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HomeMy WebLinkAboutMiscellaneous - 767 JOHNSON STREET 4/30/2018Final Approval: All Permits Paid? Well Construction Approval? Septic System Construction Approval? Certification? Other Any Variance Needed? FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: YES W_ __ -NO YES NO NO 7SS NO NO NO 7111" C'_�ic'/ 51;7/fr _ SEPTIC SYSTEM INSTALLATION y .. Is the installer licensed? Type of Construction: 7 -_ _New Construction: Certified Plot. Plan Review YES 'Nam Floor Plan Review YES NO- �--_ - -� - Conditions of Approval from Form U YES NO- Issuance O Issuance of DWC permit: YES NO DWC_Permit Paid? YES NO --- - DWC--Permit Installer: - - -- - - - B6&'Inspection: - YES- /.3 ES _Q4.3 _Zap, Excavation -Inspection:='" by - t 4r �Laf I j- Needed: ; << Passed: By._;�,,y.�:;;, Construction Inspection: _ Needed: - Satisfactory:41 Q�f� Approval. of Backfill: Date: Final Grading Approval: Date: %J By: --, Final Construction Approval: Date: y /,_q By: � Certificate of Compliance:..- Approval: =7 Date: �y r _ SEPTIC SYSTEM INSTALLATION y .. Is the installer licensed? Type of Construction: 7 -_ _New Construction: Certified Plot. Plan Review YES 'Nam Floor Plan Review YES NO- �--_ - -� - Conditions of Approval from Form U YES NO- Issuance O Issuance of DWC permit: YES NO DWC_Permit Paid? YES NO --- - DWC--Permit Installer: - - -- - - - B6&'Inspection: - YES- /.3 ES _Q4.3 _Zap, Excavation -Inspection:='" by - t 4r �Laf I j- Needed: ; << Passed: By._;�,,y.�:;;, Construction Inspection: _ Needed: - Satisfactory:41 Q�f� Approval. of Backfill: Date: Final Grading Approval: Date: %J By: --, Final Construction Approval: Date: y /,_q By: � Certificate of Compliance:..- Approval: =7 Date: �y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 767 Johnson Street Property Address Tabitha Kane Owner Owner's Name information is required for North Andover MA 01845 3/18/2014 every page. City/Town 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. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. raS iesrn A. General Information 1. Inspector: IIAR Z 4 2014 T OVv,a Oh r%CrZTH A�,-: - Neil J. Bateson i HEAL—" -I DEPART, ..- ; Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 Citylrown State 978-475-4786 S115 Telephone Number B. Certification License Number Zip Code 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 ❑ Ne(As Further Evaluation by the Local Approving Authority 3/18/2014 In ector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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 Owner information is required for every page. t5ins - 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 Johnson Street Property Address Tabitha Kane Owner's Name North Andover MA 01845 3/18/2014 Citylrown 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: 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 0 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 Johnson Street Property Address Tabitha Kane Owner Owner's Name information is required for North Andover MA 01845 3/18/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 767 Johnson Street Property Address Tabitha Kane Owner's Name North Andover MA 01845 3/18/2014 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 % day flow t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 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 767 Johnson Street Froperty Address Tabitha Kane Owner's Name North Andover MA 01845 3/18/2014 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 ❑ ❑ 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 .-CN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 767 Johnson Street Owner information is required for every page. rroperty Address Tabitha Kane Uwners Name North Andover MA 01845 3/18/2014 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 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 t5ins • 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 767 Johnson Street Property Address Tabitha Kane Owner Owner's Name information is North Andover required for MA 01845 3/18/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): 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) K ® Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts uIn. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments vP 767 Johnson Street Owner information is required for every page. Property Address Tabitha Kane Owner's Name North Andover Cityfrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 3/18/2014 State Zip Code Date of Inspection Date General Information Unknown Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 1500 gallons Measured tank. Inspect tank & tees. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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 • 3/13 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 r 767 Johnson Street Owner information is required for every page. rropeny Atltlress Tabitha Kane Owner's Name North Andover MA 01845 3/18/2014 City1rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 15 years old, 9/10/1999, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2.6 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.): Unable to see pipe through foundation finished room. 3" PVC in house no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1.6 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth: 4" ❑ Yes ❑ No t5ins • 3/13 Title 6 Oficial 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 767 Johnson Street Property Address Tabitha Kane Owner Owner's Name information is required for North Andover MA 01845 3/18/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 9" How were dimensions determined? 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.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakaae. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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 • 3113 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 .� Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 Johnson Street Property Address Tabitha Kane Owner Owner's Name information is North Andover required for MA 01845 3/18/2014 every page. Cityfrown 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.): t5ins • 3/13 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 767 Johnson Street Property Address Tabitha Kane owners Name North Andover MA 01845 3/18/2014 Cityrrown 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.): D -box level & distribution equal. Evidence of carryover, pumped d -box to clean. No evidence of leakage. 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 I Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Yard covered in snow, no sign of ponding to surface. 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 JD Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 Johnson Street Property Address Tabitha Kane Owner information is Owner's Name required wired fo for North Andover MA 01845 3/18/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 filed 24'x 70' number, dimensions: ❑ 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.): Yard covered in snow, no sign of ponding to surface. 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 y 767 Johnson Street Property Address Tabitha Kane Owner Owner's Name information is required for North Andover MA 01845 3/18/2014 every page. Citylrown 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: t5ins • 3/13 Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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 767 Johnson Street Property Address Tabitha Kane Owner Owner's Name required for is North Andover required for MA 01845 3/18/2014 every page. City/Town State Zip Code Date of Inspection t5ins - 3/13 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 3 0 ase, v%de� 195�i Dt °T i i Tine 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 767 Johnson Street Property Address Tabitha Kane vwners name North Andover MA 01845 3/18/2014 Cityrrown 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: 3 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: 10/10/1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 16 of 17 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 Johnson Street Property Address Tabitha Kane Owner's Name North Andover RAA Cityrrown State E. Report Completeness Checklist 01845 Zip Code 3/18/2014 Date of Inspection ® 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 Title 5'016cial Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 �a sur r Ir nunweann oT iviassacnusens City/Town of System Pumping Record Form 4 DEP has provided this form for us&by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that Provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left / Right front of house, Left / Right near of house : righ I �ofous Left / Right side of building, Left / Right front of building, Left /Right rear of bw�ing, Under Address City/Town State Zip Code 2. System Owner. -� Name' Address (if different from location) Cityfrown State Zip Code Telephone Number :- B. Pumping .Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons ;. 3. Type of system: ❑ Cesspool(s) mePtc Tank Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yee �o If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi n f System: 6: System Pumped By: Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: date t5form4.doa .08M3 , System Pumping Record • Page 1 of 1 Town of North Andover Tax Map # 210-038.0-0091-0000.0 Parcel Id 11533 767 JOHNSON STREET TABITHA KANE 767 JOHNSON STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.2 Acres FY 2014 UB Mailing Index Name/Address TABITHA KANE Type Loan Number Activellnact. From Until Owner 767 JOHNSON STREET NORTH ANDOVER, MA 01845 JOSEPH & SHEILA DIFRAIA Previous Customer Inactive 2/12/2009 767 JOHNSON STREET NORTH ANDOVER,` MA 01845 UB Account Maint, Account No Cycle Occupant Name Active/Inactive Bldg Id. 14355.0 - 767 JOHNSON STREET Last Billing Date 3/6/2014 2100359 02 Cycle 02 Active UB Services Maint. Account No. 2100359 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 19.00 /1 UB Meter Maintenance Account No. 2100359 Serial No Status Location Brand Type Size YTD Cons 16336883 a Active ERT METE METE w Water 0.63 0.63 433 Date Reading Code Consumption Posted Date Variance 2/6/2014 1291 a Actual 5 3/17/2014 -590/0 10/30/2013 1286 a Actual 11 12/20/2013 -30% 8/2/2013 1275 a Actual 16 9/18/2013 9% 5/3/2013 1259 a Actual 14 6/18/2013 4% 2/5/2013 1245 a Actual 15 3/13/2013 -18% 10/31/2012 1230 a Actual 16 12/13/2012 20% 8/7/2012 1214 a Actual 15 9/26/2012 13% 5/3%2012 1199 a Actual 12 6/20/2012 .5% 2/6/2012 1187 a Actual 14 3/14/2012 _4% 11/2%2011 1173 a Actual 14 12/15/2011 -2% 8/2/2011 1159 a Actual 14 9/14/2011 49% 5/4/2011 1145 a Actual 9 6/13/2011 -21% 2/7/2011 1136 a Actual 13 3/15/2011 14% 11/1/2010 1123 a Actual 8 12/13/2010 -76% 8/24/2010 1115 f Final Bill 55 8/24/2010 94% 5/4/2010 1060 a Actual 23 6/9/2010 16% 2/2/2010 1037 a Actual 20 3%11/2010 -18% 11/2/2009 1017 a Actual 24 12/11/2009 -7% 8/4/2009 993 a Actual 26 9/11/2009 8% 5/5/2009 967 a Actual 24 6/16/2009 9% 2/3/2009 943 a Actual 22 3/16/2009 -14% 11/4/2008 921 a Actual. 26 12/10/2008 -28% 8/4/2008 895 a Actual 37 9/12/2008 69% 5/2/2008 858 a Actual 20 6/18/2008 -3% 2/6/2008 838 a Actual 23 3/14/2008 -36% 11/2/2007 815 a Actual 34 1/15/2008 10% 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 f!,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 767 JOHNSON ST., NO- ANDOVER, MA 01845 Property Address --- - JOSEPH DIFRAIA Owners (Name NO. ANDOVER cityrrown MA 09845 State Zap code Inspection results must be submitted on this form. way. A. General information 1. Inspector JAMES H. CURRIER li Name of Inspector J's SEPTIC & DRAIN Company Name -- 139 FOREST ST. Company Address MIDDLETON City/Town 978-774-6685 Telephone Number B. Certification MA State 7129190 / Date of inspection :moth d in any AUO TOWN OF NOKM ANDOVM HEALTH DEPARTMENT License Number 04949 Zip Code 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. l am a TEP approved system inspector pursuant to Section 15.340 of Title 6 (310 CIVIR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7129110 Apector'sgnature date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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. TITLE V 2008.doc - 03708 "Ode 5 Official Inspectian IFamr Subsudhce Stege Disposal Systwn - Page 1 of 1 )(0 ► 10t Owner information is required for every page - Commonwealth of Massachusetts UN V Title 5 Official inspection Far Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 JOHNSON ST., NO. ANDOVER, MA +01845 Property Address JOSEPH DIERAiA Owner's Name NO. ANDOVER MA 01845 7/29/10 city/row State Zip Code B. Certification (cont.) Date of Inspection 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: SYSTEM WORKING PROPERLY B) System Conditionally Passes: ❑ One or ore system components as described in the "Conditional Pass" section need to be replaced o repaired. The system, upon completion of the replacement o"pair, as approved by the Board of ealth, will pass. Answer yes, no or no etermined (Y, N, ND) in the ❑ for the foliowi statements. if "not determined," please ex in. ❑ The septic tank is metad over 20 years old* or the se c tank (whether metal or not) is structurally unsound, exhib substantial infiltration or iltration or tank failure is imminent. System will pass inspection if a existing tank is rep ced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspectio =ditrstructurally sound, not leaking and if a Certificate of Compliance indicating that the tank is Ian 20 years old is available. ND Explain: ❑ Observat/ructionis ackup or break out or high static water lev in the distribution box due to broken pipe(s) or due to a broken, settled or uneven ribution box. System will pass inspapproval of Board of Heatth): ❑ bre replaced ❑ omoved TTLE y 20-8.doo - DN08 Title 5 Official Inspection Foam. Subsurface Sewage Disposal System • Page 2 of 2 Owner - information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Forte �1 rerea �.��4 Subsurface Sewage Disposal System Fora - Not for Voluntary Assessments 767 JOHNSON ST., NO_ ANDOVER, MA 41845 Property address -- JOSEPH UFRA'IA uwners ivame NO. ANDOVER MA 01845 City/rown State Zip Code B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The syst required pumping more than 4 times a year due to system wil ass inspection if (with approval of the Board of He ❑ broken ipe(s) are replaced ❑ obstruction removed ND Explain: 7/29/10 Date of Inspection or obstructed pipe(s). The C) Further Evaluation is Required by a Board of Health: ❑ Conditions exist which require fu er ev anon by the Roard of Health in order to determine if the system is failing to protect blic health, afety or the environment_ 1. System will pass un a oard of Health termines in accordance with 310 CMR 9 5.303(9)(b) that the syst is not functioning ti a manner which will protect public health, safety and the environ ent: ❑ Cesspool orKrrivy is within 50 feet of a surface ❑ Cesspoo or privy is within 50 feet of a bordering vegetate wetland or a salt marsh 2. System 11 fail unless the Board of Health (and Public Water 5 lier, if any) determine that the system is functioning in a manner that protects t public health, safety a environment: ❑ Thesystem has a septic tank and soil absorption system (SAS) and the S)t,6 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 p\wat supply. The system has a septic tank and SAS and the SAS is within 50 feet of a pri supply well. TT`C CWD.��i. L1O,,i"..K ui'Zi a b iEi'r} 14SWbarlr Furor. Suhuj,'We Savvnge DISRMI Systarn °r=age 3 6i 3 C) Further 60luation is Required by the Board of Health (cont): ❑ The systeNtas a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a 'vate water supply well". Method used to deteri'rr distance: ,� ** This system passes if the well orate n is, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pres of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no of r fail criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: Commonwealth of Massachusetts "Yes" or "No" to each of the following for all inspections: Yes No Title Official Inspection Foy , lD - - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . clogged SAS or cesspool ❑ (_ i m _ ; u.' 767 JOHNSON ST., NO. ANDOVER, MA 01545 due to an overloaded or clogged SAS or cesspool ❑ Property Address Static liquid level in the distribution box above outlet invert due to an overloaded - -- JOSEPH DIFRAIA ❑ ❑) Owner Owner's Name ` than'la day flow information is equired for NO. ANDOVER MA 01545 7/29/10 every page. Cityfravan State Zip Code Date of Inspection Any portion of the SAS, cesspool or privy is below high ground water elevation. B. Certification (cont.) ❑ & Any portion of cesspool or privy is within 100 feet of a surface water supply or C) Further 60luation is Required by the Board of Health (cont): ❑ The systeNtas a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a 'vate water supply well". Method used to deteri'rr distance: ,� ** This system passes if the well orate n is, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pres of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no of r fail 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 Cl 0 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'la 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. TfrLE V 2M.doc - 03108 Title 5 Official ilnspeciion Forth: Subsurface Sewage Disposal System • Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form L = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o s� 767 JOHNSON ST., NO. ANDOVER, MA 01845 Property Address JOSEPH D1FRAtA Owner Owner's Name required for is NO. ANDOVER required for 11NA 01845 7/29110 every pate. Cityrrown State Zip Code Date of Inspection--- B. Certification (cont) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ❑ l� Any ,portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ �k� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑t 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 tire -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 systema must serve a facility with a design flow of 10,000 g to 15,000 gpd. For large systems, you must �'teeither eyes" or "non to each of tfollowing, in addition to the questions in Section D. Yes No ❑ El the system is within dill) f of surface drinking water supply El El the systema is within 200 et of a , . utary to a surface drinking water supply ❑ the system is locate in a of Sens ' e area (interim Wellhead Protection Area — IWPA) or mapped Zone ll of a pu i water supply well If you have answered "yes ° fo any rte Won in Section E the system is sidered a significant threat, or answered "yes9 in Section ve the large system has failed- The o or operator of any large system considered a signifi�,—Ortc= at under Section E or failed under Section shall upgrade the system in accordance 15.304. The system owner should contact th ropriate regional office of the D ailment 7171E V ZMA*c • 03fWS Tule 5 ilfficial inspection Foran' SuDsurdace Sevrage Disponi 5ys6em •Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Fara -- Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments 767 JOHNSON ST., NO. ANDOVER, MMA 01845 Owner information is required for every page. rroperty address JOSEPH DIFRA]A owners ivame NO.ANDOVER MA 01845 City/rown State Zip code G. Checklist 7/29/10 Date of Inspection 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 ❑ 0 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 NIA) ® ❑ 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) 1310 CMR 15.302(5)] TITLE V 2008.doc - 03108 ML- 5 s3tiiciat tnspecfim fomc Subsurface Sr"e Disposal System - Page 6 of 6 D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 GPD Number of current residents: 4 Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: ComrnercialTindustriai Flow Conditions: Type of Es lishment, Design flow Basis of design flow Grease trap present? O��CMR 15.203): s/pe nstsq.ft_, etc_): Industrial waste holding tank present? Non -sanitary waste discharged to the Water meter readings, i:availa ' Last date of occunanevl Other (describe): 5 system? Gallons pew (gpd) Date 0 Commonwealth of Massach setts�i ❑ } :� ❑ Title Official Inspection Form�����3��T����i r^re Street � 3 s: •�.01 l�.A 1, 206.98 CPD yk Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 767 JOHNSON ST., NO, ANDOVER, MA 01845 Property Address JOSEPH 01FRAlA Owner Owner's Name information eis r wired for NO. ANDOVER MA 01845 7129110 every page. Citytrown State Zip Corte pate of inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 GPD Number of current residents: 4 Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: ComrnercialTindustriai Flow Conditions: Type of Es lishment, Design flow Basis of design flow Grease trap present? O��CMR 15.203): s/pe nstsq.ft_, etc_): Industrial waste holding tank present? Non -sanitary waste discharged to the Water meter readings, i:availa ' Last date of occunanevl Other (describe): 5 system? Gallons pew (gpd) Date 0 Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No 206.98 CPD ❑ Yes ® No CURRENT Elate ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No TITLE V 2MB.doe - MOB Me 5 Olfinal insoettion Form: SuBsurfut a Sewage Disposal System - Page 7 of 7 Owner information is required for every page. Commonwealth of Massachusetts 33$Ctr�'s`4' �S'�x Erc€ Tithe Ici Inspection fora ,���{ I.^ihtit`9rc Subsurface Sewage Disposal System Form Not for Voluntary ,Assessments 767 JOHNSON ST., NO. ANDOVER, MA 01845 Praperty Address JOSEPH DIFRAIA owner's Name NO.ANDOVER MA city/rown state D. System Information (cont.) Pumping Records: 01845 Zip Code General information 7129/10 Bate of tnspmWn Source of information: BoH RECORDS - LPD 1/1912000 — Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gaffons How was quantity pumped determined? — Reason for pumping: — Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool El Overflow cesspool ❑ Privy ❑ Shared system lyes or no) (if yes, attach previous inspection records, if any) ❑ lnnovative9Alterr ative technology. Attach a copy of the current operation and maintenance contact (to be obtained from system owner) and a copy of latest inspection of the I/A system by systema operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ other (describe): Approximate age of all components, date installed (if known) and source of information - COC SIGNED OFF 90/22/1999 Were sewage odors detected when arriving at the site? ■ - ►4 TITLE v 2ws.doe - o3ais Me 5 Offiofal fnsoeotien Fom,: Subsurface Somae Disoosaf system - paae 8 of 8 Commonwealth of Massachusefks - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 JOHNSON ST., NO. ANDOVER, :MA 01845 Prpperty Address -- ,JOSEPH DIFRAIA Owner Owner's Name information is required for NO. ANDOVER MA 01845 —_ every page. cityrrown State Zip Code X33 Forest tre�F MIDDLETON, MA 01949 (-WiCl) 7-174-663835 7/29/10 Date of Inspection D. System Information (cont. Building Sewer (locate on site plan): Depth below grade: 2`feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 20'+ feet Comments don condition of ioints, venting, evidence of leakage, etc.): PIPING IS BEHIND FINISHED WALLS Septic Tank (locate on site plan). Depth below grade: Material of construction: M concrete ❑ metal 18" feet ❑ 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: 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 How were dimensions determined? 10'X 5'8" -1500 GAL. 2ID - 3Ir 33" 31' 6`" 1171" - 12" SLUDGE JUDGE TM -E V 2008.doe 03108 TMS 5 Of E41 frrspaWon Form' Subsurface Sewage Disposal System - Page 9 of a Commonwealth of Massachusetts Title 5 Official Inspection Farr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 JOHNSON ST NO.. ANDOVER, MA 01845 Property Address - JOSEPH DIFRAIA Owner information is required for every page. u niers name NO.ANDOVER MA cityfrown §tate 01845 7/29/10 Zip Code Date of Inspection in.54i�1t'tS 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.): TANK IN GOOD CONDITION, TEES IN PLACE, TANK NOT READY FOR PUMPING Grease Trap (locate on site plan): epth below grade: Mate ' I of construction: ❑ concret ❑ metal Dimensions: Scum thickness Distance from top of scum to top Distance from bottom of scum to Date of last pumping: Comments (on pumping recomrr liquid levels as related to outlet h Tight or Holding Tank ank Depth below grade: Material of con ruction: ❑ concret ❑ metal ❑ fiberglass outlet tee or baffle of outlet -A a or baffle feet ❑ polyethylene ❑ other (explain): Date outlet tee or baffle condition, structural integrity, 3kage, etc.): must be pumped at time of insped ' n) (locate on site plan): ❑ fiberglass ❑ polyethylene \p other (explain): TITLE V 200B.doc - 03M f Faye 5 Official inspection Form: Subsurface Sewage Disposal System • Fagg 10 of 10 Comments(conditiogAf alarm and float switches, etc.): * Attach cOPY Of current Pumping contract (required). Is copy attached? El Yes [I No 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.): D -BOX IN GOOD CONDITION, BOX 3" BELOW GRADE. Pump Chamber Pumps in working order: Alarms In working orl/r on site n Yes El No El Yes El No TRE V 2M.dat - 030) Me 5 Ofti8l Iftsoetfion Foffn! Subsurface Sewaiie ftoasal System - page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .767 JOHNSON ST., NO. ANDOVER, MA 01845 131 ForeA Sireet MoD ETON. MIA 01949- Property Address JOSEPH DIFRAIA Owner Owner's Name information is required for NO. ANDOVER MA 01845 7/29/10 every page- Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or !ding Tank (cont.) Dimensions: Capacity: gallons Design Flow-. -ga"'Ons W day Alarm present: ❑ Yes ❑ No Alarm level.- Alarm in working order: El Yes El No Date of last pumping: W.,._ Comments(conditiogAf alarm and float switches, etc.): * Attach cOPY Of current Pumping contract (required). Is copy attached? El Yes [I No 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.): D -BOX IN GOOD CONDITION, BOX 3" BELOW GRADE. Pump Chamber Pumps in working order: Alarms In working orl/r on site n Yes El No El Yes El No TRE V 2M.dat - 030) Me 5 Ofti8l Iftsoetfion Foffn! Subsurface Sewaiie ftoasal System - page 11 of 11 Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 JOHNSON ST., NO. ANDOVER, MA 01845 '0ru pefty Address JOSEPH DIFRAIA Owner information 16 required for every page. owners r4ame NO. ANDOVER MA city/Town state D. System Information (cont.) Comments (note condition of pump chamber,' 13" forest -W,-et 'LAIDDLETION, MA 0194S 7, � S-) 7 74-.6685 01845 7/29/10 Zip Code Date of Inspection of pumps and appurtenances, etc.): z - Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: 0 leaching pits number El leaching chambers number ❑ leaching galleries number ❑ leaching trenches number, length: leaching fields number, dimensions: ONE - 70'X 24' overflow cesspool number ❑ innovativelattemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE, ALL VEGETATION LOOKS NORMAL. TITLE V 2MB.dat —03AIS Title 5 Offal tmoettion form: Subsurface Sewage DiSPOW SYMM - Page 12 of 12 Owner information is required for every page. Commonwealth of Massachusetts J's SEEP= & DW �W ON, MA 0194.9 Title 5 Official Inspection Form MI0'DL3'ET"---' street Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (978) 7774-66885 767 JOHNSON ST., NO. ANDOVER, MA 01845 Property Address JOSEPH DIFRAIA Owners Name IVO. ANDOVER MA 01845 cityfrown 'State zip Code D. System Information (cont.) 7/29/10 Date of Inspection (cesspool must be pumped as part of inspection) (locate on site plan): Number an co nfigu Depth —top of uid Depth of solids laye Depth of scum layer to inlet invert Dimensions of cesspool Materials of construction Indication of groundwater it Comments (note condition of soil, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note /ndiffiion etc.): 0 Yes El No failure, level of ponding, condition of vegetation, of soil, signs of hydraulic failure, level of ponding,bqndition of vegetation, 7ME V 2005.dw - 03106 'TWO $ WOW InsPecfim Ewan: Subsuftce SvJQ9L Disposal System - Pap 13 of 13 J 9 S&PTIC & mr,, z UffWlV Commonwealth of Massachusetts 131 Forest street ' MIDDLETION, MA 01Q/�S-, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 767 JOHNSON ST., NO. ANDOVER, MA 01845 Property Address JOSEPH DIFRAIA Owner Owner's Name information is required for NO. ANDOVER MA 01845 every page. cityiTown, state Zip Code 7/29/10 Date of Inspection D. System Information (cont.) 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. VLE V 2008.dot - 03W Tide 5 OfficW Inwecfion Farm: SUbwttace SaM98 (YISPOSW System - Page 14 at 14 V__ —.--- y ax z _ _ r � r t �s� { -Y h� GL-v``t S ---ZZZ ii '+' � S yi• - _ a'�� } ` ` r , �` Arg t '! - �' _2' (/ y �6_ # ��^± ` 1:�'. .'L"'a'E-+kms �'.-. 7 ''�^-�$ .,�T - - 3 ` �'wc ? # Y...ui' -. 1: sia �. _ �,- f� �Tr _-.`�'-S _-..-. ••a`+n '•"tea 4 i 1 ' 1.;. - '' Y- - - - fi.' - �1 Y `~ _ -w °. k. - - - " s �, a iL `�,' - w �^_ . . .� raw . r ¢-. _ _ " - h ... l _ '���y1 f -. - . .€y? - `Y " F :� ; s r:. �..� '.- �.` . - Y" i FSA _ - - .. _ :. .. _ i .. - - -' - _ - - - - . . . 3 1 r, s T n �T; Y �1_ .. ! - 3 iS. �' +"s�. ' g as ,, k os ...r ?., F .f ,r in s `5 _ *"� T : a -." s ?.; , , - - Q S.� - '` t ggj �' & 48 F3X f r car 18 � t ` -- D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water . Commonwealth of Massachusetts ❑ �'s SEPTIC & DRAIN 13I Forree st Street n�+ TitleOfficialInspection Form MIDDLETON, MA 01949 (978) 774-5585 -- Subsurface Sewage Disposal System Foun - Not for Voluntary Assessments - 767 .JOHNSON ST., NO. ANDOVER, MA 09845 Property Address .JOSEPH DIFMA owner owners Name --- �� required on is required for NO_ ANDOVER MA 01845 712911;0 every page. citylrown state Zip code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells J, Estimated depth to high ground water: s_, Please indicate all methods used to determine the high ground water elevation: Q4 Obtained from system design plans on record If checked, date of design pian reviewed: 92129/9997 Date Observed site (abutting property/observation hole within 958 feet of SAS) Checked with local hoard 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: TEST PIT DATA ON FILE WITH BoH. TITLE V 20W.dac - 03M Tate 5 Official Insoedian Form: Subsurface Sewate Disonsal Svstem • Pane 15 of 95 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 10/22/99 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X ) by Bill Hall at 767 Johnson Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # 1001 dated 6/1/98. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector TOWN OF NOR(I'H ANDOVER SEWAGE DISPOSAL SYSTEM I-N$T. LLA'rION CERTIFICATION The undersigned herebv certiiv that the Sewage Disposal System ( 'cor.su7.1Ct;; 1 (i() re^aire�: hy- located at. at '7 _L 7 was installed in conformance with the North And ver Board of He ith aoprovec' plan, System Design Pe -relit dated � ® � � wit an arcroved design flow of 330 vailons per day The materials usea were in conformar�e wtri� thas? speci.ved on the approved plan; the system was installed in accordar.ce v ith the provisions of -3 tG CMR- 15.000, Title 5 and local re--ulations, and the final 2radir.g agrees substantially with the approved plan. Ail wort: is accurateiv reoresemed on the As -built which has been submitted to the Board o- Health. Bed inspection Matz: .n�i eer Re:�r��sauve Final inspemcn tate: �n�ar: —eRei r s ::tat: re Installer: Date: [,esigr. Engineer: Date: �(------ ��' err a ati 0�i C Of HEALTIq Q77 II _ 2 4 1998 i a TOWN OF NOR(I'H ANDOVER SEWAGE DISPOSAL SYSTEM I-N$T. LLA'rION CERTIFICATION The undersigned herebv certiiv that the Sewage Disposal System ( 'cor.su7.1Ct;; 1 (i() re^aire�: hy- located at. at '7 _L 7 was installed in conformance with the North And ver Board of He ith aoprovec' plan, System Design Pe -relit dated � ® � � wit an arcroved design flow of 330 vailons per day The materials usea were in conformar�e wtri� thas? speci.ved on the approved plan; the system was installed in accordar.ce v ith the provisions of -3 tG CMR- 15.000, Title 5 and local re--ulations, and the final 2radir.g agrees substantially with the approved plan. Ail wort: is accurateiv reoresemed on the As -built which has been submitted to the Board o- Health. Bed inspection Matz: .n�i eer Re:�r��sauve Final inspemcn tate: �n�ar: —eRei r s ::tat: re Installer: Date: [,esigr. Engineer: Date: �(------ ��' err a ati 0�i C Of HEALTIq Q77 II _ 2 4 1998 NORTH. Of 4��•n ,•�ti0 40 �4• 9SS�CNUSEt Permit NO: Date Issued: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received:` /-3- Gt✓ IMPORTANT: Applicant must complete all items on this page LOCATION D417 Soy .St1'ee t Print / n PROPERTY OWNER U.557,h d 5� q Print MAP NO.:' PARCEL: grvnV AT.T" iTQV "r DITTY i17N!_' ZONING DISTRICT: UNTORIC DISTRICT YES ❑ 1 11 Ji P%I " VVL va'--.---I— TYPE OF IMPROVEMENT -- - --- - PROPOSED USE Residential Non- Residential ❑ New Building AOne family ❑ Addition ❑ Two or more family ❑ Industrial AAlteration No. of units: ❑ Repair, replacement ❑ Assessory Bldg ❑ Commercial ❑ Demolition ❑ Moving (relocation) ❑ Other ❑ Others: G Foundation only DESCRIPTION OF WORK TO BE PREFORMED OWNER: Name: Address: arc Identification Please Type or Print Clearly) Signature / _ i. In CONTRACTOR Name: T'✓c)oh &i/7701 Phone: Address: Supervisor's Construction License: C� 0��� Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Name: Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $10.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost :$ J .1 -at, 00 x10.00=FEE:$ Check No.: Receipt No.: Page I of 4 J Coo I;, rq foist _ r + JYv A:i 7 , / i1 „n•"-��++, t "�^$'yyb � f .._� I { �,.� `�11� Y� 68 �,` `�nq � (((�••��� rs f "4, ! ��„ e � � •.. rt, � ' �. - "� `fes ^�,. � ° \ �.�� p Y Az r. F� S' , r a• _ � q, r �,x . t ✓ a ' ?�, `F f �h. �' �,•, '. " l 'P^ {1; r f 'F k t 3 M.i { Ar i .1 1 i .gyp,. � f' � � ✓ y, � s � � d .Y h 3 „"4 ! ! 1 h .r .t j JI — ! fit. c s ' {' i '4p �# s✓ w > fy �e r g.: rr W si1a%+r,�rBr�'a�S`Y.t Kc, ? S t 041 it a ;� ^ � � r rf S � � {. p � t. r• � _ of y! t a �� % r 4� �C��C� {r � ,�'i dU��i � r m � � � t }, ', ' t � n 7� �' s � < y. •/ + ;, :' "*,� .� Y i y � �' iary � pi M».r*. �'Y`# ?", ? O t ( h i' . r � G. � 1 ' ! ; r ' )� f i L3 +-f � =. i i •c.; .: � g "�'a� `W1' ' c`ka° , ` ,: Awl will �u: r � a � p�tl �,,{rl � „� '�iD $4' �! >r.svaf v+ ".~fiia yr y .•�* "ttr v ��'*�'rF^s i yyMM ' y ;44. 1 -++�a.y i r , r, gyp. Nb4 .p� t�,°*' 'mwwyw,,,. \'4'�,4.ynri„ ~''^ ♦. � �' [ f / # d � a f sly "s x q "M`"'a.'w"N"�'.e.". i. F `�'' tz8 sa 4 -+r-ro ci#"',>4tl y'e'�°SPyrL+,v '3%.�7•q?"a {f `� w�t'� �� 1' .:€ LAW AM 7nuo x r^� 11 y ,° e 4i2^'^ii�ri�j','j"^r.tsss.q?'�R45tv�5 UsLAW s r`- T Irx• �7 r� M 4 x t• � p,� ?,,�di ` # bat -?x, f� TYPE OF SEWARGE DISPOSAL P4.ublic Sewer ❑ Well ❑ Private (septic tank etc R. Tanning/Massage/Body Art ❑ Tobacco Sales ❑ Permanent Dunrpster on Site ❑ Swimming Pools ❑ Food Packaging/Sales ❑ Electric Meter location to project NOTE: Persons contracting with unregister d contractors do not have access to the guaranty fund Signature of Agent/Owner- �- , Signature of Contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED ❑ ❑ ❑ Water Shed Special Permit ❑ Site Plan Special Permit ❑ Other DATE REJECTED DATE APPROVED CONSERVATION ❑ COMMENTS .- x HEALTH COMMENTS IV1 DATE REJECTED DATE APPROVED Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer connection signature & date Temp Dumpster on site yes—no— Fire Department signature/date Building Permit Approved and Issued by: Page 2 of 4 M W C o Z 0 Z 0 E a o Q W 0 O LL I J Ln > r-- x 0 J I V) Q W \ O x O Z > o U c Y c o m D w Z z Q Z uj v i o! O Ln Q _ ; x > 0 v Q c w \ > 2 V) o Q } LL O D c O Q U Z O O c 4-m 3 U 0 c J 0 3 O V CL ro LA ro a`o E W T N z Ln a� un vER r* C V) 0 0 D i •rr J LA to a) MO1 ♦** V1 a (/7 N � O APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT �L!- DATE: /c) � .CURRENT INSTALLER'S LOCATION: o J h 0 �on LICENSED INSTALLER: I SIGNATURE:NA;�Z,TELEPHONE# q 7 —:3 7 j % CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT:: .- Administrative Use Only $75.00 Fee Attached?G� Yes No Foundation As -Built? Yes No Floor Plans? Yes No Approval Date: `i JUN 2 � ry NEW ENGLAND August 20, 1997 North Andover Board of Health Town Hall Annex School Street North Andover, MA 01845 ENGINEERING S E,RA/-I;G,-E S INC ��; � � 4 1991 RE: TITLE V REPORT 767 Johnson Street, North Andover Enclosed is the Title V report for 767 Johnson Street, North Andover, MA. The system failed our inspection. If there are any questions please call me at my office, 686-1768. Yours truly, tAX Be j n C. Osgoo r., E.I.T. P ident 33 WALKER RD. - SUITE 22 - NORTH ANDOVER,. MA 01845 - (508) 686-1768 WILLIA%l F VELD Govcrno: ARGEO PAUL CELLUCCI COMMONWTALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRO'N'MENTAL PROTECTION ONE WINTER STREET. BOSTON. AIA 02108 617-292-5500 Lt. Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / // %� CERTIFICATION Property Address: %�7JS/077 04051O4f S1 IV" '/n&O'��' Address of Owner: Date of Inspection: (If different) Name of Inspector: BENJAMIN C. OSGOOD JR. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SERVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1768 TRUDY COXE Scereur� DAVID B. STRUHS Commissioncr CERTIFICATION STATEMENT I cenify 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 rnspenion. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Condrtronalh Passes _ Needs Further E,aluation By the Local Approving Authority r/Fails /J Inspector's Signature: .�-� —r �C r Date: The Svstem !nspector shallbmit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure cnte:ia as dafined in 310 CKAR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass- section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y. N. or ND). Describe basis of determination in all instances. If -not determined', explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (r -vi --d 0{/7S/97) p-9- 1 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if'(with approval of the Board of Health,. Describe observations: broken pipe(s) are replaced obstruction is removed - distribution box is levelled or replaced The system required pumping more than four 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 replaces obstruction is removed CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reauire further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment: 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMItgES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a suriace water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free'irom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (raviaad 0{/75/97) Paga 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _To A,»Soj S �. %U. i4 44ov e. -L, Owner:�(/f) �O G ON'►1 n'1 Date of Inspection: /G- D) SYSTEM FAILS: You must indicate either "Yes" or "No- as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 ,n cesspool is less than 6" below invert or available volume ,s less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Anv ponion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Am portion of a cesspool or privy is within a Zone I of a public well. Am portion of a cesspool or privy is within 50 feet of a private water supply well. Anv portion of a cesspool or privy is less than lop feet but greater than 50 feet from a private water supply well with no acceptable waterquality analysis. If the well has been analyzed to be acceptable, attach copv of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: ,You must indicate either -Yes** or "ho- as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 01/25/97) 'Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 8 CHECKLIST Property Address: 7477 _:�J it h s%"7 S'/ , ( 4ile°e" Owner: -Co L o •rt o.1 Date of Inspection: a Check if the following have been done: You must indicate either "Yes" or 'No' as to each -of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. — None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note ii they are not available with The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. f — The site was inspected for signs of breakout. V — All system components, excluding the Soil Absorption System, have been located on the site. — — The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected (or condition of barites or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owners were provided with information on the proper maintenance of Sub -Surface Disposal Svstem. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) ate 14 cT1i 0 s Qf_'+ 31 -1- n S re C f F' (� `J 4�j CJ G. a� G/ s �L Qtr :Y, Q ✓(_ E S _D o:'d C, I -"- cc. � S. G� I •i� 'r` S�4 L L.� �,`a�ti (r•vimed 0{/25/97) Page 4 of 10 Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.dJbedroom for S.A.S. Number of bedrooms: Number of current residents:_ Garbage g,.r.der (yes or no):_ Laundry connected to system (yes or no):_ Seasonal use (yes or no):_ Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): Last date of occupancy: i COMMERCI.AUINDUSTRIAL: Type of establishment: Design flow gallons/dav Grease trap present: (yes or nol_ Industrial Waste Holding Tank present: (ves or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available Last date of o:-cupancy: i OTHER: (Describe! Last date of occupancy. GENERAL INFORMATION ' PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped gallons Reason for pumping 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 0{/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron 40 PVC other (explain) Distance from private water supply well or suction hrt Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) I SEPTIC TANK:_ (locate on site plant Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polvethylene _other(explain) If tank is metal, list age _ Is age confirmed by Cenificate of Compliance _ (Yes/No) Dimensions: Sludge depth: 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 battle Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees_ or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (r. i.ud 04/25/97) P.9. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: .Tank must be pumped.prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene other(explain) Dimensions Capacity: gallons Design floes• gallonJda\ � ) Alarm level. Alarm in \vorkmg order _ Yes. _ No Date of previous pumping: Comments: i (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert Comments: (noted level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan). Pumps in working order: (Yes or Not Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/35/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible: excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions:_ overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition_ of vegetation, etc.) CESSPOOLS: _ (locate on site plan) Number and configuration Depth -top of liquid to inlet tnven: Depth,of solids layer: Depth of scum layer: Dimensions of cesspoo!: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) 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.) (revised 04/25/97) Pago 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `? (y"j O Soy` ��, 4we,, — Owner: -QJ(—o W Orl Date of Inspection: g�i� l57 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater // Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check %v!th !o --a! Board of health Check FEMA Maps i Check pumping records Check local excavators, installers Use USGS Data i• Describe in .-our own words how you established the High Groundwater Elevation. (Must be completed) t"- le 1 6,G ' i •� �z t,�o•�. 6�t�G�K„�1. GR/�Dri (r.vi..d 04/25/97) Pag. 10 of 10 rv... 17 O It t a c i t qqr y�� tl►flIg 'l 71 J6rff3K5 ' PUBLIC HEALTH DEPARTMENT Community Development Division To: All North Andover Residents with Sentie Systems and Garbage Grinders 7 Please note that due to recent reviews of Title 5 Reports, your property has been identified as maintaining a working garbage grinder that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage grinders are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this grinder could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdegi@,townofnorthandover.com. Thank you for taking the time to consider the impact that your current setup has on your septic system and'the environment. Sincerely, Susan Y. Sawyer, RENS Public Health Director /pfd Enc: Septic System Information: httD://www.mass.jzov/dep/water/wastewater/dodont.htm 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com NEW ENGLAND ENGINEERING SERVICES i INC September 24, 1999 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 767 Johnson Street Dear Sandra: Enclosed are three copies of the as built plan and certification for 767 Johnson Street in North Andover. Please fill in the design permit number and the date of the design permit on the installation certification form. Also, please forward a copy of the completed form to my office. If you have any questions or need additional information please do not hesitate to contact this office. Sincerely, 4 (f VoBenjamin C. Osgoo, Jr., EIT President ra`uA0 i A ' t ? 41999 60 BEECHWOOD DRIVE — NORTH ANDOVER, MA 01845 — (978) 686-1768 — (888) 359-7645 — FAX (978) 685-1099 WILLIAM J. SCOTT Director Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 30 School Street North Andover, Massachusetts 01845 May 29, 1998 Mr. Ben Osgood, Jr. New England Engineering Services 33 Walker Road, Suite 22 North Andover, MA 01845 Re: 767 Johnson Street Dear Ben: This letter is a confirmation that on May 28, 1998, the North Andover Board of Health granted a variance as follows: a) curtain drain is within 25 feet of the septic system Please call the Board of Health Office if you have any questions. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp cc: William Scott, Director, P&CD File David Solomon, Owner i 0 � DpgOpP��,`L BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NOTE TO FILE: September 2, 1999. RE: 767 Johnson Street At 2:30 PM I left the office and drove to 767 Johnson Street where repair of a septic system is going on. At the site there was a large dump truck in the driveway, backed up to the septic leaching area and it was dripping from the tailgate. Two men were reclining on the grass at the far end of the system. I approached and asked if Bill Hall was around. The looked puzzled and said no. I then asked who was providing the oversight for the repair job. One answered "Oh, that's Nassar Jabour. He'll be back in a few minutes." I told them they would probably be packing it in for the day since Jabour is not licensed to do septic work and nothing can be done on the system unless Bill Hall, the licensed installer, was on site. I waited. In the interim Brian Lagrasse of the NACC came by and I used his phone to call Gayton Osgood to discuss the situation with him. I stated I thought the site should be shut down since the installer wasn't present. He agreed. Nassar Jabour arrived about 3:00 PM and I told him that all work on the system would have to stop because the licensed installer wasn't on site. I informed him that under our regulations and non -criminal disposition, he could be fined up to $500.00. He stated that Bill Hall was on his way. We waited. At 3:40 PM I left the site and drove over to 299 Dale Street, another Bill Hall -Nassar Jabour site, to check if the seepage of effluent between the septic tank and the pump chamber had been taken care of. I returned to 767 Johnson Street at about 3:52. Bill Hall had arrived. I spoke to him about the possible consequences of his actions and told him that the BOH wanted him to appear before them on 9/23. We discussed the fact that the system had to be finished quickly and that he would have to remain on site while work proceeded. I left the site at 4:00 PM, killed some time and drive by again at 4:20 PM. Neither Bill Hall nor the truck he arrived in were in evidence. The rest of the crew appeared to be still on the site. May 20, 1998 Sandra Starr, Administrator North Andover Board of Health 30 School Street North Andover, MA 01845 Re: 767 Johnson Street Dear Sandra: Pursuant to our conversation last Friday I have advertised to the abutters of 767 Johnson Street a public hearing with the Board of Health for May 28, 1998 at 7:30 P.M. in the Town Hall conference room. The specific variance request is outlined in the copy of the notice to the abutters enclosed with this letter. I will be at the meeting to discuss this matter. Yours truly, Benjamin C. Osgood, Jr. 33 WALKER ROAD - SUITE 23 - NORTH ANDOVER, MA 01845- (978) 686--1768 - (888) 359-7645 - FAX (978) 685-1099 F COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION METROPOLITAN BOSTON - NORTHEAST REGIONAL OFFICE ARGEO PAUL CELLUCCI Governor TRUDY COXE Secretary DAVID B. STRUHS Commissioner May 7, 1998 David Solomon 767 Johnson Street North Andover, MA 01845 RE: APPROVAL OF DSP VARIANCE (BRPWP59b) 767 Johnson Street, North Andover (IRV) DEP Transmittal No. P22959 Dear Mr. Solomon: MAY 0 4 1� 21 a The Metropolitan Boston -Northeast Regional Office of the Department of Environmental Protection has received and reviewed your application for approval of a sanitary sewage variance pursuant to 310 CMR 15.412 with the above transmittal number. The application was received on April 7, 1998. The application contained written notification, dated March 2, 1998, stating that the North Andover Board of Health had approved variances to the following provisions of the State Environmental Code: • 310 CMR 15:212,(a), -.as it relates to depth_, to groundwater-;:- 0 roundwater;: • 310 CMR 15..242 (1) as it relates to the -long ;term acceptance rate (LTAR). In addition, the Department has determined that the proposed soil absorption system (SAS) does not meet the required setback from a curtain drain. Since the North Andover Board of Health has apparently not granted this under local upgrade approval, the Department has included it as a variance request under consideration. Accompanying the application was a plan consisting of one (1) sheet titled as follows: Title: Plan Showing Subsurface Sewage Disposal System Location: 767 Johnson Street Municipality: North Andover Applicant: David Solomon Designer: Richard C. Tangard, P.E. No. 13021 Date (Revised) : 'February 4, 1998 (March 25, 1998) An engineer of the Department reviewed the plans and the accompanying data, and it is the opinion of the Department that the plans are in compliance except for: • 310 CMR 15.212 (a) as it relates to the depth of groundwater [Three (3) feet of separation of the SAS from the estimated high groundwater is being permitted, where four (4) feet of separation is required]; • 310 CMR 15.242 (1) as it relates to the calculation of the LTAR [A 25% reduction of the proposed SAS because of site constraints is proposed] ; and • 310 CMR 15.211 (1), as it relates to the required separation of at least 50 feet between the SAS and a curtain drain [Site constraints permit only an 18 foot separation.). As part of its approval, the Department will require that the following conditions be complied with or this approval shall be rendered null and void: • Because of limited area and soil conditions of the property in which the SAS will be constructed, the Department requires that the proposed septic tank 205a Lowell St • Wilmington, Massachusetts 01887 0 FAX (978) 661-7615 0 Telephone (978) 661-7600 0 TDD if (978) 661-7679 ` be constructed as a modified tight tank, as described in 310 CMR 15.261, Title 5 of the State Environmental Code. A manual shutoff valve shall be constructed between the septic tank and the distribution box. • The North Andover Board of Health must be notified, within 24 hours, of any component or system failure. At this time, the shutoff valve shall be utilized and the septic shall be converted to a tight tank. The North Andover Board of Health will then decide what further action may be required. • Approval of the proposed system also is conditioned upon the recording in the appropriate registry of deeds of a notice that discloses the existence of this alternate system and the involvement of the Department in the approval of the sewage disposal system. • Approval of the variance for the reduced setback between the curtain drain and the SAS must be obtained from the North Andover Board of Health. • Prior to construction, the applicant must obtain a Disposal System Construction Permit (DSCP) from the North Andover Board of Health. • The system is.not designed to accommodate a garbage disposal. As such, one should not be neither installed nor used at this dwelling. • It is the applicant's responsibility to assure that the approved plans are available at the site during construction. It is the opinion of the Department that the requirements for the granting of the variances as specified at 310 CMR 15.412 have been satisfied. The enforcement of the provisions of the Code from which a variance is being sought would do manifest injustice and the applicant has proved to the Department's satisfaction that the same degree of environmental protection required under Title 5 can be achieved without strict application of the subject provision. The following paragraph outlines the Department's findings relative to manifest injustice and equal environmental protection as they relate to the variances, those granted by the North Andover Board of Health, which the Department hereby approves. The site, limited by size and soil conditions, has a high level of groundwater which requires the use of a curtain drain to intercept and redirect seasonal high groundwater. In addition, there is severe slope conditions from the property lines. The State Environmental Code allows the granting of a variance for less than the required four foot separation of the bottom of the SAS and the estimated high groundwater. The Code also allows the setback requirement of the curtain drain and SAS be decreased. The plan also depicts the high slopes of the property, from the property line to the proposed SAS, and that these slopes are in excess of 25 to 30 percent. The area from the property line to the proposed SAS was judged as unusable and that a decrease of 25% in the required area of the SAS was necessary. Based on this information, the Department has concluded that to deny these variances would be manifestly unjust and that the applicant has provided equal environmental protection. If you have any questions or additional information is required, please contact George A. Kretas at (978) 661-7744. Sincerely, Madelyn Morris Deputy Regional Director Bureau of Resource Protection mm/gak CC: - Board of Health, 30 School Street, North Andover, MA 01845 - Benjamin C. Osgood, Jr., New England Engineering Services, Inc., 33 Walker Road, Suite 23, North Andover, MA 01845 'MAY 14191 NEW ENGLAND ENGINEERING SERVICES INC April 10, 1998 Sandra Starr, Health administrator North Andover Board of Health 30 School Street North Andover, MA 01845 Dear Sandra: APP g Enclosed are copies of all of the information that was sent to the department of environmental protection regarding the request for a variance at 767 Johnson Street. This information is being sent to you for your file. If you have any questions please do not hesitate to contact this office. Sincerely, S,7 Benjamin C. Osgood, Jr., EIT president 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 Town of North Andover oHORTH OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES ° 30 School Street : �o North Andover, Massachusetts 01845 �,9 °°q. •� WILLIAM J. SCOTT SSACHuse Director March 2, 1998 New England Engineering, Services, Inc. 33 Walker Road, Suite 22 North Andover, MA 01845 RE: 767 Johnson Street, North Andover Dear Mr. Osgood: This letter is to confirm that the North Andover Board of Health at their regularly scheduled meeting on February 26, 1998 granted two variances for the proposed septic repair at the property at 767 Johnson Street. These two variances allow the decrease in separation between the bottom of the septic system and the water table of four feet to three feet, and a reduction of 25% in the size of the leaching area. The applicable Title 5 references are 310 CMR 15.212(a) and 310 CMR 15.242(1), respectively. If you have any questions, or need any other assistance, please do not hesitate to call the Health Department. Sincerely, 9 Sandra Starr, RS. Health Administrator Cc: David Solomon William Scott, Dir. CD&S File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 s NEW ENGLAND ENGINEERING SERVICES IMN North Andover Board of health 30 School Street North Andover, MA 01845 Re: 767 Johnson Street variances request Dear Mr. Chairman: Please accept this letter as a formal request for a variance to the provisions of the state sanitary code Title 5. The request is being made for a proposed design for a repair at 767 Johnson Street. The variances being requested are as follows: 1. Reduction in the required minimum vertical separation distance between the bottom of the stone underlying the soil absorption system and the water table from the required four feet to three feet. This is a variance of Title 5 section 15.212(a). 2. Reduction of the required soil absorption system area that will result in a higher than allowed effluent loading rate. The required effluent loading rate is 0.15 gallons per square foot per day. The requested effluent loading rate is 0.2 gallons per square foot per day. This results in a soil absorption system that is reduced in size by 25%. This is a variance to Title 5 section 15.242(1). These requests were previously made in a letter dated February 4, 1998. This office is notifying the abutters of a hearing for these requests on February 26, 1998 at 7:00 P.M. in the Town Hall library meeting room. If you have any questions please do not hesitate to contact this office. Yours truly, 6� Benjamin C. Osgood, Jr., EIT 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 NEW ENGLAND ENGINEERING SERVICES ter« Joseph and Mary Ellen Kennedy 777 Johnson Street North Andover, MA 01845 Re: Abutters notice for 767 Johnson Street variances request Dear Joseph and ,Marry Ellen Kennedy: Please accept this letter as a formal notification of a public hearing regarding the request of Lisa and David Solomon for variances to the provision of the state sanitary code Title 5. The request is being made for a proposed design for a septic system repair at 767 Johnson Street. The variances being requested are as follows: 1. Reduction in the required minimum vertical separation distance between the bottom of the stone underlying the soil absorption system and the water table from the required four feet to three feet. This is a variance of 310 CMR 15.212(a). 2. Reduction of the required soil absorption system area that will result in a higher than allowed effluent loading rate. The required effluent loading rate is 0.15 gallons per square foot per day. The requested effluent loading rate is 0.2 gallons per square foot per day. This results in a soil absorption system that is reduced in size by 25%. This is a variance to 310 CMR 15.242(1). There will be a public hearing to discuss these requests at a meeting of the North Andover Board of health on February 26, 1998 at 7:00 P.M. in the Town Hall library meeting room. The applicant shall demonstrate to the Board that: A) that enforcement of the provisions of 310 CMR 15.00 from which a variance is sought would be manifestly unjust, considering all the relevant facts and circumstances of the individual case; and B) a level of environmental protection at least equivalent to that provided under 310 CMR 15.00 can be achieved without strict application of the provisions of 310 CMR 15.00 from which a variance is sought. If you have any�questions please do not hesitate to contact this office. Yours truly, '6 e, 0 Benjathin C. Osgooc'f, Jr., EIT 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 NEW ENGLAND ENGINEERING SERVICES MW 91 Greater Lawrence community antenna Inc. C/O Media One 180 Greenleaf Ave. Portsmouth, NH 03801 Re: Abutters notice for 767 Johnson Street variances request Dear Sirs: Please accept this letter as a formal notification of a public hearing regarding the request of Lisa and David Solomon for variances to the provision of the state sanitary code Title 5. The request is being made for a proposed design for a septic system repair at 767 Johnson Street. The variances being requested are as follows: 1. Reduction in the required minimum vertical separation distance between the bottom of the stone underlying the soil absorption system and the water table from the required four feet to three feet. This is a variance of 310 CMR 15.212(a). 2. Reduction of the required soil absorption system area that will result in a higher than allowed effluent loading rate. The required effluent loading rate is 0.15 gallons per square foot per day. The requested effluent loading rate is 0.2 gallons per square foot per day. This results in a soil absorption system that is reduced in size by 25%. This is a variance to 310 CMR 15.242(1). There will be a public hearing to discuss these requests at a meeting of the North Andover Board of health on February 26, 1998 at 7:00 P.M. in the Town Hall library meeting room. The applicant shall demonstrate to the Board that: A) that enforcement of the provisions of 310 CMR 15.00 from which a variance is sought would be manifestly unjust, considering all the relevant facts and circumstances of the individual case; and B) a level of environmental protection at least equivalent to that provided under 310 CMR 15.00 can be achieved without strict application of the provisions of 310 CMR 15.00 from which a variance is sought. If you have any questions please do not hesitate to contact this office. Yours truly, ,6 o Benj7min C. Osgood, Jr., EIT 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 NEW ENGLAND ENGINEERING SERVICES INC Veronica Mandry 219 Summer Street North Andover, MA 01845 Re: Abutters notice for 767 Johnson Street variances request Dear Veronica Mandry: Please accept this letter as a formal notification of a public hearing regarding the request of Lisa and David Solomon for variances to the provision of the state sanitary code Title 5. The request is being made fora proposed design for a septic system repair at 767 Johnson Street. The variances being requested are as follows: 1. Reduction in the required minimum vertical separation distance between the bottom of the stone underlying the soil absorption system and the water table from the required four feet to three feet. This is a variance of 310 CMR 15.212(a). 2. Reduction of the required soil absorption system area that will result in a higher than allowed effluent loading rate. The required effluent loading rate is 0.15 gallons per square foot per day. The requested effluent loading rate is 0.2 gallons per square foot per day. This results in a soil absorption system that is reduced in size by 25%. This is a variance to 310 CMR 15.242(1). There will be a public hearing to discuss these requests at a meeting of the North Andover Board of health on February 26, 1998 at 7:00 P.M. in the Town Hall library meeting room. The applicant shall demonstrate to the Board that: A) that enforcement of the provisions of 310 CMR 15.00 from which a variance is sought would be manifestly unjust, considering all the relevant facts and circumstances of the individual case; and B) a level of environmental protection at least equivalent to that provided under 310 CMR 15.00 can be achieved without strict application of the provisions of 310 CMR 15.00 from which a variance is sought. If you have any questions please do not hesitate to contact this office. Yours truly, Benjin C. Osgo2d, Jr., E I T 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 NEW ENGLAND ENGINEERING SERVICES INC March 31, 1998 Massachusetts Department of Environmental Protection Water Pollution Control 10 Commerce Way Woburn, MA 01801 Dear Sirs: Enclosed with this letter is an application for an approval of a local variance to Title 5. The property in question is located at 767 Johnson Street, North Andover, MA. A complete application is enclosed outlining the two variances being requested. In short DEP is being asked to allow a groundwater offset variance combined with a size reduction variance. Each of the requests is allowed singly as a local upgrade approval, however the combination of the two requires that DEP approve the local variance. The reason for the request is that the site is not large enough to accommodate the proper size system with the proper groundwater offset. It should be noted when looking at the plans that the large area behind the house slopes upward to the property line with slopes in excess of 25 to 30 percent, thus precluding this area as being usable for a subsurface disposal system. If any additional information is needed please do not hesitate to contact this office. Yours truly, o Benjamin C. Osgood, Jr., EIT President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 Massachusetts Department of Environmental Protection For DEP Use Only. 22295q. Permit No Transmittal Transmittal Form for Permit Received Date if Reviewer Permit. ❑Denied t Application and Payment Decision Date Facility ID (if known) ' Application Information Instructions Permit,, Approval or other Category (seven character code from the first page of the directions on How to Apply). Examples: BWPADOI, BRPWP01, etc. 1. Please type or SZF- P 11 F_ ro V 0 print. Use a Category Name . separate��� Transmittal Form Brief Project Description for each permit application. Applicant or Legally Responsible Official 2. This form has been revised and is no longer a three-part color - coded form. Therefore, please make three copies of this form: copy 1 must accompany permit application copy 2 must accompany payment copy 3 retain for your records. 3. Make check payable to Commonwealth of Massachusetts. Please mail check and a copy of this Transmittal Form to: Department of Environmental Protection, P.O. Box 4062, Boston, MA, 02211. 4. Both fee - exempt and non- exempt applicants must mail a copy of the Transmittal Form to: Department of Environmental Protection, P.O. Box 4062, Boston, MA, 02211. Last Name First Name Middle Initial Address ..---M'O918)b��" �`� 2 ext`F--.---__ _..... ... a ..........._- . CWTown State Zip Code Telephone Number (including area code and extension) Contact Facility, Site or Individual Requiring Approval Namee rfFacility, Site or Individual Address �-�q_'-i-S (9 Zb) 6 E� Sq9 ext• -- — Cily/Town State Zip Code Telephone Number (including area code and extension) ' Application Prepared By (if different from section B) CL rr i n Last Name First Name Middle Initial Address /ti _ Av /Vl R—._ © t s yS (4z6) 86 ! c6 8 ext. CiVTown State Zip Code Telephone Number (including area code and extension) Contact LSP Number (for 21E only) Other Related Permits: if you are applying for other permits related to this application, please list them below. Amount Due Special Provisions: ❑ Fee Exempt" (city, town, district, or municipal housing authority) (state agency if permit fee is $100 or less) ❑ Hardship Request (payment extension according to 310 CMR 4.04(3)(c) ❑ Alternative Schedule Project Request (according to 310 CMR 4.05 and 4.10) There are no fee exemptions for 21E sites, regardless of the applicant's status. ff Check No.- �'1 �3 __........_ Dollar Amount $ -- _. 2 Dc) ' ----- _ Date _3_1--�—' -- --- Make check payable to Commonwealth of Massachusetts. Please mail check and one copy of Transmittal Form to: Department of Environmental Protection, P.O. Box 4062, Boston, MA, 02211 Rev 6/97 Massachusetts Department of Environmental Protection Transmittal /Ig Bureau of Resource Protection - Water Pollution Control Facility ID Cf known) I Title 5 Permit Application BRP WP 59b DEP Approval of Local Variance BRP WP 59c DEP Issuance of Variance PtanIE'Requirements ication is to be filed by.persons required to obtain approval for the categories above in accordance with 310 CMR 15.000: The State Environmental Code Title 5: for the Siting, Construction, Inspection, Upgrade and Expansion of On-site Sewage Treatment and Disposal Systems and for the Transport and Disposal of Septage. DEP approval is subject to fees established under Massachusetts General Laws, Chapter 21A, Section 18 and regulated under 310'CMR 4.00 Timely Action Schedule and Fee Provisions. A. Applicant Information 1. Which permit category are you applying for? V BRP WP 59b DEP Approval of Local Variance ❑ BRP WP 59c DEP Issuance of Variance 2. Applicant: Name Z (0�1 o so Sf t�e"t' Address JUS r�Lt 14 - A Qc t CityrFown State Zip q7'8 - (o8`I' 8q 8 Telephone 3. Facility Address/Location: AAddArPcs _/ v rT D.121L /Vt P4 O L �- City/Town State Zip 4. Design Engineer or Sanitarian: C. Name Z. 3 Address City/Town State Zip 47IAP —6, AC, - !'7 f, S — Telephone nnn aim cn�, cn_ e.... 7l71lOC i of 3 Massachusetts Department of Environmental Protection Transmittal #P2.2V Bureau of Resource Protection - Water Pollution Control Facility M (if known) S. Registration: nn --- P.E. Sanitarian I3 �a1 Registration Number 6. Does this project require a filing under 301 CMR 10. 00, The Massachusetts Environmental Policy Act? ❑ Yes A No If yes, has final action been taken? ❑ Yes ❑ No Date 7 The legal entity which will own this facility is: P Individual ❑ Municipality ❑ Private Partnership ❑ Federal ❑ State/County ❑ Corporation ❑ Other (Specify) 8. 71vo complete sets of plans and specifications, including a locus map, properly stamped and signed by a Massachusetts Registered Professional Engineer or Massachusetts Registered Sanitarian must accompany the application. Are plans and specifications enclosed? 0 Yes ❑ No Have the plans been revised? J ' (� A Yes ❑ No Q)4ni c: 'f&.ctoj' arC P e-��G✓lS 9. Variance(s) from the following Title 5 provision(s) is/are being sought: 1. Reduction in the required minimum vertical separation distance between the bottom of the stone underlying the soil absorption system and the water table from the required four feet to three feet. This is a variance of Title 5 section 15.212(a). -� 2. Reduction of the required soil absorption system area that will result in a higher than allowed effluent loading rate. The required effluent loading rate is ---- 0.15 gallons per square foot per day. The requested effluent loading rate is 0.2 gallons per square foot per day. This results in a soil absorption system that is -- reduced in size by 25%. This is a variance to Title 5 section 15.242(1). -- . 2of3 Massachusetts Department of Environmental Protection Transmittal # Bureau of Resource Protection - Water Pollution Control Facility ID (if known) 10. Ifapplying for a local variance approval (BRP WP 59b), the letter issued by the local approving authority having jurisdiction over the site granting the subject variance must accompany this application. Is the approval letter attached? ¢� Yes ❑ No 11. If applying for a local varix .ce approval (BRP WP 59b) which requires notificarion of the abutter to thhee subject property, a copy of the certified notification sent to the abutters must accompany this application. Is proof of notification attached? Yes ❑ No 12. In accordance with 310 CMR 15.410, the applicant must prove that the strict enforcement of the provision of the code for which the variance is being sought would do manifest injustice and that the same degree of environmental protection required under the code can be achieved without strict application of the particular provision. Is documentation is support of meeting this requirement attached? q Yes ❑ No 13. Is the variance requested for new construction? ❑ Yes � No 14. Is the complete application submitted to the local authority attached? 'Ayes 0 N B. Certification "I certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, a_re true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing vinlations." J PP1Zcan.ts sig re Print name LY rI CX m, C Q &qq o U� 2 Name of Preparer Date BRP WP 59b. 59c.App 3/31/95 3 of 3 s3-7oeei2113 2'4 $ 3 NEW. ENGLAND ENGINEERING SERVICES, INC. 887807675 33WAIJCER RD S. -23 PH. 978-686-1768 3 q NORTH "ANDOVER,' MA 01845 DATE q .. PAY TO THE 1�Y11a� �tJCu 11V� S ORDEROF S •�'"�'� J rcX Y't DOLLARS 8 IPSWICH SAVINGS BANK WSMCK MASSACHUSEM 019M MEMO c O -X 2 L "?058?1: 88780767 Sill 24 3 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 30 School Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director March 2, 1998 New England Engineering, Services, Inc. 33 Walker Road, Suite 22 North Andover, MA 01845 RE: 767 Johnson Street, North Andover Dear Mr. Osgood: This letter is to confirm that the North Andover Board of Health at their regularly scheduled meeting on February 26, 1998 granted two variances for the proposed septic repair at the property at 767 Johnson Street. These two variances allow the decrease in separation between the bottom of the septic system and the water table of four feet to three feet, and a reduction of 25% in the size of the leaching area. The applicable Title 5 references are 310 CMR 15.212(a) and 310 CMR 15.242(1), respectively. If you have any questions, or need any other assistance, please do not hesitate to call the Health Department. Sincerely, Sandra Starr, R.S. Health Administrator Cc: David Solomon William Scott, Dir. CD&S File ,to , o a BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NEW ENGLAND ENGINEERING SERVICES INC North Andover Board of health 30 School Street North Andover, MA 01845 Re: 767 Johnson Street variances request FEB 181998 Dear Mr. Chairman: Please accept this letter as a formal request for a variance to the provisions of the state sanitary code Title 5. The request is being made for a proposed design for a repair at 767 Johnson Street. The variances being requested are as follows: 1. Reduction in the required minimum vertical separation distance between the bottom of the stone underlying the soil absorption system and the water table :from`the required four feet to three feet. This is a variance of Title 5 section 15.212(a). 2. Reduction of the required soil absorption system area that will result in a higher than allowed effluent loading rate. The required effluent loading rate is 0.15 gallons per square foot per. day. The requested effluent loading rate is 0.2 gallons per square foot per day. This results in a soil absorption system that is reduced in size by 25%. This is a variance to Title 5 section 15.242(1). These requests were previously made in a letter dated February 4, 1998. This office is notifying the abutters of a hearing for these requests on February 26, 1998 at 7:00 P.M. in the Town Hall library meeting room. If you have any questions please do not hesitate to contact this office. Yours truly, 6. Benjamint C: Osgood, Jr.,'EIT 33 WALKER RD. - SUITE 22 - NORTH ANDOVER,. MA 01845 - (508) 686-1768 NEW ENGLAND ENGINEERING SERVICES INC February 4, 1998 Sandra Starr, Health Administrator North Andover Board of Health 30 School Street North Andover, MA 01845 Re: 767 Johnson Street Dear Sandra: This letter is a response to your letter dated January 30, 1998 regarding the septic system design at 767 Johnson Street in North Andover. The plan has been revised and each of your comments addressed as follows. 1. If an additional deep hole is needed I would like to schedule a time to do this as soon as possible. We should be able to go out on a warm day this month. If you will not go this month I would ask that the plan be approved conditionally pending the excavation of an additional deep hole. 2. The revised plans are stamped. 3. Side lot lines are shown. 4. The site evaluation forms are included with this letter. 5. The first 2' level note is included under the D -Box detail. It has also been added to the profile. 6. Assessor's map and parcel number have been added. 7. The perc elevation has been added_ . 8. The north arrow has been moved and corrected. 9. This design is less than 4' to groundwater. A local upgrade approval is needed for this design. A note to that effect was included on the plans. 10. The number of bedrooms is specified in the design calculations. The number of bedrooms has been added to the plan view of the existing house. 11. The breakout elevation given on the plan was for the low side of the system. The elevation has been changed to reflect the breakout elevation on the high side. 12. The calculations are not incorrect. The bed has been reduced in size by 25% of the required area. This was, and still is, noted on the plans as a local upgrade approval. 13. A local bylaw variance is being requested for the use of an alternative to a concrete wall in order to vary the required slope. This has been noted on the plans. 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 PAGE 2 Since each of the items has been corrected I am requesting that the local upgrades and the local variance be discussed at the next Board of Health meeting. You should be aware that the combination of the two local upgrade approvals will need a variance issued from DEP since it is noted under the local upgrade section of Title 5 that each can not be granted in conjunction with the other. This office will prepare a legal notice to be sent to the abutters to advertise this hearing. Please inform this office of the hearing date at least two weeks prior to the hearing. If you have any questions I can be reached at 978-686-1768. Yours truly, 1157 C Benjamin C. Osgood, Jr., EIT c.c.: David Solomon William Scott WILLIAM J. SCOTT Director Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 30 School Street North Andover, Massachusetts 01845 January 30, 1998 New England Engineering Services, Inc. 33 Walker Rd., Suite 23 North Andover, MA 01845 Re: 767 Johnson St. Dear Mr. Osgood: This is to inform you that the above referenced plans have been disapproved for the following reasons: 1. Additional deep hole required at driveway end of system to check GW and ledge before approval. 2. Plans not stamped (3 10 CMR 15.220(2)). 3. Side lot lines'must be shown. 4. Site evaluation forms missing. (3 10 CMR 15.018(2)). 5. First 2' after D -Box to laid level -note missing from profile. 6. Assessor's map and parcel missing (N.A.8.02a). 7. No perc evelations (N.A.8.02n). 8. North arrow needs to relate better to site plan 9. Less than 4' to ground water (310CMR 15.212(a)). 10. Number of bedrooms is not specified (N.A. 8.021). 11. Breakout elevation is somewhat higher than 99.00 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Disapproval letter 767 Johnson St. January 30, 1998 Page 2 12. Calculations incorrect - leaching for only 252 gallons per day provided (310CMR 15.203(2)). 13. Breakout not met and slope greater than 3.1. Barrier for breakout not concrete (310CMR 15.255(2) (N.A.9.02). Please do not hesitate to call the number below if you have any questions. Sincerely, Sandra Starr, Health Administrator rel c.c.: David Solomon William Scott File NEW ENGLAND ENGINEERING SERVICES H« Greater Lawrence community antenna Inc. C/O Media One 180 Greenleaf Ave. Portsmouth, NH 03801 Re: Abutters notice for 767 Johnson Street variances request Dear Sirs: Please accept this letter as a formal notification of a public hearing regarding the request of Lisa and David Solomon for variances to the provision of the state sanitary code Title 5. The request is being made for a proposed design for a septic system repair at 767 Johnson Street. The variances being requested are as follows: 1. Reduction in the required minimum vertical separation distance between the bottom of the stone underlying the soil absorption system and the water table from the required four feet to three feet. This is a variance of 310 CMR 15.212(a). 2. Reduction of the required soil absorption system area that will result in a higher than allowed effluent loading rate. The required effluent loading rate is 0.15 gallons per square foot per day. The requested effluent loading rate is 0.2 gallons per square foot per day. This results in a soil absorption system that is reduced in size by 25%. This is a variance to 310 CMR 15.242(1). There will be a public hearing to discuss these requests at a meeting of the North Andover Board of health on February 26, 1998 at 7:00 P.M. in the Town Hall library meeting room. The applicant shall demonstrate to the Board that: A) that enforcement of the provisions of 310 CMR 15.00 from which a variance is sought would be manifestly unjust, considering all the relevant facts and circumstances of the individual case; and B) a level of environmental protection at least equivalent to that provided under 310 CMR 15.00 can be achieved without strict application of the provisions of 310 CMR 15.00 from which a variance is sought. If you have any questions please do not hesitate to contact this office. Yours truly, !!fi�n ,6 Ben�min C. Os?od, Jr., EIT 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 PUBLIC NOTICE Please accept this letter as a notification of a public hearing regarding the request of Lisa:and David Solomon for a variance of the provisions of Title 5, the state sanitary code. The request is being made for a proposed design of a septic system at 767 Johnson Street, North Andover, MA 01845. The request is as follows: 1. 310 CMR 15.211(1) Reduction in the setback distance from a leach facility to a curtain drain from the required 50 feet to a distance of 18 feet. There will be a public hearing to discuss this request at a meeting of the North Andover Board of Health on May 28, 1998 at 7:30 P.M. in the Town Hall conference room. The applicant shall demonstrate to the Board that: 1. The enforcement of the provisions of 310 CMR 15.00 from which a variance is sought would be manifestly unjust, considering all the relevant facts and circumstances of the individual case; and 2. A level of environmental protection at least equivalent to that provided under 310 CMR 15.00 can be achieved without strict application of the provisions from which a variance is.sought. If you have any questions please do not hesitate to contact this office. Benjamin C. Osgood, Jr., EIT President ru / q 72. « e 4) cd . m L) R@"tj S, \o q \C ~/ \U .\ e 96ewd¥008 »qs � w 2 2 j t {�00 rLI u 2 / %/7 0 -D4 o' _ L _ _ /0 / ' C A— $ uff O%b.,�®$ (D k & a®J k %$ Z)IX ru / q 72. « e 4) cd . m L) R@"tj S, \o q \C ~/ \U .\ e 96ewd¥008 »qs M j ni Cc �3 2 / %/7 0 -D4 o' _ L _ _ /0 / 1-2§ C A— $ uff k G 7'� a. 7 0 ?� ru / q 72. « e 4) cd . m L) R@"tj S, \o q \C ~/ \U .\ e 96ewd¥008 »qs NORTH ANDOVER BOARD OF HEALTH l DESIGN REVIEW REPORT DATE FEE: 10� PERMIT # 1/061 DATE RECEIVED bt q l Cl 7 APPLICANT -D}�U/1h 5666M-04)MAPPARCEL ADDRESS J �lD 7 OffA)5p Aa 5j, LOT # STREET # 7wl % ENG. Q S666b, 3e STREET o14 Aj,5o ENGINEER'S ADD.63 PLAN DATE 11 /% /9 % REV. DATE CONDITIONS OF APPROVAL ... a".219] DISAPPROVED REASONS FOR DISAPPROVAL: %g T S Y5 TE/"� TI C' /�� G /c G' Gv yy e m,e is, AaO(q)' LD T /!(JES /v1 Usk �acvrt> , l C Vlg l- U/� T/�/c-) �D.�./�15 /'tel / 5 S /� G • �31 v C� � /IJ�TC /moi E� d� e6 r �FvS 71fi� 7-6- C GU/J,D 6up""e /D 4C Mf - 9. NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT - CONTINUED Page /Z, of 7(9 7 Joh��l5det� IL)u M B c le 40- �uT 13.. -3,c-A timc, d6; -bAvlb s6LOMO" PLAN REVIEW CHECKLIST ADDRESS 7cla % ENGINEERG//�,�E',�J/Cl� GENERAL 3 COPIESy STAMP/ LOCUS NORTH ARROW SCALE`S CONTOURS �- PROFILE �Sc) SECTIONI---' BENCHMARK SOIL & PERCS ELEVATIONS WETS. DISCLAIMER �✓ WELLS & WETS v WATERSHED?I#Z) DRIVEWAY! WATER LINE `- FDN DRAIN M&Pz SCH40 TESTS CURRENT? t✓ SOIL EVAL SEPTIC TANK MIN 1500G ✓ .17 INVERT DROP(Z GARB. GRINDERA/0 (2 comps +200) 10' TO FDN t✓ MANHOLE `� ELEV GW ## COMPS. I GB D -BOX SIZE ## LINES FIRST 2' LEVEL STATEMENT INLET , /L9, - OUTLET q8-15' _ ( 2" OR .17 FT) TEE REQ' D?/t/O LEACHING MIN 440 GPD?A/- RESERVE AREA 4' FROM PRIMARY? 20 SLOPE 100' TO WETLANDS -- 100' TO WELLS `' 4' TO S.H.GWz (5'>2M/IN) 20' TO FND & INTRCPTR DRAINS 1--' 400' TO SURFACE H2O SUPP --' 4' PERM. SOIL BELOW FACILITY? MIN 12" COVER BREAKOUT MET? -,,,Y' TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/100') W OR D (MIN 6') RESERVE BETWEEN TRENCHES? BE 10' MIN. 4" PEA STONE? VENT? BOT + SIDE (L x W x ##) Copyright 9 1996 by S.L. Starr (DXLx2x## ) FILL?-- (15') SIDEWALL DIST. 3X EFF. IN FILL? MUST (>3' COVER; LINES >501) X LDNG = TOT (G/ft2) PITS MIN 440 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 440 GPD` 900 ft2 BED ✓ GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4" PEA STONE? � DIST LINE SLOPE .005? �-- >3'COVER-VENT SCH 40 MIN 12" COVER �- RATEIoO /''1 ---r1 (�`'= R P. ) X -s = TOTAL -C L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY qpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. l' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ENUF STORAGE? Copyright © 1996 by S.L. Starr I SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES $60.00/Plan--F REVISED PLANS: YES $25.00/Plan DATE: i z/ k7 DESIGNENGINEER: 1111 --gin; When the submission is all in place, route to the Health Secretary meq/ -:2-7 SEPTIC PLAN SUBMITTALS LOCATION:, '-767 ` ti r� S -74 - NEW PLANS: YES $60.00/Plan REVISED PLANS YES $25.00/Plan DATE: DESIGN ENGINEER: 7, When the submission is all in place, route to the Health Secretary .. +.+.nr�•+..�Y ter.. - .. � _.... . . .... ....-.. v ... .. . Town of North Andover, Massachusetts Form No. 2 q NORr„ BOARD OF HEALTH w 9 ' -• DESIGN APPROVAL FOR �Ss�cHusEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM i Applicant_�U/ D. �o�d M Test No: Site Location 767 J-0AWs0.t% Reference Plans and Specs.3�A OS5600b i' ENGINEER DESIGN DATE i Permission •is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD OF HEALTH Fee-1*6 Site System Permit No. /U0/ Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH 19 APPLICATION FOR SITE TESTING/INSPECTION Applicant 9 w_ ( Ne iN ME ADDRESS TELEPHONE Site Location � ( b Engineer °..14'f1r1 (. 5Q11r NAME Test/Inspection Date and Time r/ Fee 1, CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. BOARD OF HEALTH 146 MAIN STREET TEL. 688-9 540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: LOCATI N F SOIL TESTS: 1&7 ZY6kv, ,- +Iv Assessor's map & parcel number: OWNER: halo mon TEL. NO.: ADDRESS: Ne -C.- � s ;1 e o r.: q� �:�•z�� Tit. ENGINEER:_ 4y, Ossa©0 ::T� / TEL. NO.: CERTIFIED SOIL EVALUATOR: c T"' i A s�o� cJ f'�. Intended use of Land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. FS 2 DATE: / b -- 7 — LOCATION: -2 ENGINEER: - BOH WITNESS: 11 PERCOLATION TEST # BOTTOM DEPTH OF PERC TEST: v1 L TIME OF SOAK: TIME AT 12" TIME 9" TIME AT 6" OVERNIGHT SOAK TIME STARTED 7 NEXT DAY SOAK: -O L4 ^ 6) < < I TIME AT 12" 5?.- 1 7 TIME AT 9" j TIME AT 6" r (At least 15 minutes long) r -o --2 - � 7 (At least 15 minutes) f l� DATE:a- LOCATION: C� U ENGINEER: G��Crvt BOH WITNESS: v PERCOLATION TEST, # BOTTOM DEPTH OF PERC TEST: TIME OF SOAK: _/, �� / C`� ` ��� (At least 15 minutes long) TIME AT 12" / U i TIME AT 9",wti - (. TIME AT 6"""� OVERNIGHT SOAK TIME STARTED a- I O NEXT DAY SOAK: A t o,& ' C �� (At least 15 minutes) -0 s TIME AT 12" TIME AT 9" TIME AT 6" FORM 11 - SOIL EVALUATOR FORM: Page I of 3 No. 4� Date: Commonwealth of Massachusetts , Massachusetts o, A mrinclov"O"t fAr On-.Idte Sewaze-&ismo—sal —':Z�6- Date: Performed BY: ; . Z-->/ .. ..................... ................. ...................... -'5- -' ..... .................. ................................ I ... . . Witnessed BY: --- - - ---- 0.4 . ...... ie ......... 7�?� .... � -::,7-Owner's Nam. LA=flon Address., 767 -V/V 1, Address, and .41-4 V 009;�' 1,74 Tekpbom I -7(a--7 I /Vv. ew Construction epair .office RevieW Published Soil Survey Available: No ❑ Yes Year Published ........ Publication Scale Soil Map Unit . ........ .. ........... ... .. ...... Drainage Class,��e- Soil Limitations ..... . ........ Surficial Geologic Report Available: No [N Yes M Year Published Publication Scale GeologicMaterial (Map Unit) ............................................................ ... ............................................ .. ..... ........ Landform. ...................................................... ....................... .... ... .... ....... .............. .. Flood Insurance Rate Map: Above 500 year flood boundary No 0Yes Within 500 year flood boundary No RYes ❑ Within 100 year flood boundary No DYes R Wetland Area: National Wetland Inventory Map (map unit) ...... .................. . ... .... .. .... ...... ..... ......... . ...... Wetlands Conservancy Program Map (map unit) .................. .......................................................... . ............... Current Water Resource Conditions (USGS): Month 0c7rz6�9� Range :Above Normal EINormal ElBelcw Normal Other References Reviewed: WDEP APPROVED FORM - 12107195 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 t Location Address or Lot No. On-site Review ,y� t"��iC Deep Hole Number Z Date�iime�iO�a�, Weather%�' Location (identify on site plan) Z/v-lpe �/Qi :::..gL7 _..:....:.. Land Use.���-�//`��.(D�''9L Slope (%1 .:..2. Surface Stones Vegetation.. <61— �$. ::......:::.::.. .....::..::::......,...:.:.: Landform Position on landscape (sketch on the back) Distances from: Open Water Body IZ3n feet Drainage way.: �. feet Possible Wet Area 2vo feet Property Line .. tom'... feet Drinking Water Welles feet Other :. . DEEP OBSERVATION HOLE LOG* Depth from Surface ilnches) Soil Horizon Soil Texture (USDA) Soil Color IMunsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) 7" /,S 70 �T1,L Cil SL 25 0 00W �g Ze1'/1 s� d , � MINIMUM ur z HULta ntUU1MCv A I CVCn, rnvrwcv w- v- Parent Material (geologic)! f T` DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: _ Weeping from Pit Face: Estimated Seasonal High Ground Water: Y& --- DEP APPROVED FORM - 12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. -7a7 On -sate Review Deep Hole NumberRho- Weathe Location (identify on site plan) .. ............ . .. .. ... Land Use Slope M Surface Stones Vegetation .... .... .. .. ......... . Landform 5e- 6,—= Position on landscape (sketch on the back) ... ... Distances from: --le) f eet Drainage way...F.:�.F". feet Open Water Body IZ6 Possible Wet Area feet Property Line ... feet Drinking Water Well 700feet Other DEEP OBSERVATION HOLE LOG* Depth from Surface (inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) VIZ �12- -t7,4 &,elvotj .37yz 41 /mss -vis — 15"1 /S VR- & 7Z SAS hc-- MINIMUM Ur z HULt,') htUU1htU Hi tVrM T rnVr%J-'Z'CU LJiOFVQP%A- Parent Material (geologic) Depthto Bedrock*— Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water:— &/ DEP APPROVED FORM - 12107/95 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. Z6% UOf><i��-fix( 57 , NO �� 1774 Determination for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole .................. inches ❑ Depth weeping from side of observation hole inches � r ® Depth to soil mottles ...::..:.: inches �, 4e ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date ................... Index well level ......._.......... Adjustment factor ................... Adjusted ground water level ....................................................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? y�-� If not, what is the depth of naturally occurring pervious material? Certification I certify that on �% (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15. 17. Signature Date DEP APPROVED FORM . 12/07/95 1 Wy ti I F +I '•7 e i 4 }} 14 i 1 uy {a 1 � M i � r t` 4[« s � ? r k c� 11111 �9�,