HomeMy WebLinkAboutMiscellaneous - 769 FOREST STREET 4/30/2018<�l
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Town of North Andover QqNOR�t6ED T{�
' 161.�
Office of the Health Department 3?
Q
Community Development and Services Division * i
27 Charles Sfreet
North Andover, Massachusetts 01845 9SS�CHUS
Susan Y. Sawyer, REHS/ RS 978.688.9540 - Phone
Public Health Director _ 978.688.9542 - Fax
RTI FICA�I� OE COqVI<1 J. -P.1 C'�
As of:
,duly 12, 2004
This is to cert that
the individualsu6surface disposaf system
repairecf(X)— EuCCSystem
6y
James �eCCett
at
769 'Forest Street
North Andover, gm 01845
has 6een installed in accordance with the provisions of Title V of the State Sanitary Code and
with the North Andover 0oard of ,7feafth regulations.
The Issuance of this certificate shall not 6e construed as a guarantee that the system will
function satisfactorily.
`Y. Sawyer, RE,h
Ifeafth Director
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTI-1 688-9540 PLANNING 688-9535
0 0
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed;
()<) repaired;
by--__
located at % o m—+ S
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit.#, plan dated , with a design flow
of y'{Z> gallons per day. The materials used were in conformance with those specified
on the approved plan; the system was installed in accordance with the provisions of 310
CI1M.15.0001, Title S and local regulations, and the final grading agrees .substantially with
the approved plan. All work is. accurately represented on the As -built which has been
submitted to the Board of Health. 1 1
Bed inspection date: /
Final inspection date: l �( a q
Installer:
Engineer:
Date:
Representative
Date: ' 3" G
w� � - n
M
NEW ENGLAND ENGNIC EERING SERVICES
Susan Sawyer
North Andover Board of Health
27 Charles Street
North Andover, MA 01845
Re: 769 Forest Street, North Andover, Septic System As -Built
Dear Susan:
June 21, 2004
TOgY14 OFF NORTH! ANDOVER/
BOARD OF Flci"
JUN 2 2 9nn,
New England Engineering is submitting a septic system as -built for the above referenced
property. We have also included the system installation certification form. Enclosed are
three (3) copies of the as -built plan and one copy of the installation certification.
If you have any comments or questions please do not hesitate to contact this office.
SinI—
"
erely,
Thomas H ctor
New England Engineering Services, Inc.
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
Dellechiaie, Pam
From: Sawyer, Susan
Sent: Wednesday, June 23, 2004 3:59 PM
To: DelleChiaie, Pamela
Subject: FW: 769 Forest Street
-----Original Message -----
From: Dan Ottenheimer [mailto:info@millriverconsulting.com]
Sent: Tuesday, June 22, 2004 3:38 PM
To: Susan Sawyer; amcbrearty@miliriverconsulting.com; 'Pamela Dellechiaie'
Subject: 769 Forest Street
Sue and Pam,
Page 1 of 1
Attached please find the final construction inspection report for 769 Forest Street. Thanks for your help checking
on the manhole.
Dan
HI
Daniel Ottenheimer, President
Mill River Consulting
Septic System Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www.millriverconsulting.com
info ,,millriverconsulting.com
7/12/2004
MILL RIVER CONSULTING
Septic System Management Services
TOWN OF NORTH ANDOVER
SEPTIC SYSTEM CONSTRUCTION NOTES
ADDRESS: 769 Forest Street MAP: LOT:
INSTALLER: Jim Kellett, Kellett Excavating
DESIGNER: New England Engineering Services
PLAN DATE: 4/26/2004
BOH APPROVAL DATE ON PLAN: 4/28/2004
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: 6/14/2004 and 6/15/2004
DATE OF FINAL GRADE INSPECTION:
SELECT SYSTEM TYPE Gravity Distribution
COMPONENT SUMMARY FROM PLAN
GALLON TANK = 1500
LOADING OF SEPTIC TANK = H10
GALLON PUMP CHAMBER = none
LOADING OF PUMP CHAMBER = n/a
TYPE OF SAS = Infiltrator Field
DIMENSIONS AND DETAILS OF SAS: 60x25, 4 sets infiltrator in butterfly configuration
SITE CONDITIONS
[]Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
®Topography not appreciably altered
Comments:
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com
Page 1 of 1
MILL RIVER CONSULTING
Septic System Management Services
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
® 1500 gallon tank has been installed
H-10 loading Monolithic construction
®
Watertightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
® Inlet tee installed, over access port
® Outlet tee (gas baffle or effluent filter) installed, over
access port
® 24 inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
® Hydraulic cement around inlet & outlet
Comments:
D -BOX
❑ Installed on stable stone base
❑ Inlet tee (if pumped or >0.08'/foot)
® Hydraulic cement around inlet & outlets
® Observed even distribution
® Speed levelers provided (not required)
Comments:
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com
Page 2 of 2
v
MILL RIVER CONSULTING
Septic System Management Services
SOIL ABSORPTION SYSTEM
❑ Bottom of SAS excavated down to soil layer, as
provided on plan
® Size of SAS excavated as per plan
® Title 5 sand installed, if specified on plan
❑ 3/4-1 Y2" double washed stone installed
❑ 1/8-1/2" (peastone) double washed stone installed
❑ laterals installed and ends connected to header (and
vented if impervious material above)
❑ Orifices @ 5 & 7 o'clock positions
® Gravelless disposal systems: type, number and
location as per plan
® Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
❑ Retaining wall (boulder / concrete / timber/ block)
❑ Final cover as per plan
Comments:
Fill over SAS had stones >6" in size, will be checked at final grade inspection.
SYSTEM ELEVATIONS
Benchmark: 100.00
Rod at Benchmark: 1.19
Height of Instrument: 101.19
INVERT ON DESIGN PLAN INVERT ELEVATION
Building Sewer OUT
98.62
98.63
Septic Tank IN
97.11
97.25
Septic Tank OUT
96.86
96.99
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
96.80
96.74
Distribution Box OUT
96.63
96.59
Manifold
Infiltrator Top (1-1)
97.00
96.94
Lateral 1 LOW
97.00
96.86
Lateral 2 HIGH
97.00
96.94
Lateral 2 LOW
97.00
96.90
Top of Sand
96.00
95.81
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com
Page 3 of 3
Page 1 of 3
0 Q
Dellechiaie, Pam
From: Sawyer, Susan
Sent: Friday, June 11, 2004 8:49 AM
To: DelleChiaie, Pamela
Subject: RE: Bed Bottom Inspection Request: 769 Forest Street - Jim Kellett
thank you
-----Original Message -----
From: DelleChiaie, Pamela
Sent: Friday, June 11, 2004 8:39 AM
To: Sawyer, Susan
Subject: FW: Bed Bottom Inspection Request: 769 Forest Street - Jim Kellett
Susan,
FYI....
-----Original Message -----
From: Dan Ottenheimer [mailto:info@miliriverconsulting.com]
Sent: Friday, June 11, 2004 8:38 AM
To: pdellechiaie@townofnorthandover.com
Subject: RE: Bed Bottom Inspection Request: 769 Forest Street - Jim Kellett
Pam,
Spoke with Jim Kellett. We will do the inspection either tomorrow or Monday afternoon.
As to the inspection form, I didn't forget. We are going to need to make a few minor changes to make it
useable for both of us. Should have it to you early next week.
Dan
Daniel Ottenheimer, President
Mill River Consulting
Septic System Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www. millriverconsultin. com
info@millriverconsultin-.com
-----Original Message -----
From: Pamela DelleChiaie [mailto:pdellechiaie@townofnorthandover.com]
Sent: Thursday, June 10, 2004 3:39 PM
To: Daniel Ottenheimer (E-mail)
Subject: FW: Bed Bottom Inspection Request: 769 Forest Street - Jim Kellett
Hi Dan,
7/12/2004
Page 2 of 3
O
Engineer called and said this is all set for a Final Inspection. Please call Jim at: 781.953.7146.
Also, can you send us that blank construction form so we can fill out the Bed Bottom info.? Tx,P
-----Original Message -----
From: Sawyer, Susan
Sent: Monday, June 07, 2004 11:51 AM
To: DelleChiaie, Pamela
Subject: RE: Bed Bottom Inspection Request: 769 Forest Street - Jim Kellett
1 am going to try to do this Tues Am before 8:30 ... if I remember
-----Original Message -----
From: DelleChiaie, Pamela
Sent: Monday, June 07, 2004 11:24 AM
To: Sawyer, Susan
Subject: RE: Bed Bottom Inspection Request: 769 Forest Street - Jim Kellett
Importance: High
Yes - approved in January. I believe this is his first job with us.
P
-----Original Message -----
From: Sawyer, Susan
Sent: Monday, June 07, 2004 11:23 AM
To: DelleChiaie, Pamela
Subject: RE: Bed Bottom Inspection Request: 769 Forest Street - Jim Kellett
I agree, we need a good system. I will call him now. Is he a new installer?
-----Original Message -----
From: DelleChiaie, Pamela
Sent: Monday, June 07, 2004 11:20 AM
To: Sawyer, Susan
Subject: Bed Bottom Inspection Request: 769 Forest Street - Jim Kellett
Importance: High
Hi Susan,
Jim Kellett called to schedule a BB Inspection for tomorrow, June 8th, as early
call to confirm with him at: 781.953.7146.
Is it possible for you to use the same type of form that Dan uses for the inspec
we can just take one of the filled in ones, blank it out, and use it for the BB an(
see the BB anyway, as he will be doing the Finals. If you are going to consists
out how we are going to work that so that we don't run into any snafus.
Tx,
P
Pamela DelleChiaie, Health Dept. Assistant
7/12/2004
1 �4.
i
J O
I ♦ y .
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
27 CHARLES STREET �o
NORTH ANDOVER, MASSACHUSETTS 01.845
gCMUSE
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.9542 — FAX
bealtbdept@townofnorthandover.com
www.townofnorthandovei-.com
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE. v Y_C --�
Town of North Andover /.,.7/
LOCATION: (O Health DePartment Date: �
Location:
l
LICENSED INSTAL : (Indicate Address, if Residential, or Name of Business)
Check #:
Type of Permit or License: (Circle)
SIGNATURE: ➢ Animal
➢ Dum j�
MsP'Block �
i()5.0_0072-
monwealth of MassarhuSetts ?CM04o.
Com BNP-2-�"'3-
Board O f Health -
North Ando'Ver $2W.00 --
PA.
on ,perMit
ispOsal Worbcs Construct - -
- ----
Dte3AW'
Permission is heteby VIM
sal .System. ----'
Disp° ---
individual Sewage une 04, 2044
Individual -------------
No
769 FOREST STREworksConslructionPermitNo• `�._ i
,�
- licatior,forDiSPo ----------------
as
---- -- 7H -
as shown on 'e app Bo
.
- Map.Block Lot
......................
Issued On:
jun-04-204, -----
0o12-----....................................................... 105
ugettS -
.............................. of Mas
sach
.............goes.......... m
Com onweafth
Board Of Health
North, Andover,n
ce
Certificate of C° D System M.epair)
y,That the
Sewage°
--
THIS IS TO CT
-------------- meter
by SAME ental Code ffi des�� the
--- State Envtronm
769 FORE _ _
ET --=---- E 5 of tl�e p4�20�
visions of TI
at,No acc TL l �� Iune
S
bas been W� arwc thns provisions
No. Bim -2044 04- _-----------
Board 0. Wtb --
apPlicato DisPo
d�hi:lun-4MZODQ
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at Gi t70 Q�5� ��+� relative to the application
of , % dated D for plans by ��`�s and
dated�'Aith wrevisions dated r/4
I understand the following obligations for management of this project:
1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior
to performing any work on a site. I must have the approved plans and the permit on site
when any work is being done.
2. As the installer I must call for any and all inspections. If homeowner, contractor, project
manger, or any other person not associated with my company schedules an inspection and the
system is not ready then item three shall be applicable.
3. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a $50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be
on site.
4. As the installer I understand that only I may perform the work (other than simple excavation)
required to complete the installation of the system identified in the attached application for
installation. I further understand that work by others unlicensed to install septic systems in
North Andover can constitute reasons for denial of the system, and/or revocation or
suspension of my license to operate in the Town of North Andover; significant fines to all
persons involved are also possible.
5. As the Installer I understand that I must be on site during the performance of the following
construction steps:
a) Determination that the proper elevation of the excavation has been reached.
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff or consultant.
d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer I understand that I am solely responsible for the installation of the system as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve me of this obligation.
Undersigned Licensed Septic Installerlz�� 14e_� �r
Date: 6 -z ytaY
Disposal Works Construction Permit #
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( )'constructed;
repaired;
by �J ?Ar' 7,'S kc e'I +
located at�-
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit .# , plan dated , with a design flow
of gallons per day. The materials used were in conformance with those specified
on the approved plan; the system was installed in accordance with the provisions of 310
CMR 15.000, Title S and local regulations,and the final grading agrees substantially with
the approved plan. All work is accurately represented on the As -built which has been
submitted to the Board of Health.
Bed inspection date:
Engineer Representative
Final inspection date:
Engineer Representative
Installer: 6�-_-.- Lic.#:
Engineer: __ Date:
Date: 6 2,41-4;y
01 0
FORM - U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all -necessary approval /permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
1.
APPLICANT 'A-) 1—)c Ell rr/ S � vPHONE G� �3 ���� �_
ASSESSORS MAP NUMBER "1� LOT NUMBER
SUBDIVISIONLOT NUMBER hc3zs�.
STREET /-63 74 STREET NUMBER
a .wand ■. m. A. w. m w w d e• ........................48.0—Amen .................... ■
OFFICIAL USE ONLY Q)
RECONIIvIENDATIONS OF TOWN AGENTS
one 0a■a a a■■a.d.■ ■anaaa as a a a a a a 2 a a a a a a a a A.■■■ A. a a..... an www... ■m am m a d e ad
(� "f ]^ �y _ DATE APPROVED
CONSERVATION ADMINISTRATOR
DATE REJECTED
TOWN PLANNER
COMMENTS
FOOD INS TO -
L,e/ P, CINECTOR - HEALTH
DATE APPROVED
DATE REJECTED
DATE APPROVED
DAME REJECTED
DATE APPROVED s a�
DATE REJECTED
COMMS ..& _ a s>tsy�.
PUBLIC WORKS- SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
a.
TOWN .oF NORTH ANDOVER. MASSACHuSETTS
orrsce or
CONSERVATION COMMISSION
00 IN
oi, TELEPHONE 683-7105
Ap�
t
Pursuant to the authority of the Wetlands Protection Act,
Massachusetts General Laws Chapter 131, Section 40, as amended,
and the Town of North Andover's Wetland Protection By Law, the
North Andover.Conservation commission will hold a Public Hearing
on July 16, 1986 at 8:00 P.M. at the Town Building
Meeting Room, 120 Main Streetj North Andover, MA on the Notice of
In I tent of YELLOW MAIZE CORPORATION to alter land.at sewer
line and Lots 11 through 16 on Barker Streetfor purposes of
Construction of six homes and driveways.
Plans are available at the Conservation Commission Office,
Town Building, 120 Main Street' North Andover, MA on weekdays,
from 8:30 A.M. to 4:30 P.M. and by appointment.
By: G Vicens
&airman, NACC
Aun once in the North Andover Citizen on July 10, 1986
cc:
Planning Board
_d__o
L H &_ I-tV
Public Works
Highway Dept.
Applicant
Eng ineer
DEE
FIRE CHIEF
`' 97fU36 -9}1ovV ��J
d DAN Ol 07011 -7 7, .l 1,, 4,V
Q�n�is i,nSf��
If C ��10 (97Nh1�d w�3SZs SdM
'O SGnJ X115 �11510
-Loagll
1 L -L(2i
�S ��L
5 �f 5
J
3 6 6
7. ,
8 8
9 1 I 9
10 1 10 �___ --� 10 1--J
Benchmark Location_
Elevation Datum
Percolation Tests -Date
.24/.7 7 i - _-? =79
5
6
7
8
9
10
Pit Number ` 1 r2 3 4 5
.Start Saturation �; y
Soak -Mins.
5
Start Test -Time IV w
Drop of 3" -Time.
Dr02 of 611 -Time It ,Lpq
Mins.lst 3"Dro
Mins.2nd 3"Dro v
i.. ueiin s & Associates, North And.
Pv-,
F67 A/ 077
SOIL PROr'ILL &
PERCOLATION TEST DATA
P.4i
Town/City No.&Street
er/� �Jf�C� �'
Lot No.
Loc./Subdiv.
Plan Owner
/j
Investigator/3_ a
Observer
SOIL
PROFIL$S-DATE
1' E ev. �' Elev.
a6
3' Elev.
!-'Elev. k Lj- ,
77
o
0
0
1
1
1
`2
2
2
3
3
3
r •.
4
—
4
4
-,_77
5 �f 5
J
3 6 6
7. ,
8 8
9 1 I 9
10 1 10 �___ --� 10 1--J
Benchmark Location_
Elevation Datum
Percolation Tests -Date
.24/.7 7 i - _-? =79
5
6
7
8
9
10
Pit Number ` 1 r2 3 4 5
.Start Saturation �; y
Soak -Mins.
5
Start Test -Time IV w
Drop of 3" -Time.
Dr02 of 611 -Time It ,Lpq
Mins.lst 3"Dro
Mins.2nd 3"Dro v
i.. ueiin s & Associates, North And.
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NO --H -'DOVER BOARD OF HEALT"
INSTALLATION CHECK LIST
APPROVED DATE DISAPPROVED DATE -0-i, �J 5j 1 hXCAVATION OK
:. --17 -7 r8 LIZA-
FAIL
OK
1. Distance To:
✓W tlands I
s
Well � / ��\ � �✓ � 0 � n
Mater Line Location
�'-�. 7 Z5-�% 'i�,YIN� '(•O t=1G��C Gv i IF TI -I(
'rNo PVC Pipe WOS EVER ACTu4vl RFKO"E�'-
4. Tank tua A5
�ees - Len h -&-'v Out Cove
ipe to Tank - t Sides of Tank
5:' ion Box
.waver & Box'- a-Cry--
vwTrig Equal Amouuns r
o Back Flow -
6. ach Field or Trench
,.Dimensions
Stone Depth �f ' 1',<(t�- /1•3omnl.
Capped Ends
Clean Double Washed Stor
7. Leach Pitsv'v`iy iJ -
Dimensions
Stone Depth
Splash Pads 1111
Tees
Cement Pipe to Pit - Boi
Clean Double Washed Stoi �•
8. No Garbage Disposal G&,4_
-If: Final Grading Inspection
Barracading Covered System
11. As - Built Submitted
Lot Location /, d
Dimensions of System "1
Location with Regard to'
Elevations / J
Water Table
�4 JRM U -LOT RELEASE FORM
ducTiIaas-,4This form is used to verify that all necessary approvals/permits from
q daandp�rtments having jurisdiction have been obtained. This does not relieve
apP#fdanfand/or landowner from compliance. with any applicable or requirements.
" — APPLICANT FILLS OUT THIS SECTION'
(f App CANT r£� PHONE a3 -
TION: Assessor's Map Number PARCEL
SUBDIVISION LOT (S)
STREET 7(x,9 Fn�fsl S�' ST. NUMBER_7�
USE ONLY""""'""'^""""'_._.
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
} DATE REJECTED
COMMENTS
FOOD IN PECTOR-HEALTH DATE APPROVED
/ DATE REJECTED
S TIC INSPECTOR -HEALTH DATE APPROVED 3
DATE REJECTED
COMMENTS —7 -t-le Gs �L7�c 2Ei -e- vas coo/ �y cer7L t � *. sip,
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMITII__ n
IRE DEPARTMENT�u.,,-cj Y Pw-L W,,feL S' rr,ct� (��c�r R,—T-C. AM C/ !O
RECEIVED BY BUILDING INSPECTOR DATE r �g
LIT
NORYH ANDOVER BOARD OF HEALTH �G
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
APPROVED PROVIDED DISAPPRWID
i�15-2.18
General Information
Reg. 2.5
Fail
OB
The submitted plan must show as a minimum:
—W. -the lot to be served (area,dimensions, lot #, abutters)
b) location and dimensions of system (including reserve area)
)'-`design calculations
/�►''%
(3) calculations showing reouired leaching area
existing and proposed contours
(£4 location and log of deep observation holes -distance to ties '
L
/p?A5•T_
—(-ff)-location and results of percolation tests -distance to ties.
location of any wet areas within 100' of the sewage disposal
1
system or disclaimer
(i) surface and subsurface drains within 1001 of sewage disposal
,[des F
system or disclaimer
location of any drainage easements within 1001 of sewage
disposal system or disclaimer
(-k known sources of ,-atn-,r supply within 2001 of sewage disposal
system or disclaimer
--(1) location of any .proposed well to serve the lot (1001 from leaching facility
,(m) --location of water lines on property (10' from leaching facilities)
(n) maw mum ground water elevation in area of sewage disposal system
(o) location of benchmark
(p) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
(g) driveways
- (r) garbage disposers
,.(s) a profile of the system (elevations of basement, plumbers pipe
septic tank, distribution box inlets and outlets, distribution
field piping and any other elevations)
."(-t) no PVC is to be used in construction
S tic s
Reg. 6.1
a'a
(a) C acities - 1501" of, flow
Reg. 6.7
(b) ylAter table
Reg. 6.$
(c) Tees
Reg. 6.9
.) Depth of tees
Reg. 6.1
e) Access
Reg. 6.1
(£) Pumping
(g) Cleanout i.
Reg 3.7
(h) 101 from cellar wall or inground summing pool
(i) 25' from subsurface drains
Pup s
Reg. 9.1i
ApprovalReg.
9.6
�-_('a
(b) Stand-by po�;er
Sue, SUQFACE D1sPOSAIr SYSTEM DESIGN
OF
LOT D
FOREST S-'lzEEr
NORM-- ANDOVER- � MA.
P R E PAfZ�O F OIZ
�'RIAN EMEC�O
-7O( STREET
NoRTN ANO(OV5:R) MA c:)(84S
- GiLpJNK C.G�L,NAS A1�1O ASSOCIATT�i
ENGINEERS ANO AQCNIT�CTS
C 1\OR,TH ANDOVER OG-F�cs PvR�
V ' Norz-rN Ar�oo..�Q,Mv. o�84s
AvIr
ia.Pnf� 2- , (S-78
DF''G DATA j CALCULATIONS
SOIL OBSERVATIONS BYE >._,_:,:A.RMAC;AL-.LCa-__ WITNESS _- t--14(LLIP5
PERCOLAT ION ZEST ?40.
OAT E
'To P -ELEVATION
IIS- BOTTOM - ELEVATION
SAZURATIoN -MIKS.
12 9" DROP -MINS.
9" � 6"" DFtoP_MINs.
PERC ,RATE -MIN,/=N.
SOIL PROFILE -DEEP PIT NO.
DATE
{—TOP -ELEVATION
TOPSOIL
SUBSOIL
PARENT SOIL
WATER TABLE
3 122 1_78
101, to
0--1- p'
1'-O"- 7W
P-,01.IEy
177 LL
4 I - 5 --
Ko WATER
REFUSALT 13OTTO
i f II
WA-TERTABLE ELEVATION 93.10
BOTTOM ELEVATION
BUILOINGTYPE —D IlVELL lf�Ir
3 B.R.,OR X 4�U GAL.+UNIT = 4 S GPD FLOW
4S-0 (;,PD FLow x 150=_(e2S__GPD USE I(nnc) GAL.S EPTIC -TAT-AK
L£ACHINGT AREA
BEo:
I
2
3
4
S
00 SE
Z122118
TYPE 4 MvR.(Ty P.)
too, IU
SIDEWALL AREA:.
—.. _SF x_.
�GALs.�SF =
GPD
BOTTOM AREA :_
—SF x_.
—GAIs./ SF _
GPD
—
_ _ _
GPD PIT
GPD FLOW=
_ __GPD/PIT=_
_
TRENCHES
21
SIDEWALL AREASF
'—
— LFX_
—GALS 'SIP =
GAL./L1N.FT"
31
_ SF/LF X___
. __ GALS/SF =
1
TOTALTRENCH LEACHING
SOIL PROFILE -DEEP PIT NO.
DATE
{—TOP -ELEVATION
TOPSOIL
SUBSOIL
PARENT SOIL
WATER TABLE
3 122 1_78
101, to
0--1- p'
1'-O"- 7W
P-,01.IEy
177 LL
4 I - 5 --
Ko WATER
REFUSALT 13OTTO
i f II
WA-TERTABLE ELEVATION 93.10
BOTTOM ELEVATION
BUILOINGTYPE —D IlVELL lf�Ir
3 B.R.,OR X 4�U GAL.+UNIT = 4 S GPD FLOW
4S-0 (;,PD FLow x 150=_(e2S__GPD USE I(nnc) GAL.S EPTIC -TAT-AK
L£ACHINGT AREA
BEo:
4SO GPD FLOW x t.9C)
8SS SF BF -D USE
00 SE
PITS
TYPE 4 MvR.(Ty P.)
SIDEWALL AREA:.
—.. _SF x_.
�GALs.�SF =
GPD
BOTTOM AREA :_
—SF x_.
—GAIs./ SF _
GPD
TOTAL PIT LEACHING= CAPACITY _
_ _ _
GPD PIT
GPD FLOW=
_ __GPD/PIT=_
_PI-MREQ'D. USE PITS
TRENCHES
SIDEWALL AREASF
'—
— LFX_
—GALS 'SIP =
GAL./L1N.FT"
BOTTOM AREA
_ SF/LF X___
. __ GALS/SF =
GAL./ LIN. FT.
TOTALTRENCH LEACHING
CAPACITY _
_ _ _ _
GAL L1N.FT.
SPD FLOW _
CCAL.ILIN.V-T.=
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TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845 !39 s�aHusc�l�
Susan Y. Sawyer. REHS/RS 978.688.9540 - Phone
Public Health Director 978.688.9542 - Fax
healthdept @ townofnorthandover.com
www. townofnot-thandover.coni
Benjamin C. Osgood, Jr., EIT
From:
Pamela
To:
NEW ENGLAND ENGINEERING
SERVICES, INC.
60 Beechwood Drive
North Andover, MA 01845
978-685-1099
Pages:
Fax:
978-686-1768
Date:
Phone:
i
Septic Plan Response
CC:
File
Re:
❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
• Comments:
Attached is the response from the Health Agent regarding Septic Plans for the following property:
A copy has also been mailed to the homeowner.
Please call 978-688-9540.for assistance with any questions. Thank you.
Cc: File /
1
HP Fax K1220xi
Last 30 Transactions
Log for
NORTH ANDOVER
9786889542
May 18 2004 2:26pm
D= Time 1_)W Identification Duration Pa= Result
May 17 12:15pm Fax Sent
817812460202
1:08
4
OK
May 17 12:18pm Fax Sent
89786865227
3:34
4
OK
May 17 12:26pm Received
0:48
2
OK
May 17 12:47pm Fax Sent
819783276544
0:45
3
OK
May 17 1:34pm Received
0:38
0
No fax
May 17 2:25pm Received
0:42
1
OK
May 17 2:50pm Received
0:27
1
Error 283
May 17 2:53pm Received
1:23
2
OK
May 17 3:01pm Fax Sent
89789468046
0:20
1
OK
May 17 4:02pm Received
9782509121
1:00
2
OK
May 17 4:06pm Fax Sent
819785328410
0:45
0
Error 420
May 17 4:21pm Fax Sent
819784698747
3:30
5
OK
May 17 4:43pm Received
0:22
1
OK
May 17 5:02pm Received
0:38
0
No fax
May 17 5:04pm Received
5084854295
0:47
4
OK
May 17 5:20pm Received
9786855900
0:29
1
OK
May 18 3:06am Received
M.V.Cham
0:48
1
OK
May 18 8:01am Fax Sent
89786641713
1:16
1
OK
May 18 8:50am Received
0:38
0
No fax
May 18 9:16am Received
FAX
0:35
1
OK
May 18 9:41am Received
19786823363
3:37
4
OK
May 18 10:15am Fax Sent
816035287653
0:38
2
OK
May 18 10:27am Fax Sent
89786836595
0:59
2
OK
May 18 11:06am Received
603 528 7653
1:29
2
OK
May 18 11:12am Received
1:52
9
OK
May 18 11:24am Fax Sent
818884868823
0:48
1
OK
May 18 11:48am Fax Sent
816175731460
0:43
3
OK
May 18 11:49am Fax Sent
816175731460
0:48
OK
May 18 2:18pm Fax Sent
819786851099
2:44
4
OK
May 18 2:23pm Fax Sent
819782820012
2:10
�
OK
Page 1 of 1
DelleChiaie, Pamela
From: Dan Ottenheimer [info@millriverconsulting.com]
Sent: Monday, May 17, 2004 1:32 PM
To: Susan Sawyer; amcbrearty@millriverconsulting.com; 'Pamela Dellechiaie'
Subject: 769 Forest Street
Sue & Pam,
Attached please find plan review approval for 769 Forest Street.
Dan
Daniel Ottenheimer, President
Mill River Consulting
Septic System Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 ort -800-377-3044
fax: 978-282-0012
www.millriverconsulting _com
info _ millriverconsulting.corn
5/17/2004
TOWN OF NORTH ANDOVER o, hO p*� ,aa
Office of COMMUNITY DEVELOPMENT AND SERVICES a'
HEALTH DEPARTMENT
27 CHARLES STREET r J
NORTH ANDOVER, MASSACHUSETTS 01845 SS,„sr
Susan Y. Sawyer, REHSIRS 978.688.9540 - Phone
Public Health Director 978.688.9542 — FAX
healthde tc.townofnorthandoveccom
www.townoffiorthandover.com
May 17, 2004
Timothy & Doreen Prisby
769 Forest Street
North Andover, MA 01845
RE: Subsurface Sewage Disposal System Plan for 769 Forest Street, Map 105D, Parcel 72
Dear Mr. & Mrs. Prisby,
The North Andover Board of Health has completed review of the septic system design plans for
the above referenced property submitted on your behalf by New England Engineering Services
dated April 26, 2004 and received by this office on April 28, 2004. The design has been
approved for use in the construction of a replacement onsite septic system. This approval is valid
for three years from the date of this letter and during this time a licensed septic system installer
must obtain a permit and complete this work, and a Certificate of Compliance must be endorsed
by the installer, designer and the Town of North Andover. The time period for which this plan is
valid is reduced to two years from the date of a septic system inspection which did not meet the
acceptable criteria in the state regulations. The time period for which this plan is valid may be
reduced by the North Andover Board of Health in the event an imminent health problem such as
sewage backup into the dwelling is occurring.
This approval is subject to the following conditions:
1. If site conditions are found in the field to be different from those indicated on the design
plan and/or soil evaluation, the originally issued Disposal System Construction Permit is
void, installation shall stop, and the applicant shall reapply for a new Disposal Systems
Construction Permit (3 10 CMR 15.020(1)).
2. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and municipal
requirements are met. These may include review by the Conservation Commission,
Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical
Inspector. The issuance of a Disposal System Construction Permit shall not construe
and/or imply compliance with any of the aforementioned requirements.
3. The plan does not call for installation of a septic tank effluent filter but one is
recommended. Please be advised that only certain brands of filters are permitted for use
in Massachusetts and each is required to follow certain approval criteria. Your designer
or installer should work with you to assure a licensed brand is selected for use, if you
choose to install one.
Your effort to provide a properly functioning septic system for your dwelling is greatly
appreciated. The Health Department may be reached at 978-688-9540 with any questions you
might have.
Sincerely,
an Y. Sawyer, REHS/R�i-
ublic Health Director
encl: List of licensed septic system installers
cc: New England Engineering Services
file
Um"
NEW ENGLAND ENGINEERING SERVICES
INC
April 27, 2004
Susan Sawyer
North Andover Board of Health
27 Charles Street
North Andover, MA 01845
Re: 769 Forest Street, Septic System Design
Dear Susan:
Enclosed are the following documents concerning the above referenced property.
1. 5 Copies of septic system design plans.
2. Copy of Form 11 -Soil Evaluator Form.
3. Copy of Form 12 Percolation Test Form.
4. Application for approval plans.
5. Check to cover the approval fee.
These plans are being submitted for approval. Please contact this office with any
questions or concerns at (978)-686-1768.
Sincerely,
/x'61
Thomas Hector, EIT
New England Engineering Services, Inc.
Enclosures (9)
60 BEECHWOOD DRIVE -NORTH ANDOVER, MA 01845-(978) 686-1768 - (888) 359-7645 -FAX (978) 685-1099
Town of North Andover ,.
HEALTH DEPARTMENT
27 Charles Street
North Andover, MA 01845
978.688.9540
TOWN OF NORTH ANpOVFR/
OFHFALTH
healthdenteatownofnorthandover.com
BOARD
APR 2 8 200
SEPTIC PLAN SUBYHTTAL FO
DATE OF SUBMISSION: H/ a-7 )o y
SITE LOCATI qON: / � ' 9 are.51 greet
ENGINEER: Nes, E-141CIJ Lna pwlAq SecV�C
NEW PLANS: YES X $225.00/Plan s.no Check#: 65$0
(Includes and Re -Review Only)
REVISED PLANS: YES $ 75.00/Plan Check #:
SITE EVALUATION FORMS INCLUDED: YES NO
LOCAL UPGRADE FORM INCLUDED: YES NO
Telephone #: (17 6 V 76 H Fax #: 6 8] 6a5-10,79
E -man: neeseog 0a61 DC.oM
HOMEOWNERNAME:Iwa�., 4>nc en 4'1c6
OFFICE USE ONLY
When the submission is complete (Including check):
L 4//Date stamp plans and letter
2. r/ Complete and attach Receipt
3. 11 i py File; Forward to Consultant
4. Enter on Log Sheet and Database
FORM 12 - PERCOLATION TEST
Location Address or Lot No. � Fw _t4 at ee+
COMMONWEALTH (WEALTH OF MASSACHUSETTS
4(--�l, J`Atv�Awr Massachusetts
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed 4 Site Failed ❑
.......................................................... ............................................ .......... _................... —_..... _...... _
Performed By: Der��cwh�n C OSAAn I Tr
Witnessed By: ,�rarP" AAA IIf cd�v /u'�I Zygr Coneol�anls
Comments: .
® DEP MFROVFD FORM-
uro�ros
Percolation Test`
Date: __..._.....�%
i'J O y Time:.
...,i.(� �..._
Observation Hole #
I
a
Depth of PercS-c,
i 8 ,i
YD"/17
Start -Pre-soak
/OZ13
l o; `/y
End Pre-soak
/.0 3C)
Il;0
Time at 12"
3rN
CNill.
' 00
Time at 9"
ff ;iS
Time at
:31
Time W-6")
Rate Min./Inch
�bo.4e �{
Min
Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed 4 Site Failed ❑
.......................................................... ............................................ .......... _................... —_..... _...... _
Performed By: Der��cwh�n C OSAAn I Tr
Witnessed By: ,�rarP" AAA IIf cd�v /u'�I Zygr Coneol�anls
Comments: .
® DEP MFROVFD FORM-
uro�ros
V- III? LUU4 Zia Jo I (0ij34u1I D ANk.LqKVK rAUL UI
No.
a 34
FORM 11 - SOIL, EVALUATOR FORM
Page I of 3
Date:
Commonwealth of Massachusetts
Massachusetts
Soil Suitability Assessment for On -Ate Sewage Dispersal
Performed By: Date:
Witnessed By: ..........
iew construction [I Repair 0 97LR
oftice Review
Published Soil Survey Available: No ❑ Yes 21
Year Published Publication Scale Soil Map Unit
Drainage Class Soil Limitations -7L'
Surficial Geologic Report Available; No FKI Yes M
Year Published Publication Scale
Geologic Material (Map Unit) ..................
Landform............................................ . ... ...
Flood Insurance Rate Map!
Above 500 year flood boundary No 0 Yes
Within 500 year flood boundary No [Dyes ❑
Within 100 year flood boundary No DYes ❑
Wetland Area:
National Wetland Inventory Map (map unit) . .......
Wetlands Conservancy Program Map (map unit) . .... ..
Current Water Resource Conditions (USGS): Month 4VE-14—
Range :Above Normal f7Nurrnal nBek-iNormal
Other References Reviewed: —
FORM 11 - SOIL EVALUATOR 10101
Page t or 3
-ocalron .Address or Lot ;Jo. 76�?_-�zr<f(�`7 �P�O ,�,kQn, -
_On-site Review
�6
Deep Hole Number � Date: ��5� Time: 9r�0 Weather P�!>?`—
Location (identify on site plan)e,..,..��6rF� GST
Land Use%��,+`/1L'Y<cT/�y4 Slvpe (%) Surface Stones
Vegetation w�vr-4
Landform
Position on landscape
Distances from:
Open Water Boay 4�" feet Drainage way � leer
d'
Possible Wet Area 6 C' feet Property Lino feet
Drinking Water Well X010 feet Other
DEEP OBSERVATION HOLE LOG'
I
i
Cepth (ram
Svrle°e (Inches,
Sell Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Din°,
(51ruci•.rre, Slnnes, eeulders, Cunsn;enc r. `�.
G�evep I
T
i
QyQ
I
p � d7At/6�
I
Parent Mateoal Deothtoeedrock: _
Depth to Groundwater Standing Waier in the Hole: — Weeping from Pit Faee:
Esm„atetl Seasonal High Grpvnd Water;_e66D
® UEP APPROVED FORA(. 11/0705
u�r .ar.tuuw:. �:al:.00 Ira: J3YG12a .,..o�c•. •'I�HrvgHKLA". - ��: ... t'WUC _'.:nom,•, ..
FORM 11 • SOIL EVALUATOR F01<\1
y� Pr19C I of J
Location Address or Lo: Ido. yDf�!/?�
/ Q7/1, -sit a Review
y T/" / `�% ! - � WeatheLAOIF—,� o
Deep Hole Number D�atse: Time!
Local ion !iG ntify On site plan) 7," . �W C7".�
Land Use, $j iJ,44-1 Slope M) "- Surface Stones
Vegetation GUamwiy
Landform 6;7—A. .
Position on landscape
Distances from:
�m0
Open Water Body QcrO feet Drainage wayfeet
Possible Wet Alta �� feet Property Line �� feet
Drinking Water Wall X43 feet Other
DEEP OBSERVATION HOLE LOG'
I
Depth from
Surteee Inches)
Soil Horiron
Soil Tamura
(USDAI
Soil color
IMunaNll
Soil
Montine
Omar
Btruen.ue. Stones, Boulders. Ccnw-I-nc,. 5.
GrarCll
I
0-4
I
i
i;VLFIY
PROPOSED
DISF89AI ARM,
Pu—t Material Igoolopicl rid. , 7 7%G c�-- Depthw8adrock:
h roundwater. Slandinq Water in the Hole:_ Wooping from Pit FrieC'—
Estimated Seasonal High Ground Water:,. /VD J&e T/`Z.+,:5 4111R?�
DEP MPRQVf,D FO RAI. 12ra'r93
LV .4: -JO 11 p1JJHV1IV
1-ocation Address or Lot wo. /�O9
FORM I1 - SOIL EVALUATOR FORM
Pagc 2 of 3
On-site Review
Deep Hole Number Date:.Time- AQ Weathe[l/�/>�• �-7w
Location (1 ntify on site plan) �j0�.......Z r<�7.
Land Use O<A744— Slope M ' . Surface Stones
Vegetation
Landform
Position on landscape
Distances from:
Open Water Body�r teat Drainage way 3�6 feet
Possible Wet Area feet Property Line ° feet
Drinking Water Well feet Other 7..
DEEP OBSERVATION HOLE LOG
Depth nom
Surlace (lncheal
Soil Horizon
Soil Texture
IUSDA)
Soil Color
IMunsell)
Soil
Mottling
Other
IStrucaue, Stones, Boulders. Consistency, 4s
Gravell
� o/
3721
/
1
�GIiJ
Parent Ma;er'al (9e010eie) DeDthtoBedrodo
Depth to GroundwaterStanding Water in the Hole. y_ _ Weeping tram Ph Faoe:
E511mated Seasonal High Grounc Water:---/ V--
® DEF APPROVED FOPhs . 1:107195
FORM 11 • SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot .'o. �at-'1P---:P7" ,-V11 N
On-site Review
s
Deep Hole Number Dete:41� 0%"AA Time //,',w Weatherczi?7V Y¢7
Location fine Ify on site plan) /V140Z..Rlp*o C7=
Land Use ,/G- Slope f%1 — Surface Stones ..
vegetation���''r'�yss
Landform✓�CRA(//,�
Position on landscape 5,-.7)- -6,e.-OP-4—
Distances from: AA
Open Water Body�Pgolo, feet Drainage way �feet
Possible Wet Area tome feet Property Line 10�57 feet
Drinking Water Well l4%CP feet Other ...,,.
DEEP OBSERVATION HOLE LOG
i
Depth fromSoil
Surface ilnches)
Horizon
Soil Texture
(USnAI
SolI Color
(Munsell)
Soil
Mottling
Other
(Strucnrre, Stones. Boulders, Consiatencv, %
�s 1
t
Aarent tdaterial Ipeologipl Cra�U%%�i4�% %7eG Depthto8edrock:
Cepth to Groundwater; Standing Water in the Hole: r`1 _ Weeping from
Pit Face:
Estimated Seaaenal High Ground water:__&
c?
DEP APPRC VED rftm . t2ia1,95
�� n4l�t'Jl-[nn4': .[1.: 3b �lftli':ij4n11'J � °�•-y.-�•�q;i;NUAkUk .. .. ., ,.. !'L1Ct.;•..'btl." ... '.' .
FORM 11 - SOIL LVALUATUft F'OR.%4
1'29e 3 of 3
Location Address or Lot No. 7�P 7'f5;F,9f';- :!:�' �/O
Determination for Seasanal High Water Table
Method Used•
Depth observed standing in observation hole. inches
El Depth weeping from side of observation holencf es
Depth to soil mottles inches �`
❑ Ground water adjustment.... feet Nd
Index Well Number... Reading Date ....... .. /.""Index well level
Adjustment factor ground round water level ....
J
Depth of Nature 11 Dccurring,Pervious Material
Does at least four feet of naturally occurring pervious materiel exist inqJI yareas
X�
observed throughout the area proposed for the soil absorption system? - -tF
If not, what is the depth of naturally occurring pervious material? —
Certification
I certify that on 4� (date) I have passed the soil evaluator examination
approved by the apartment of Environmental Protection and thatthe above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 16.017.
Signatur ���� Date
IMM
DEP ♦PPF O �Tb FORM. 1210'!1,
'a3� � Commonwealth of,Massachusetts
�l4 kVj
City/Town of NORTH ANDOVER, MASSACHUSETT
System Pumping Record f
Form 4 _
DEP has provided this form for use by local Boards of Health. he System Pumping Re rd must
be submitted to the local Board of Health or other approving au oritylM 17 N10
A. Facility Information _ rcunRTWANDOVER
Important: HEpLtnv�r.. When filling out 1. System Location:
forms on the C'1�
computer, use TO -71,r� �]]
only the tab key Address n _ , ,
to move your t-J7� 01� '-1.
cursor - do not Cit /Town
use the return y State Zip Code .
key. 2 System Owner:
` - Vt/E(,�ll�
. Name
Address (if different from location)
City[Town - State Zip Code
Telephone Number
B. Pum m9� Record
p
44
1. Date of Pumping Date1
,�(0 / 3 2. Quantity Pumped: o
Gallons
3: Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ 'Other (describe):
4. Effluent Tee Filter present? 291 es ❑ No If yes, was it cleaned? 2 Yes ❑ No
5. Condition of System:. i
6. System Pumped By
Na�m'effLL,, t
lA .c Z rnS
Company
7. Location where contents were disposed:
.. IA r until. .. 0 0 ,, z1>i'l— / .I 1 (lnrn
Vehicle License Numb
Signature of Hauler • - Date
http://www.mass.gov/d6p/wate.r/approvals/t5forms,htm#ins'pe-ct
t5form4.doc• 06/03 , System Pumping Record • Page 1 of 1
�L\ Commonwealth of Massachusetts RR�
City/Town of NORTH ANDOVER MAS ACHl kifS
System Pumping Record MAY 1 0 2001.
Form 4
TOWN OF NG. BR
DEP DEP has provided this form for use b local Boards of Hea HEALT °
Y TEin
be submitted to the local Board of Health or other approving authority. ysttem-P_SiRecord must
A. Facility Information
Important:
When filling out 1. System Locatio
forms the
computer,
utoter, use ll only the tab key Address
to move your A 7 \� � ` / 4q—
cursor
/1
cursor - do not Cit Rown 1�/I rT
use the return y State Zip Code
key.
2. System Owner:
cl� A
Name c — --
�Q
Address (rf different from location)
Cilyfrown State Zip Code
tTelephone Number
B. Pumping. Record
1. Date of Pumping Date 3 2. Quantity Pumped: Ga ons --/��—
3. ,Type of system: ❑ Cesspool(s) ['Septic Tank ❑ Tight Tank
ft
❑ 'Other (describe):
4. Effluent Tee Filter present?,..Yes ❑ No If yes, was it cleaned? 3E�—Yes ❑ No
5. Conditi�n of^^Sy$tem:. �l
:WGt
6. �S stem Pumped By:
Vehicle License Number
A Ins— __
Company V
7. Location where contents were disposed:
it
_
Signature of Hauler Lfl�I��
Date I —
http:I/www.mass.gov/dep/water/approvaIs/t5forms,htm#inspect
t5fonn4.doo- 06103 System Pumping Record • Page 1 of 1
Page 1 of 1
DelleChiaie, Pamela
From: Dan Ottenheimer [info@milldverconsulting.com]
Sent: Monday, March 22, 2004 5:01 PM
To: pdellechiaie@townofnorthandover.com
Subject: RE: 769 Forest Street - Soil Test
On April 5 we are scheduled to test 769 Forest Street and 69 Oakes Drive with New
England Engineering Services.
Dan
0
Daniel Ottenheimer, President
Mill River Consulting
Septic System Management Servicer
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 ort -800-377-3044
fax: 978-282-0012
www.millriverconsulting.com
info@millriverc-onsulting.com
-----Original Message -----
From: Pamela DelleChiaie [mailto:pdellechiaie@townofnorthandover.com]
Sent: Monday, March 22, 2004 4:26 PM
To: Daniel Ottenheimer (E-mail)
Subject: 769 Forest Street - Soil Test
Importance: High
Hi Dan,
When is the soil test scheduled for 769 Forest Street?
Thanks,
Pam
Pamela DelleChiaie, Health Dept. Assistant
Town of North Andover
Community Development & Services
27 Chartes Street
North Andover, MA 01845
pdellechiaie@townofnorthandover.com
Tel. 978-686-9540
Fax 978-688-9542
3/30/2004
Page 2 of 3
Daniel Ottenheimer, President
Mill River Consulting
Septic System Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 ort -800-377-3044
fax: 978-282-0012
www.mi I Iriverconsulting,com
infb@miliriverconsulting.com
-----Original Message -----
Prom: Pamela DelleChiaie[mailto:pdellechiaie@townofnorthandover.com)
Sent: Thursday, March 18, 2004 4:19 PM
To: Daniel Ottenheimer (E-mail)
Subject: Soil Test - 542 Salem Street
Importance: High
Hi Dan,
Have you had a chance to schedule a soil test for the above yet? Bill Dufresne
called asking about it today. Thanks,
Pam
3/30/2004
NORTH
BUILDING PERMIT °` "'•',�
TOWN OF NORTH ANDOVER F
APPLICATION FOR PLAN EXAMINATION
«o
Permit NO Date Received
�sswcHuse�
Date Issued:
IMPORTANT: Applicant must com Tete all items on this page
LOCATION '"�
Pnnt" .
PROPERTY OWN,dine/9-C
Gt//zroPontnone tvn Joto PARCEL: 7a ZONING DISTRICT:;ISTORIDISTRICT yes no
TYPE OF IMPROVEMENT
PROPOSED USE
idential
Non- Residential
❑ New BuildingOne
family
❑ Two or more family
❑Industrial
❑ Addition
❑ Alteration
Nn. of units:
❑ Commercial
PItepair, replacement
❑ Assessory Bldg
❑ Others:
❑ Demolition
Gl'Septie Cf Well a `
❑Other
o Floodplain ❑Wetlands
" "A
❑ Watershed District. ,
❑`Water/Sewer -. tw"`2
dentirication Please Type or Print Clearly)
ur-O IRIr 1 wiN yr ........ .....r —• "-'---
dy (&Ax
Lrnr
Os )c✓a O/1 64ck wA k 4 iS
d
n
�v. !./ R &C&
ai" iJfll Q. MG rh�ui.N. •.. L2
n
dentirication Please Type or Print Clearly)
OWNER: Name: /) CAAQ.l a/hChe&
L2Sor' Phone:
9'?g-aLW-05A
Address: S t�ze E
-,--.,,Phone:
R
:•CONTRACTORrName-'
�v
y
Address:
•.
r� uyg
Supervisor's Construction License:
Exp Date:
g
•.
Horde Improvement Licenser .
Exp. Date:
ARCHITECT/ENGINEER
Phone:
Address:
Reg. No.
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
FEE: $
Check No.:
Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Sgnar"" �ture of Agent/wner' _>. r;,
Signature of contractor
"- xg u;''R
Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑
Tanning/Massage/Body Art ❑
Swimming Pools ❑
Well exy
Tobacco Sales ❑
Food Packaging/Sales ❑
Private (septic tank, etc.
Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT ❑ ❑
COMMENTS
/ E REJECTED DATE APPROVED
X CONSERVATION
((
COMMENTS_No VtU6 S
\ / DATE REJECTED DATE APPROVED
i( HEALTH ] S� �a 7 � 7
I\ 6 G
COMMENTS_r�-�•�' aw.,zr �s hv`i�• �'v �z✓r_ ✓rte; r,
L, K i 710 7�= . >/ o Xv
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Water & Sewer Connect
Located at 384 Osgood Street
ENT - Temp Dumpster on site'yes no
Located at 124 MainStreet
Fire Department signature/date ''
Page 1 of 1
DelleChiaie, Pamela
From: Dan Ottenheimer [info@millriverconsulting.com]
Sent: Friday, April 16, 2004 10:48 AM
To: Susan Sawyer; Pamela Dellechiaie
Subject: Soils Test Results
Sue and Pam.
Attached please find the soil test results for the properties at 542 Salem Stre t and 769 Forest Street o your
records.
Dan
0
Daniel Ottenheimer, President
Mill River Consulting
Septic System Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 ort -800-377-3044
fax: 978-282-0012
www.mil lriverconsulting.com
infoa�millriverconsulting.com
4/16/2004
' �
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cd
White - Applicant Yellow - Dept. Pink - Treasurer
�d�fs
TOWN F NORTH ANDOVER
BOARD OF HEALTH/�%
Location
Permit
Food Service
$
Retail Food
$
Limited Retail
$
Seasonal
$
Disposal Works Installers
$
Disposal Works Construction
$
Soil Testing ,/
$ �2—
Design Approval Permit
$
Dumpster Permit
$
Burial Permit
$
Swimming Pool Permit
$
Animal Permit
$
Recreational Camp Permit
$
Well Construction Permit
$
Funeral Directors Permit
$
Massage Establishment License $
Massage Practice License
$
Suntanning Establishment
$
Offal/Trash Hauler
$
Other
$
7490 :
Health Agent
White - Applicant Yellow - Dept. Pink - Treasurer
BOARD OF HEALTri
NORTH ANDOVER, MASS. 01845
978-688-9540
APPLICATION FOR SOIL TESTS
DATE: 3 S " Dy MAP & PARCEL: -Map [) L,ff 7a
LOCATION OF SOIL TESTS: 761 For S- i et
OWNER::Ewd� 4 DQr vet al's bv TEL. NO.: %%S' 6 $ 3- )3:31
ADDRESS: -34 q tCnryc f S-1 reef .lJ,4 AoL fpr /AA-
ENGINEER:jkWT4 EnJI��r� efso < TEL.NO.: q78 -696- 17(08
CERTIFIED SOIL EVALUATOR:Q!�o� ZTr
l7 —�
Intended use of land: Residential Subdivision Single Family Home Commercial
Is This: �/
Repair testing /� Undeveloped lot testing Upgrade for addition
In the Lake Cochichewick Watershed? Yes No
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 $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests
required for each disposal area. Fee of $360.00 per lot for repairs or uperades.
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 disposal area.
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 V-100') shall be submitted to the Board of Health showing th
location of all tests (including aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval:
Date Received: Check Amount: Check Date:
z,o TC
G /L 9 Z-4) T
o°
o AIS -A = 4S
u�
9
sulk
Test
A (eo,
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a o
�Tovse�
0•��4
C
53-7054/2113
6 4 73 .
NEW ENGLAND ENGINEERING SERVICES, INC. 887807675
60 BEECHWOOD DRIVE PH. 978.686-1768
I 1
.NORTH ANDOVER, MA 01845
PATE ��slDi
TH
FAYTOE TO.��
ORDER OF (+� �M�f
//nnI�
flTv[tlJ JY/L
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Massachusetts Wo=t,,,MA016W
MEMO
Ai:211370545t: 887807675Il'
6473
7�`
,. .
A. BOARD OF HEALTH
NORTH ANDOVER, MASS. 01845
978-688-9540
APPLICATION FOR SOIL TESTS
DATE: 3 O y MAP & PARCEL: -,MgA Laf %Z
LOCATION OF SOIL TESTS: X69 Fof S7 7
v F
OWNER. -&d— 5 D t.'` A P"51'V
TEL. NO.: 2'22-6.83-1331
ADDRESS: -26 S -i reef , A1,4ll
ENGINEER:Ahw elj j4lfta�
TEL.NO.:_US -696- 00
CERTIFIED SOIL EVALUATOR:Jj� m..
Intended use of land: Residential Subdivision
Single Family Home Commercial
Is This:
X
Repair testing Undeveloped lot testing
Upgrade for addition
In the Lake Cochichewick Watershed? Yes
No )—
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 $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests
required for each disposal area. Fee of $360.00 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 disposal area.
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 V-100') shall be submitted to the Board of Health showinl
location of all tests (including aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval: 4& D
Date Received: Check Amount: Check Date:
I TOWN OF NORTH ANDG';'9R/
BOARD OF HEALTH
F MAR - 9 2004
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
�✓�
Location��� jT s
Permit #
Food Service $ _
Retail Food $ 1,
.Limited Retail $.
Seasonal $
Disposal Works Installers' $..
Disposal Works Construction- $
Soil. Testing / $,
Design Approval Permit $
Dumpster,Permit
Burial`Permit $
swimming Pool Permit $ -✓
Animal Permit $
Recreational Camp Permit $:
Well ConstructionPermit $
Funeral 'Director's Permit $
.Massage Establishment License $
Massage Practice License $'t'
Suntanning Establishment $
Offal/Trash Hauler .. $
Other $
F
m
7490.
p
Health Agent
x
White - Applicant Yellow - Dept., pink - Treasurer
3
a
{'�
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
�✓�
Location��� jT s
Permit #
Food Service $ _
Retail Food $ 1,
.Limited Retail $.
Seasonal $
Disposal Works Installers' $..
Disposal Works Construction- $
Soil. Testing / $,
Design Approval Permit $
Dumpster,Permit
Burial`Permit $
swimming Pool Permit $ -✓
Animal Permit $
Recreational Camp Permit $:
Well ConstructionPermit $
Funeral 'Director's Permit $
.Massage Establishment License $
Massage Practice License $'t'
Suntanning Establishment $
Offal/Trash Hauler .. $
Other $
F
7490.
} x
Health Agent
x
White - Applicant Yellow - Dept., pink - Treasurer
l yG
�1
.�
Test
,}sfea
3 L O / : N
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0
G/LBE4)T o,� G/.LBr2T
o
15,7O0il
um
95. 0320
o�so �� nay Fo R S T
IF
`53-7054/2113 6473.
NEW ENGLAND ENGINEERING SERVICES, INC. 887807675
60 BEECHWOOD DRIVE PH. 978E86-1768
.NORTH ANDOVER, MA 01845 DATE
PAYTOTHE To.-.-. A� n
€ORDER OF [+� /✓�M%(/[iXJJY/L i $(�Q,O
7L1 /IPL LiJ ntY 4`�� r-s�XTi r�SL '-DOLLARS e ...
WBankno `h 370 Maiu Strxl .
Massachusetts Wore c,,MA016W
MEMO ��^ ✓ `� � / �
+�:.2ii370.5451: 887807675ii' 64 3
pa� OA-ess
,� ��S���n-� ✓tick
FORM 4 - SYSTEM PUrvTNG RECORD
Commonwealth of Massachusetts
/t/-AvOulI , Massachusetts
51em Location
�ysie � r
-760 Fores� Sk
Tape Emergency O Routine /
Cesspt DI No ❑ Yes ❑ Scptic Tank: No es
� ❑
Y
_ p3 Qua -wing Pumped: Opd gallons
Ease r Pumping:
BORACZEK'S Permit =:
S,sie! Pumped by (Company):
.onto is transferred to
Cam. Ls disposed at: JJ
�G, Ltrh,
D -ie (9 - — Pumper Sienarure-
Cent :(ion of systenvm
oiher coments:v
1vU
DEP MPROS'ED iV 0.i i:io S�9S
Page 1 of 1
DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Wednesday, June 23, 2004 3:59 PM
To: DelleChiaie, Pamela
Subject: FW: 769 Forest Street
-----Original Message -----
From: Dan Ottenheimer [mailto:info@millriverconsulting.com]
Sent: Tuesday, June 22, 2004 3:38 PM
To: Susan Sawyer; amcbrearty@millriverconsulting.com; 'Pamela Dellechiaie'
Subject: 769 Forest Street
Sue and Pam,
Attached please find the final construction inspection report for 769 Forest Street. Thanks for your help checking
on the manhole.
Dan
Daniel Ottenheimer, President
Mill River Consulting
Septic System Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 ort -800-377-3044
fax: 978-282-0012
www.miltriverconsulting.com
info@millriv_erconsuIting.com
6/23/2004
MILL RIVER CONSULTING
Septic System Management Services
TOWN OF NORTH ANDOVER
SEPTIC SYSTEM CONSTRUCTION NOTES
ADDRESS: 769 Forest Street MAP: LOT:
INSTALLER: Jim Kellett, Kellett Excavating
DESIGNER: New England Engineering Services
PLAN DATE: 4/26/2004.
BOH APPROVAL DATE ON PLAN: 4/28/2004
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION: 6/14/2004 and 6/15/2004
DATE OF FINAL GRADE INSPECTION:
SELECT SYSTEM TYPE Gravity Distribution
COMPONENT SUMMARY FROM PLAN
GALLON TANK = 1500
LOADING OF SEPTIC TANK = HIO
GALLON PUMP CHAMBER = none
LOADING OF PUMP CHAMBER = n/a
TYPE OF SAS = Infiltrator Field
DIMENSIONS AND DETAILS OF SAS: 60x25, 4 sets infiltrator in butterfly configuration
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
®Topography not appreciably altered
Comments:
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsultin .com
Page 1 of 3
MILL RIVER CONSULTING
Septic System Management Services
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
® 1500 gallon tank has been installed
H-10 loading Monolithic construction
® Water tightness of tank has been achieved
Visual or Vacuum Test or Water held for 24hrs)
® Inlet tee installed, over access port
® Outlet tee (gas baffle or effluent filter) installed, over
access port
® 24 inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
® Hydraulic cement around inlet & outlet
Comments:
D -BOX
❑ Installed on stable stone base
❑ Inlet tee (if pumped or >0.08'/foot)
® Hydraulic cement around inlet & outlets
® Observed even distribution
® Speed levelers provided (not required)
Comments:
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com
Page 2 of 3
MILL RIVER CONSULTING
Septic System Management Services
SOIL ABSORPTION SYSTEM
98.62
❑
Bottom of SAS excavated down to soil layer, as
97.11
provided on plan
®
Size of SAS excavated as per plan
®
Title 5 sand installed, if specified on plan
❑
3/4-1 ''Y." double washed stone installed
❑
1/8-1/2" (peastone) double washed stone installed
❑
laterals installed and ends connected to header (and
96.80
vented if impervious material above)
❑
Orifices @ 5 & 7 o'clock positions
®
Gravelless disposal systems: type, number and
location
as per plan
®
Elevations of laterals installed as on approved plan
❑
40 Mil HDPE barrier installed
❑
Retaining wall (boulder / concrete / timber/ block)
❑
Final cover as per plan
Comments:
Lateral 2 LOW
Fill over SAS had stones >6" in size, will be checked at final grade inspection.
SYSTEM ELEVATIONS
Benchmark: 100.00
Rod at Benchmark: 1.19
Height of Instrument: 101.19
INVERT ON DESIGN PLAN INVERT ELEVATION
Building Sewer OUT
98.62
98.63
Septic Tank IN
97.11
97.25
Septic Tank OUT
96.86
96.99
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
96.80
96.74
Distribution Box OUT
96.63
96.59
Manifold
Infiltrator Top (1-1)
97.00
96.94
Lateral 1 LOW
97.00
96.86
Lateral 2 HIGH
97.00
96.94
Lateral 2 LOW
97.00
96.90
Top of Sand
96.00
95.81
5 Blackburn Center, Gloucester, Massachusetts 01930-2259
toll free 1.800.377.3044 978.282.0014 info@millriverconsulting.com
Page 3 of 3
—vent y
urero
3E7rIG TPMK LEACH FIELD ry 1
Septic Compliance, Inc. J r_
F. Paul Cardone, Soil Evaluator
September 18, 1998
No. Andover Board of Health
27 Charles Street
No. Andover, MA 01845
Attn: Susan Ford
Re: Sanitary Disposal System Inspection
769 Forest Street - Doreen Prisby
Dear Ms Ford
In accordance with the Commonwealth of Massachusetts, Department of Environmental
Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find
attached a "Subsurface Sewage Disposal System Inspection Form" for your records.
If you have any questions regarding this report or any of its contents please do not hesitate to
contact this office. We thank you, in advance, for your continued cooperation in these matters.
Very truly yours,
SEPTIC C IANCE, INC.
Paul Cardone
Certified Septic Inspector
Attachment
PC/JMP
title5 prisby-ps
• TITLE 5 SYSTEM INSPECTORS • D.E.P. SOIL EVALUATORS
447 Boston St., Topsfield, MA 01983 371: Baremeadow St., Methuen, MA 01844
Tel (978) 887-8586 Fax (978) 887-3480 (978) 681-0726
—vent rs !
a
.z
Xmr,TFNK LFAGN FIELo
Yrktw7aWe.
Septic Compliance, Inc.
F. Paul Cardone, Soil Evaluator
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:. Doreen Prisby Address of Owner:
769 Forest Street, No. Andover, MA 01845 (if different)
Date of Inspection: September 11, 1998
Name of Inspector: Paul Cardone
I am a DEP approved septic inspector pursuant to Section 15.340 of Title 5 (3 10 CMR 15.000)
Company Name, Septic Compliance, Inc.
Address and 447 Old Boston Road, Topsfield, MA 01983
Telephone Number: (978) 887-8586
Certification Statement
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X Passes
Conditionally Passes
Needs further Evaluation By the Local Approving Authority
Fa'
Inspector's Signature:
The System Inspector shall submit 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.
• TITLE 5 SYSTEM INSPE pl�qAS0flP.E.P. SOIL EVALUATORS
447 Boston St., Topsfield, MA 01983 3Th Baremeadow St., Methuen, MA 01844
Tel (978) 887-8586 Fax (978) 88J]0 on
on
World Wide Web http://www.magnet.state.ma.us/dep (978) 681-0726
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11, 1998
INSPECTION SUMMARY:
Check A, B, C, or D:.
A) SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310
CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B) SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.
The. system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no,. or not determined CYN; or ND):. Describe basis of determination in.all instances. If "not determined", explain why .
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.
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 leveled or replaced
Page 2 of 18
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11, 1998
B) SYSTEM CONDITIONALLY PASSES (continued)
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 replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS THE BOARD OF HEALTH DETERMINES 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 surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a
public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a
private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50
feet or more from a private water supply well, unless a well water analysis for coliform bacteria
and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
Method used to determine distance (approximate not valid.)
Page 3 of 18
(Misw oeaven
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A,
CERTIFICATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11, 1998
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH (continued):
3) OTHER
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 in cesspool is less than 6" below invert or available volume is 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
Page 4 of 18
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11, 1998
D) SYSTEM FAILS (continued)
Yes No
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be
acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,
ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" 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 exists:
Page 5 of 18
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CHECKLIST
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inpsection: September 11, 1998
E) LARGE SYSTEM FAILS (continued):.
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 Il 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.
Page 6 of 18
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART A
CHECKLIST
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of hipsection: September 11, 1998
Check if the following. have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Yes Pumping information was provided by the owner, occupant, or Board of Health.
Yes 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.
Yes Asbuilt plans have been obtained and examined. Note if they are not available with N/A.
Yes The facility or dwelling was inspected for signs of sewage back-up.
Yes The system does not receive non -sanitary or industrial waste flow.
Yes The site was inspected for signs of sewage breakout.
Yes All system components, excluding the Soil Absorption Syste, have been located on the site.
Yes The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for
condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of
SCUM.
Yes The size and location of the Soil Absorption System on the site has been determined based on:
Yes The facility owner and occupants (if different from owner) were provided with information on the proper
maintenance of Subsurface Disposal System.
Yes Existing information. Ex. Plan at B.O.H.
Determined in the field (if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
Page 7 of 18
aarzsron
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inpsection: September 11, 1998
RESIDENTIAL
Design flow:
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):
Laundry connected to system (yes or no):
Seasonal use (yes or no):
Water meter readings, if available
(last 2 year usage (gpd):
Sump Pump (yes or no):
Last date of occupancy: Occupied
CONEWERCIAL/INDUSTRIAL:
FLOW CONDITIONS
440 g.p.dibedroom for S.A.S.
3
2
No
Yes
No
Yes
Type of establishment:
Design flow:
Grease trap present (yes or no):
Industrial Waste Holding Tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system
(yes or no).
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe):
Last date of occupancy:
Page 8 of 18
gallons/day
SUBSURFACE, SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection September 11, 1998
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection (yes or no): Yes
If yes, volume pumped: 1,000 gallons
Reason for pumping: To check baffles, to check for any apparent cracks, To check for any excessive
runback
TYPE OF SYSTEM
X Septic. tank/distributionbox/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (If yes, attach previous inspection records, if any]
UA Technology etc. Copy of up-to-date contract?
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Approximate age: 17 years Date installed: unknown Source of Information:
Sewage odors detected when arriving at the site (yes or no): No
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 line
Diameter
Comments: (condition ofjoints, venting, evidence of leakage, etc.)
(m nd WRL9'>) Page 9 of 18
Owner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September Il", 1998
SEPTIC TANK: Yes
(locate on site plan)
Depth below grade: 6'
Material of construction: x concrete metal Fiberglass Polyethylene Other (explain)
If tank is metal, list age Is age confirmed by Certificate. of Compliance (Yes/No)
Dimensions: 8'x 5'x 5'5"
Sludge Depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were. determined: Septic Dip -stick
10"
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.)
We recommend tank be pumped once every two years, Baffles were on and working, liquid levels were good, structural integrity
was Rood, No evidence of leaks
Page 10 of 18
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inpsection: September 11, 1998
GREASE TRAP: N/A
(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:
(Recommendations 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.)
TIGHT OR HOLDING TANK: N/A
(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):
Page 11 of 18
(revised 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11, 1998
TIGHT OR HOLDING TANK (continued)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order
Date of previous pumping:
Comments:.
(Condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: Yes
(Locate on site plan)
Depth of liquid level above outlet invert: Good and Even
Comments:
(Note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc.)
Yes; No
Level was equal, distribution appeared to be equal, No evidence of Solids Carryover, No evidence of leakage in or out of box.
Page 12 of 18
(m+ M 04nro7)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 769 Forest Street No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11, 1998
PUMP CHAMBER: N/A
(Locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(Note condition of pump chamber; condition of pumps and appurtenances, etc.)
SOIL ABSORPTION SYSTEM (SAS): Yes
(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:
X Leaching fields, number, dimensions: 1 field approx. 20' x 4o'
Overflow cesspool, number:
Alternative system:
Name of technology:
Page 13 of 18
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11,.1998
SOIL ABSORPTION SYSTEM (SAS) (continued):
Comments:. (note. condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Condition of soil: Normal
Signs of hydraulic failure: None
Level of ponding: None
Condition of vegetation, etc.: Normal
CESSPOOLS: N/A
(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 (cesspool must be pumped as part of inspection):
Comments (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 14 of 18
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11, 1998
PRIVY:_ N/A
(Locate on site plan)
Materials of construction:
Depth of solids:
Dimensions:
Comments (Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 15 of 18 (-i eoa m
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner. Doreen Prisby
Date of Inspection: September 11, 1998
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).
See Attached
Page 16 of 18 (—;.danm
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 769 Forest Street, No. Andover, MA 01845
Owner: Doreen Prisby
Date of Inspection: September 11, 1998
DEPTH TO GROUNDWATER
Depth to groundwater: Approx. 4'-6' feet
Please indicate all methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
X Observation of Site (Abutting property, observation hole, basement sump etc.)
X Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
X Check pumping records
X Check local excavators, installers
Use USGS Data
Descirbe in your own words how you established the High Groundwater Elevation. Nust be completed)
Dug hole in leaching area stone was dry and clean. Sump pump hole was dry. All levels in tank and D -Box were good.
Page 17 of 18
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector Paul Cardone
Company Septic Compliance, Inc.
Address 447 Boston Road, Topsfield, MA 01983 (978) 887-8586
Certification Statement
I certify that I have.personally inspected the sewage disposal system at this address and that the information
reported is true, accurate and complete as of the time of inspection. The inspection was performed and any
recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in
the proper function and maintenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails to adequately protect public health or
the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the
X FAII.URE CRITERIA section of this form.
I have determined that the system fails to protect public health and the environment as defined in 310 CMR
15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form.
Inspector's Signature: Q
Date:
Copies to: No.Andover Board of Health
Buyer (if applicable) Approving authority:
(m;. M5mr)
Town of North'Andover
Health Dipaart/ment Date:
Location: / (O T CJ ST S77
(Indicate Address, if Residential, or Name of Business)
Check #: l 5
Tuve of Permit or License: (Circle)
$
➢ Animal
$
➢ Dumpster
$
➢ Food Service - Type:
$
➢ Funeral Directors
$
➢ Massage Establishment
$
➢ Massage Practice
$
Offal (Septic) Hauler
$
➢ Recreational Camp
$
➢ SEPTIC PERMITS:
❑ Sepi'c -Soil Testing
$
Septic - Design Approval
n
$ 99s
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI)
$
➢ Sun tanning
$
➢ Swimming Pool
$
➢ Tobacco
$
D TraslVSolid Waste Hauler
$
➢ Well Construction
$
D OTHER: (Indicate)
039 Health Agent Initials
White -Applicant Yellow -Health Pink -Treasurer
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