN 660 GPD?/Z RESERVE AREA 4' FROM PRIMARY? ' 2% SLOPE 100' TO WETLANDS 100' TO WELLS 4' TO S.H.GW f5'>2M/IN) 35' TO FND & INTRCPTR DRAINS C/� 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY j,,,--- MIN 12" COVER,---�FILL? (25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpdX SLOPE (min .005 or 611/1001)x/ SIDEWALL DIST. 3X EFF. W OR D (MIN 6') L! RESERVE BETWEEN TRENCHES? �-, IN FILL? C--- MUST BE 10' MIN. '--� 4" PEA STONE? r/ VENT? (>3' COVER; LINES >501) BOT & 7 + SIDE L13 X LDNG TOT (L x W x #) (DxLx2x#) (G/ft2) 47,3, Z6 -6 a Copyright 0 1995 by S.L. �rr `� "LSv:`i c OP M.S1 OSMT.. DATE: 10bu Jg i CURRENT INSTALLER'S LICENSE# 26-i LOCATION: � D��G� s?-- LICENSED INSTALLER: SIGNATURE: 44LTELEPHONE# CHECK ONE: NEW CONSTRUCTION: L-_" IT NEW CONSTUCTION, PLEASE AT'T'ACH FOUNDATION AS -BUILT. Administrative Use Only 4w,.... $75.00 Fee Attached? Yes No Foundation As -Built? Yes No Approval Dater/Z a—ek FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this sect APPLICANT: APPLICANT: /�%'/71��i' ( ���D�O Phone 5D9�B7?V/5T 2 LOCATION: Assessor's Man Number i0�'i C Parcel Subdivision /Wwff' Street ,ADT _Z9 �Ll" ST Lots) St. Number ************************Official Use Only************************ RECOMN DAT ON OF WN AGENTS: Conservatio Administrator Comments �_l Comments Food Inspector -Health ,.4 A � Septic Inspector -Health Comments Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Date Approved 6 vl Date Rejected Public Works - sewer/water connections (�iJ - driveway permit -T &�(J Fire Depart of_�i Received y V y1# 6 3 0 7hatateKdes C'a ocatar #0 Vow* f 66 LITTLETON ROAD wES.'FORD. MA 01886S 508) 692.839 FAX (508) 692-0023 1.800.649•TEST I Report Numbert C -*my -17437 Report nater October 17, 1995 Clients sample Taken Ott (,(% E.M. young Artesi n Wellf l,ot D vale St; 36 Pelham ad. N.Andover,Mavo. Salem NM 03079 Lot 31 sample Taken Bys im Young staff Ont October 1 1995 i TEST PARAMETEkt Total Coliform (Pj i i CERTzrxcATE or ANALYsSis j } EPA max 0 RESULTS VNITS 0 Per 100m; iron (,a) 0.3 0.06 Manganese (s) 0.05 'C0.01 mg/L Sodium 28 8.1 mg/L chloride (0) 250 52.7 ' mg/L i Hardness No 'Limit, 148 � mg/r{ Nitratesl(as N)($) 10 1.1 Mg/14 Nitritoo(as N) 1' <0,01 mgJL pH (a) 6:5-8,5 7,1 SU E 2 31995 E NT -Not Tested, #s -Value Exceeds EPA STD, TNTC -Too Numerous t0 Count —Raekg>wound SactOria Dtoted, "-,4AA Advisory LiMit j -Ekoeeds EPA Adv. gory Limit (P)mPritttary VIA 0andard, ($)¢Secondary EPA Standard (may affect aesthetics of dri king water i.e. taste, colon etc.,) This water samp� as submitted, meet$ or exceeds E health standards for the paramuters� listed above. The quality of thisIwater is accepted as POT�BiE according to EPA Standards. Msassachus otts state certified Testing LaboratbrV #mA048 Michael Calson, for Thorstenoen Laboratory inc. .A ,'..,Z-,::►`'h� BOARD OF HEALTH ,SSACHUSEt NORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT Permit0 Date O �/��- -� TOWN OF NORTH ANDOVtR/ BOARD OF HEALTH OCT 2 31995 A permit is requested to: drill a well X install a pump�C _ LOCATION: to' % D 0-191e Lot # AA Zo 9 L Owner Fl.�niNony Did'Address Sys �!y/e�' S� Tel Well Contrctr yoglv(p Add.26 1eAlOn �� Tel dG3 �'9X�SUy 7 6'4 /r • 7 Pump Contrctr Add. Tel WELLS (To be completed at time of pump test.) Type of well D/i'%//eo Use /,) .0 )�17eJV Diameter of well �o" Size of casing 4% a D Depth of bed rock $�� Depth casing into bedrock JS Seal been tested? Yes No (_) Date of test1VY Depth of well '305- Water -bearing rock �� /4c 74R < o .Ce o.1 ,- o Delivers /� GPM for �` ,4,WI S Depth to water / (how long�.) Drawdown 106" feet after pumping 41 hours at /8 GPM Date of completion I°LIy ys Signature o ell �ntractor PUMPS (To be filled in before installation.) Name & size of pump 6' P V SS Type �ij g3 / H� Size of tank :5a,a Pump delivers GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic (L ­p' Sleeve used to protect pipe? Yes (_) No (L -f Type well seal/��% fo� r Date /o Signat re 6f pump installer Da Y ********************************************************************** Date water analysis report submitted to Board of Health %0/ % i Plumbing inspector Wiring inspector Board of Health .......... Department of Environmental Mai gem it/D�'jv['�iI nrgf WELL COMPLETI N R PORT L WELL LOCATION Address u OGRAPHIC DESCRIPTIO _ o N S —W0 f (feet! (circle) City/Town Nearer MASS Well owner ,77/-lo'r f/ Oi 4i D (road) Address S5' 9 6!/i n ter{ J i S NCS? E W of d16,P TN /llr7lyr,(� /Yl (n,l. in tenths/ (circle) /ig s- Board of Health permit obtained: ,-,/ yes E no ❑ intersect. w/ ? treed) WELL USE / WELL DATA Domestic /Public p Industrial ❑ Total well depth 3os ft. Monitoring ❑ Other Depth to bedrock ft, Water -bearing rock/unconsolidated material: «„QV Method drilled /d �3 _ DescriptionAc /`� <�4 i(ic K Date drilled Water bearing zones: CASING C a�' pie 1) From. To Type `r� �`' 2) From To Length 029 It. Dia(.I.D.) in. Length into bedrock is ft. 3) From To Gravel pack well: dia. Protective well seal: /J�«Je %fa a Screen: dia. Grout. Other Slot'' length from_ to STATIC WATER LEVEL (all wells) Static water level below land surface �G ' ft. Date /e /7 ,gf _ WELL TEST (production wells) Drawdown /64 ft, attar pumping J"—' hr. min. at 149' gpm How measured OafY M Recovery F'B " ft. after_hr,g?O min. LOG of FORMATIONS I COMMENTS El ,- ,; L 3 Driller �' �fe SVS 4/tj!� ,S.a,o 7,7 Firm Address City/Town JA �'' m 1 Supervising Driller Reg.# f�3 If BOARD OF HEALTH COPY NUMBER FEE T/, 4) �) THE COMMONWEALTH OF MASSACHUSETTS - 0 (T.�J�, -� - TOWN_ of NORTH ANDOVER - - - ......-••-------------- ---------•-•- This is to Certify that ............... ,.M,.,,,,Young-•.Artesian Well .................................... . NAME --_..3.6...PeLham..Raadt_..Salem, N-R...... 0.3.0_Z.9....................................................................... ADDRESS IS HEREBY GRANTED A LICENSE Well Permit - Lot D Dale Street For----------------------••-- - - --•--•------------------------------•-••--...-----•-•------------------------------------._...----...---------- ..... ...........•--------------------...--•--------------•----------------•----------------------------------------•-------------------------------------------------------- -----------------------------------•---------------------------------------------------•---•-•---------------------------------------------------------• ------------------ This license is granted in conformity with the Statutes and ordinances relating thereto, and expires ..... ?.eQ.P-mbe_x•_... 3.J....... 1.9.9.6............... unless sooW suspended oEjevoked,.- n October 1.6_i ...................... 19-- 95 / FORM 433 HOBBS & WARREN, INC. Town of North Andover . OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street KENNETH R. MAHONY North Andover, Massachusetts 01845 Director (508) 688-9533 August 21, 1995 Scott Giles 50 Deer Meadow Road North Andover, MA 01845 Re: Lot "D" Dale Street Dear Scott: 6D , This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Depth of trenches do not coincide on profile and section. 2) Trench lines must be connected to vents if over 50 feet in length. (310 CMR 15.251(11) and 15.241 (a) -(f).) 3) Note three concerning fill material shall read: "Fill material shall comply with 310 CMR 15.255. 4) Please note top of stone is at 104.96. 5) Septic tank must have a manhole to grade. If you have any questions, please do not hesitate to call the Board of Health Office at the number above. SS/cjp Sincerely, Sandra Starr, R.S. Health Administrator BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D. Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell Town of North Andover . OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street KENNETH R. MAHONY North Andover, Massachusetts 01845 Director (508) 688-9533 August 21, 1995 Scott Giles 50 Deer Meadow Road North Andover, MA 01845 Re: Lot "D" Dale Street Dear Scott: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: 1) Depth of trenches do not coincide on profile and section. 2) Trench lines must be connected to vents if over 50 feet in length. (310 CMR 15.251(11) and 15.241 (a) -(f).) 3) Note three concerning fill material shall read: "Fill material shall comply with 310 CMR 15.255. 4) Please note top of stone is at 104.96. 5) Septic tank must have a manhole to grade. If you have any questions, please do not hesitate to call the Board of Health Office at the number above. Sincerely, Sandra Starr, R.S. Health Administrator SS/cj p BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Par ino D. Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: PERMIT # 7c: 0 DATE RECEIVED APPLICANT IqV61,�/U --L MAP ADDRESS LOT # PARCEL ENG. ��T�� /GAS ST. --Di�L-E JT. ADD. V�`� �EF.� !'%/9Z occ) %V • � IYf� PLAN DATE -7 6 A?j A REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: a ` 7",eWc���-asses Av ©ro i Xv c i v cad C ��• a� i <� - (d ) OC-. 13, `��1� I� `�icc- �.�3r�,eir� � 8 ��� cap-1/,•�i� ,7-0 6,e ,�g b Z--, f 9 .ir 404 i � �+ . A �� ��'� "�� +�'� tx .r�-'',�r� '� 1 '� s+ -i .r .r ai' .t•. f '. F t f -!4e _ .r ,peF¢s'»� S is ter. � .{3 ,� � ' i'3 ,�, r j t . s. .w .k . •...` 4 " • `t' I AV qdEf f, ir q... r { ..+�yyy7"""��i�3 Y �.�. ,s,. � � 1 'f1 j±+ 41r. Tf.t,`. lei ,h a;• '• ..' ,. I�fJi '` Fe 1'- .q i, }. S .,=i t - �; { R� �a \. ♦ - 1;. t `.. � 0 • � � ` t` + a \ � .'a' `! t r`` + ♦ .;tie". i \ \ - � . � �,� 1��i "(�i � \ .+�k e,. ! :i3i � y t`i,�nt � �4� , a •J, ` .�.ti'k..i.'Tvt�.+i..._'G).\.'t.•^a�ee.i�r•t±l.\}:+ea�..t re��.t.!�"?h iB.G`�74"l`a�:�f lsw, ! Ir v Commonwealth of Massachusetts ljo, /9,U'bo vim- , Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By: _........... 701 'f'lon Witnessed By: fi/JD eA ............................................................................................................................................................................................................................................................. Location Address or —L�qL.� �T��' �'�_ Owner's Name, JONA-)5'MOLA t- Loi p Address. and J� Sp , a3%2 9 bG02 D �T Telephone p New construction Kl' Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes Year Published Jqel Publication Scale 1-'A 5940 Soil Map Unit . -'�6. Drainage Classm,to,D. Soil Limitations ........ Surficial Geologic Report Available: No Ei— Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) .. ._.............................................._....._............................ __.'. ................. Landform _ .. _ _.... . Flood Insurance Rate Map: �f30P� qQ 06 p 7 C Above 500 year flood boundary No ❑ Yes Lam' Within 500 year flood boundary No Yes ❑ Within 100 year flood boundary No Yes ❑ Wetland Area: National Wetland Inventory Map (map unit)....................................................................................................... . Wetlands Conservancy Program Map (map unit) ................. __......... .......... ...... .............. I......... Current Water Resource Conditions (USGS): Month ../:&95 Range : Above Normal ❑ Normal 0� Below Normal ❑ Other References Reviewed: On-site Review p v, 03/rVPy Deep Hole Number _ /. Date: `%�`� /� Time: / oto Weather iaUNN Yw- C01,D Location (identify on site plan) _. __ _... _.. _ _ .......... __ ......... _...... .. ..... Land Use LVaDbJ,..A { b . __ Slope (°iol Surface Stones ... .._07 Vegetation ..... Landform ..... 007-601' �%-V Position on landscape (sketch on the back) ... .............. --- ... ....... ... Distances from: Open Water Body .............. feet Drainage way............ feet Possible Wet Area >. /60 feet Property Line _ . .......... feet Drinking Water Well _ feet Other . .._ _. OBSERVATIONDEEP HOUE LOG Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (Inches) (USDA) (Munsell) (Structure, Stones, Boulders, Consistency. % Gravel) G'�A ANUG A/� /D — a�`f ` �� G�,9.w y Firv� ���� ��� —kE D OX 0 33,/:, ,. -�3Z" --pG,C06146 4n. +in)c y�lsTT T)va 7-c Parent Material (geologic)_.._Q.C�f��........... ............. _ Depth to Bedrock: Depth to Groundwater: Standing Water in the Hole:./ Weeping from Pit Face: . Estimated Seasonal High Ground Water:.' ."_ r Oft -site Review V, Wr,oDY A Deep Hole Number ...o� Date: `T/0-/% Time: 12.�30 Weather -UNNy Location (identify on site plan) ................. ............ __ ......... _ _....... I ...... ....... ................ ....... _...._._.... _ . Land Use .... .14)004fJ..A)b Slope (°ro) Surface Stones ..... -..... _ ...... ............... . Vegetation ....— 7R . ".... ........... _. .. .. Landform .. .. ... ....... ......_ _._ .... ... ............ ......... ...................... Position on landscape (sketch on the back) ............ .................................. .___ _ ............... Distances from: Open Water Body _....._... feet Drainage way .......... feet Possible Wet Area feet Property Line _.___ feet Drinking Water Well .......... feet Other DEEP OBSERVATION HOLE LOG Depth from Surface Soil Horizon Soil Texture Soil Color Soil Mottling Other (Inches) (USDA) (Munsell) (Structure, Stones, Boulders, Consistency, °,o Graved Y QA C��✓��. V, r, ZOA3My L�j )/ ---F-0'0T5 To 39 Parent Material (geologic) Depth to Groundwater: Standing Water in the Hole:..' Depth to Bedrock: ... Weeping from Pit Face: Estimated Seasonal High Ground Water: _.04.'1 1 � p(4 . i t � C' o E.R.D. to PA CEL` D T W E C.B. A. EXCEEDS 75 o v� ` v M Sao W f � -- i 1 R� 825 OO E �LROD SET ,,2441 Ra825 ®`/c�.O DO' 9`/3•. .00.4 1 N/F HELEN R.$ H. MICI SMOLAK 24.8 ACRES V- REMAINING LQ O h REV. ROD SET F11* O CO,o N o b O ^1 N O U a o 0 v fi 4 c d E E 0 U t Cx C6 T u � 0 a o F- 00 0 0 N M y O R O Q � Q U C N C O O U) m a �U C N N J tp N O O O N 9 2 0 c� N 00 c � o � r � n b O N O U a a L � 7 G N R op a LICA i.4 ee — a y C3 O N cz r F en V I � V j V I V y E C 1 1 4 . c � o � r � n N N M 0 O U a a L � 7 G N R op a LICA i.4 ee — a y C3 c N cz r F en V I V j V V y E C � 7 O � I I �I H � � O y I •O Q O V C � H co . c � o � r � G y � N N M 0 O U a a � C 7 G N R op a LICA wo�Ic'a — a y C3 c N cz r F en V Qi0 V L"i'R�r10 V V y E C a 7 O � J d N y Q O V C � H co 00 O O O N U O N ON In D •;; C G Q '7 kn oo � Ln 7 00 r � v •v iaQ �.0 N � t � aJ � Y oc W U on C U oa aJ J � b O N 'aj •� x b I .5 N N E cL O O b 5 7 vl oo > � E _ d z.f >y E Ol 3 a,s = o❑ C N > G ❑ 5z: 3ab a m ❑� O J O � °� w O C .n � Y cC oDp O c oo C C E y U O O R bl � O O O O� cC C CQ a � 'OO R C a) � •� cCd 7 y a. C O d VZ = a m "I > cGy o' � o > t o y= ❑ .m K •o '� ° O O v o 'bq to 4 o ao �aE > Q L O b U O w 01 0.O•-�zQVE a �W cn v y y > °�' 'cC Z', o L1 o •E a 0 G E x .� s: v E °' o f s E v E 3 °��' 9`a oE °° E �. o 4 E o �a c- o ae on a°io o U 0 F -U a/)Z:2❑ZU❑ Z v Cea E FHS uli QI, m lift!" c � o � r � U c vi c O .3 O >, 0 � a � C a c a LICA wo�Ic'a a y C3 c V Qi0 V L"i'R�r10 V uli QI, m lift!" c � o � r � U c vi c O .3 0 � a � C a c •U Q y C3 c z � 3 a � J d N y H co 00 O O O N O N CERTIFIED PLOT PLAN LOCATED IN NORTH ANDOVER, MA. SCALE:1 "= 40' DATE: 10/10/96 Scott L. Giles R.P.L.S. 50 Deer Meadow Road North Andover, Mass. I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BY LAWS OF NORTH ANDOVER WHEN BUILT OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON -CONFORMITY WHEN CONSTRUCTED. 13972 TO DATE TIM Al P /LPMI H FROM AREA ODE O NO. / f>3-4 J ?p7 f� �xr OF EM ,� �- - M s E s e, M G Gyp r PHONE CALL ❑ RETURNED ❑ WANTS TO ❑ WILL CALL WAS IN ❑ URGENT ❑ V. Iz;>HIII H 1 6c 1 ljlaie� Mancheste'r Sand, GrovelA Cement Co. .1355 Hooksett Rd. ,Hooksett NH 031W849 ii.ephone (603 ) 6116400 824.1430 size : Retained Attn. Bently Warren Mike (I V Laboratory, Gunny Done Perkins :.:1 ��P0 A . ........ 0 VWD. 0.0 100.0 ............................. .... ...... ......... ......... .. ....... .. .......... ......... 40 0.4 99.6 3/4%: ......... 1/2" 158 1.7 98.3 ZA 04 362 J 311 96.2 .. . . .............. SWiI.Poilm..� .... . .. .... .... ....... ..... .. . ... $4 0 0.0 100.0 .. ..... ..•.............. ....... .... .......... .... . . . ......... ............ o`' N;G iii' v IT4 020 371 9.1 90.9 .............................................. T4.... ..........•... #80 —6343.5 84.5 15.5 o........... . ...... . .... ....... 0,200 4001 98.6 1.4 ROSOA: —Or2anIc Grams: 9548 Ted 0, $4 Sieve : 406.7 (I V Laboratory, Gunny Done Perkins :.:1 ��P0 A