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Miscellaneous - 796 WINTER STREET 4/30/2018 (2)
SEPTIC PLAN SUBMITTAL FORM LOCATION: NEW PLANS: REVISED PLANS: YES SITE EVALUATION FORMS INCLUDED: DATE: 4�05-11rcv' DESIGN ENGINEER: ,,e/ 6 $160.00/Plan $ 60.00/Plan RK DATE TO CONSULTANT: Rt_ $.n. When the submission is all in place, route to the Health Secretary: , Applicant_ Site Location Town of North Andover, Massachusetts Form No. s BOARD OF HEALTH ®/ X3 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Test No._�'?� Reference Plans and Specs. 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 411(,Site System Permit No. lk NEW ENGLAND ENGINEERING SERVICES INC June 22, 2001 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 796 Winter Street, North Andover, Septic system design Dear Sandra: Enclosed are the following documents concerning the above referenced property. 1. 5 sets of design plans, 1 with original signature. 2. Submittal form for approval. 3. Soil evaluator sheets. 4. Check to cover the fee. If you have any questions please do not hesitate to contact this office. Sincerely, Benjamin C. Osg�o Jr., EIT President f 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 NOONAN & Mc DOWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice (978) 667-9736 Fax (978) 671-9565 Email: nm(a�netway.com Date: July 18, 2001 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770/021 796 Winter Street Assessors Map 104B, Lot 115 Dear Members of the Board, Please be advised that Noonan & McDowell, Inc. has reviewed the plan dated June 15, 2001 by New England Engineering Services, Inc. It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health `By -Laws" if the following is addressed: 1) In the profile the bottom of the leaching area and end invert are not at proper grade. 2) Need to submit local upgrade approval request form. 403(1) 3) Please write out civil beneath stamp. 4) Missing designer's certification statement. 5) Provide boyance calculations for pump chamber. 6) Septic tank should be inspected to ensure outlet pipe has a tee to proper depth and gas baffle. 7) The percolation rates indicate a denser class II material than what is called for in soil log. Design for one dose per day. 8) Include with pump design, discharge rate and plot head for various discharge rates on graph. 9) Provide a concrete or clay barrier 10 feet from leaching area. NA9.02 & 255(2)(g). 10) Provide detail for vent and end connection to ensure no cross flows. 11) General Note 7 should be reworded to state design meets state and local regulations, but you have no control over construction or use by owner. Respectfully, John L. Noonan, P.L.S.-P.E. G:office/forms/1770021 Land Surveyors Civil Engineers Environmental Planners NOONAN & Mc DOWELL, INC. 25 Bridge Street, Suite 6, Billerica, MA 01821-1023 Voice (978) 667-9736 Fax (978) 671-9565 Email: nm@netway.com Date /% Q 1 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, MA 01845 RE: Subsurface Sewage Disposal System Plan Review, 1770/ 0 Z WV, -v1? ---n— S T - Assessors Map /o ¢ B, Lot Dear Members of the Board, Please be advised that Noonan & McDowell, Inc. has reviewed the plan dated d Voy-c / 5x'z(7c / by ov c--'Lv ez7v e,- a-- o&-rv/e-t s , /,eve--.. It is our opinion that the proposed design will meet the requirements of Title 5 and the North Andover Board of Health `By -Laws" if the following is addressed: % /'NJ ThE %�z�1=i z, E 7-0<46�'- ^;7 /9� j 4)-f&�0''v,2 /ivd,carr'T /P7tE" n/o -r -g TG�i9Ora- g� G 4 c -j JlJ E �-l-t� �j►�,O�t�r ci-q L ,.�� j T� r2f,2I'9, l¢'GI: r) �- /v/ 5 s i n/ � w 4o; 4o , fs�S c Caz r i ox - ,9 t. v ti 37--5" 71P -,--yew. ?' -9 T, v S �'a Pviy 7-0 l7��%f rli-.i p G.5pt- S Respectfully, John L. ivoonan, F.L.J.-F.h. G: office/forms/tonarev �J�.+v fJ 2 S Dig /- Land Surveyors Civil Engineers Environmental Planners ,oma ,-1 o /s't'i'T�6cS' i9�r✓�J PGv T' ,��v ��� tf•r-cri�/S rU/Sc��.-�'cC ,K,ea V Ie '65- GoN CiG c TE e Grail r l3�� r t'�'C / 4 ! ` T �-� OJ C� .�vi✓ � c T iQ � o �-�v S urs Geo 5 S •c-vw S i M Tz:- G v ��v- T� szNS ,fir/ T y� s ivccv.v>ao` -NEW ENGLAND ENGINEERING SERVICES lk INC July 20, 2001 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 796 Winter Street, North Andover, Septic system design Dear Sandra: Enclosed are revised plans for the above referenced property. The following changes have been made. The numbers below correspond to the concerns in the consultants letter dated 7/18/2001. 1. The profile has been adjusted to indicate the bottom of the bed and the end invert at the proper elevation. 2. The local upgrade request form is enclosed. 3. The word civil has been written below the stamp. 4. Designers certification statement has been added below soil logs. 5. Buoyancy calculations are on the plan in the left column under the construction notes and pump dosing calculations. 6. Note number 15 addresses installation of new inlet and outlet tees as well as a gas baffle for the existing tank. 7. The dosing calculations have been revised. 8. This has been plotted on the pump curve. 9. A membrane with a block wall is still the detail on the plan. This detail has been accepted on designs approved by DEP. 10. A vent detail has been provided. 11. The second sentence of note # 7 has not been removed. We do not guarantee the functioning of the system. We only design what the regulations require. If you have any questions please do not hesitate to contact this office. Sincerely, � 5 C BenjairYin C. Osgoo r., EIT President i STC 4`, - a ,1UL 2 3 2001 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 — FAX (978) 685-1099 Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Sandra Starr Health Director July 24, 2001 Ben Osgood, Jr. New England Engineering 60 Beechwood Drive North Andover, MA 01845 Re: 796 Winter Street Dear Ben: Telephone (978) 688-9540 Fax (978) 688-9542 This is to notify you that the revised plans dated 7/9/01 for 796 Winter Street have been approved. The following variances have been granted: 1. Reduction of ground water separation from 4 feet to 3 feet. 2. Use of a rubber membrane and segmental block retaining wall in lieu of a concrete wall for slope reduction. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Health Director SS/smc cc: Williford File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 Pagel of 5 9A - APPLICATION FOR LOCAL UPGRADE APPROVAL Commonwealth of Massachusetts North Andover, Massachusetts Application for Local Upgrade Approval Title 5,310 CMR 15.000 DEP approved form required by 310 CMR 15.403(1) Tobe submitted to Local Approving Authority/Board of Health: For the upgrade of a failed or non -conforming system with a design flow of <10,000 gpd, where full compliance, as defined in 310-CNM 15.404(1), is not feasible. To be submitted.to DEP: For the upgrade of a failed or non -conforming system with a design flow of 1.0,000 up to 15,000 gpd and/or for upgrade of state of federal facility, where full compliance, as defined in 310 CMF 15.404(1), is not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above<the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15/000. 1) Facility/System Owner: Name: Es -A RI� ftM 0 1., eW tr rt 1�t 7 , 11; F� 2 � Address: � q t, �, n,-ve 5T'2e e7-, ivo a7?rr Phone #: 176- -1q g- q3 z Z Address of facility: Z q 6 w k vt ey 5--&et - , N o iz -rK /k,J-Dbo e,� 2) Applicant (if different from above) Name: .5a cis Ria 'It- Address: Phone #: 3) Type of Facility: _Residential Commercial School Institutional (Specify) 4) Type of Existing System: _privy cesspools) other(describe) Page 2 of 5 ✓conventional system Type of soil absorption system (trenches, chambers, pits, etc.) �.ea--re r I E L,7 5) Design Flow Based on 310 CMR 15.203: a) Design flow of existing system ? gpd Approved: des Approval date: 7 no Why: b) Design flow of proposed upgraded system H 0 gpd Why --!A i'ievrooms c) Design flow of facility_ 440_Md 6) Proposed upgrade of existing system is: a) Voluntary required by order, letter, etc. (attach copy) _ Required following inspection required by 31 CMR 15.301 (provide date inspection form was b tted to t e approving authority) Anb� /y 6l (date) b) Describe the proposed upgrade to the system: (n� c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per inch (state actual perc rate) Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) A Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) 4'—)-o j3' P"' RSL t0 m i uC Page 3 of 5 Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the code) System upgrades that cannot be performed in accordance with 31 CMR 15.404 & 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high ground water elevation pursuant to 310 CMR 15.405(1)(1)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater 3 feet As determined by: Evaluator's name: A4 ,s Evaluator's Signature: Date of evaluation: 8) Notice to Abutters: No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property Oor well is affected by certified at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. Page 4 of 5 List of affected abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) An upgraded system in full compliance with 310 CMR 15.000 is not feasible: ___ h A A- ._ I_ LI_ _ 1 11, 4 r. 5 b) An alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible. c) A shared system is not feasible. I / d) Connection to a sewer is not feasible. N� ck di. c n 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? V/ yes no Page 5 of 5 11) Certification ; 1, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." FacilVy Owner's SK#iue Date Print Name l e��; (f 0s yycs U /Z- 7�2 3 vi Name of Preparer Date l%e- &9G- /766 ( D 4tA/00CQ Telephone No. & Address of Preparer NOTE: Title 5,310 CMR 15.403(4) requires the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. Wt ..2� � -tom' c� _ - : ;.?•. . ��. TOWN Or NORrfH ANDOVER Sr�VAGE, DISPOS.�r: S� S�'�\-t I\,STALLAT iot-q CERTI IC:�TrOiN The uneersis med !sere ,v ceriiv that the S, •,xa2c Disposal Syste n i ! cor.stc,.ict a; located at was installed in cOnrcrmance with the North "Over Board of Heajth a-_-:Proves plan, Svsten Desi,-,n Pe:.rit =dated l �_—, wit an speroved desisn flow of Qallons per day The mater aa,usec were in cotuormar_ce %vith those specinea on the approved plan; the system was installed in accordarc:e ��.�th the provisions of 31 10 CMR 15.000, Title 5 and'Local res.-alatiors, and the anal gradipn agrees substantially with the approved plan. .-til work is accurate;v_ represented :fir she As-built which has been submitted to the Board e: Health. Bed inspection date: L ��- Enp-ineer R:prese :stive Final inspect:en cater _—A1AP101 — Em'ree: Represeraat e Insta'er: Date: Cesli , nQineer: P(i�L s Date: AS -BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC / TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION �1 LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX ORIGINAL STAMP & SIGNATURE .� IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED s N & M Job number 1770/ 0 TOWN OF NORTH ANDOVER INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Site: Final Date: Installer:A,:mo,4 Tel: Date Yes No Initials A. Bottom of Bed -1W10 1. Excavation to proper depth A / /� 2. With trenches, sides of excavation are beneath B horizon /Y1 ' 3. Edge of excavation specified distance from foundation, etc. Comments: (Use back of sheet for diagrams.) B. Retaining Wall gj b 1. 'Wall height and width as specified 2. Waterproofed �- 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" --- 2. Schedule 40 pipe 3. Inlet to tank cemented 4. Slope minimum 0.01 or 1/8" er foot minimum 5. Pipe properly set on co act firm base 6. Pipe laid on contmu s grade in straight line 7. Cleanouts pre ced 11 change in alignment and grade 8. Manholes at a 90° change 9. 10' minimum offset to water line Comments: D. Sepik Tank I/ Q o 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to w/in 6" of grade 5. Manholes ov center and each tee 6. 3-20" m les 7. Out fine cemented 8. ' — 3" drop from inlet to et 9 Pipe set 0. Compact base w' 6" of 3/4" crushed stone under 11.—Tank is wat fight 12. Tees 12" side of tank N v N �` 6�� CvN G /3fi•�'GL�' P N & M Job number 1770/ (7 Date Comments: Yes No Initials E. Pump Chamber 1. If separate from tank, compact base with 6" of stone underneath ? _- 2. Minimum 2" pipe to d -box if gravity system 3. 20" access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present��� 9. Alarm in building on separate circuit .� 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d -box -o ents: F. Distribution Box 1. D -box level 2. Minimum 0.1T' (2") drop from inlet to outlet 3. Minimum 6" sump 4. Outlet pipes show equal distribution 5. Compact base with 6" of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe 9. First 2' from box laid level Comments: G � !V1 I /.v se.Ee-- Ow/. &-- ;r -- G. G. Soil Absorption system 1. All stone double -washed — 3/a" — 1 '/2" - pea stone �I Bucket test done? 2. Minimum 2" of pea stone above distribution lines L� 3. Minimum 6" stone beneath pipey 4. Distribution lines capped or connected together 5. Toe of slope stops minimum 5' from edge of property; 5a. if not, then Swale. Comments: r S� P$V 7 2; Z N� - -7; OPr= 119 �n At- F-orz. 72;M- N & M Job number 1770/ Date H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches a with plan. (Max. length 100') 3. Width of trench grees with plan Minimum 2'; m 4. Vent pres >50 feet or specified 5. Min' distance between trenches 10' 6. a slope minimum 0.005 or 6" 0' 7. Depth of trenches below out vert minimum of 6". S. Pipes set on stab b / Comments: Yes No I. Leach Field j 1. Maximum length of field 100' (�- 2. Pipe slope minimum 0.005 or 6" per 100' r 3. Separation between pipes 6' maximum v 4. Pipes connected at end & vent end raised 5. Separation between adjacent fields 10' minimum e 6. Pipes set on stable base —- 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines Comments: J. Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall ben 12" and 48" wide 4. Access pmdiholes on each pit 5. Pi cemented with hydrau�c cement 6. Comments: Final Grade 1. Slope over soil absorption system minimum 0.02 / 2. All system components covered by at least 9" soil — 3. 4. Cover soil free of stones larger than 6" Grading slopes from dwelling away �L 5. No areas over system that may pond 6. Grading meets 3:1 slope 7. Minimum of 9" of fill graded over system J Initials ,90M<7/ CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS N & M Job 1770/ � � t' The following is a checklist that incorporates all Title 5 and local regulations for septic plans. Name of Applicant: 1—f y IZA A -*c Name of Designer: w er1%J G cry 1!t� G Plan Date: /—I5" Q/ Revision Date: Date of Review: Property Address: W/,v7a� 5- ! Map: 0 Lot: // -5-- BOH Reviewer: d L- .nv4z;' eP ti /f N Type of Plan (new oKpgrade):�_ Number of Bedrooms in.Assessar`s'Mords: gpd) Garbage Disposal Allowed: A?,6T/6-JC General Information: N.A. = North Andover Septic Regulations Other numbers refer to Title 5 O) Problem N/A t/ Street number and map/lot - 220(4)(u) Maximum scale of 1 "=40' for plot plan - 220(4) Maximum scale of 1 "=20' for profile and component details - 220(4) Legal boundaries of the facility being served - 220(4)(a) Names of abutters from recent tax map - NA 8.02j Number of bedrooms, design calcs., - NA 8.021 Name & address of record owner & applicant - NA 8.02k Name & address of designer - NA 8.021 Holder and location of all easements - 220(4)(b) Date plan drawn & any revision date - NA 8.02m All dwellings and buildings, existing and proposed - 220(4)(c) Location of all existing or proposed impervious areas - 220(4)(d) All distances on site plan — NA 8.03a -c Elevation of proposed driveway - NA 8.02t Location and elevation of foundation drain - NA 8.02y Location and dimensions of the system incl. reserve (new const.). - 220(4)(e) Limits of excavation of leach area on site plan - NA 8.02z Locus plan - 220(4)(t) (Not to scale) North arrow - 220(4)(g) Existing and proposed contours - 220(4)(g) Locations and logs of deep holes - 220(4)(h) Locations and logs of percolation tests - 220(4)(i) Date(s) of soil testing - 220(4)(h) & (i) Existing grade elevation of each deep hole - 220(4)(h) Elevation of percolation tests — N.A. 8.02n Name of approving authority representative - 220(4)(h) & (i) Name of soil evaluator - 220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines, drains, and subsurface utilities - 220(4)(m) Observed and adjusted g.w. elevation in the vicinity of the system - 220(4)(n) Complete profile of the system to scale - 220(4)(o), NA 8.02c Cross section of leaching facility - NA 8.02w (Not to scale) Location of benchmark(s) within 50-75 feet of facility - 220(4)(q) Note listing all variance requests with proper citations - 220(4)(p) Local upgrade approval request form submitted - 403(1) Original R.S./P.E. stamp, signature & date - 220(1) & (2) If P.E., discipline specified within stamp. MGL C. 112 s. 81M sfc. supplies (w/in 400'), pub. wells (Win 250'), pvt. wells (w/in 150') - 220(4)( Location of watercourses, wetlands, wells, etc. Win 150' of system — NA 8.02r Wetland disclaimer — NA 8.02s RLS plan reference & certification required (prop line setbacks) - 220(3) Plan contains designer's certification statement Use approvals / standards checked for UA system - DEP docs., y� d6N p /iv V=+cT iV o 1 Street number and map/lot - 220(4)(u) Maximum scale of 1 "=40' for plot plan - 220(4) Maximum scale of 1 "=20' for profile and component details - 220(4) Legal boundaries of the facility being served - 220(4)(a) Names of abutters from recent tax map - NA 8.02j Number of bedrooms, design calcs., - NA 8.021 Name & address of record owner & applicant - NA 8.02k Name & address of designer - NA 8.021 Holder and location of all easements - 220(4)(b) Date plan drawn & any revision date - NA 8.02m All dwellings and buildings, existing and proposed - 220(4)(c) Location of all existing or proposed impervious areas - 220(4)(d) All distances on site plan — NA 8.03a -c Elevation of proposed driveway - NA 8.02t Location and elevation of foundation drain - NA 8.02y Location and dimensions of the system incl. reserve (new const.). - 220(4)(e) Limits of excavation of leach area on site plan - NA 8.02z Locus plan - 220(4)(t) (Not to scale) North arrow - 220(4)(g) Existing and proposed contours - 220(4)(g) Locations and logs of deep holes - 220(4)(h) Locations and logs of percolation tests - 220(4)(i) Date(s) of soil testing - 220(4)(h) & (i) Existing grade elevation of each deep hole - 220(4)(h) Elevation of percolation tests — N.A. 8.02n Name of approving authority representative - 220(4)(h) & (i) Name of soil evaluator - 220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines, drains, and subsurface utilities - 220(4)(m) Observed and adjusted g.w. elevation in the vicinity of the system - 220(4)(n) Complete profile of the system to scale - 220(4)(o), NA 8.02c Cross section of leaching facility - NA 8.02w (Not to scale) Location of benchmark(s) within 50-75 feet of facility - 220(4)(q) Note listing all variance requests with proper citations - 220(4)(p) Local upgrade approval request form submitted - 403(1) Original R.S./P.E. stamp, signature & date - 220(1) & (2) If P.E., discipline specified within stamp. MGL C. 112 s. 81M sfc. supplies (w/in 400'), pub. wells (Win 250'), pvt. wells (w/in 150') - 220(4)( Location of watercourses, wetlands, wells, etc. Win 150' of system — NA 8.02r Wetland disclaimer — NA 8.02s RLS plan reference & certification required (prop line setbacks) - 220(3) Plan contains designer's certification statement Use approvals / standards checked for UA system - DEP docs., Perc rate >30 MPI - not allowed for new, LUA for upgrade - 245(1)&('3) `— Perc rate > 60 MPI - must use modified tight tank or UA technology - 245(4) ---L--Proposed system qualifies as "shared" system - 002 (definitions) �e--Flow is over 2,000 gpd - No R.S. allowed - 220(1) Design flow was set in accordance with code- 203 Existing system location and note on proper abandonment - 354 L— Leaching facility at least 1' above Base Flood elevation — NA 9.05 All piping Sch 40 minimum — NA 10.01 Basement floor minimum 1' above groundwater elevation — NA 5.04 —jz-" Foundation drain present with elevation — NA 8.02y On-site Soil and Groundwater Review OK Problem N/A Proper deep observation hole logs on plan - 220(4)(h) d� All deep holes and peres shown, including aborted tests — NA 8.02n Soil evaluation forms submitted within 60 days of field work - 018(2) Proper percolation test log - 220(4)(i) �—" Ample deep observation holes in primary disposal area (minimum 2) - 102(2) Ample deep observation holes in secondary disposal area (minimum 2) - 102(2) Ample perc testing (one in each disposal area, 3 in prim. > 2,000 gpd) - 104(4) Deep hole testing conducted within two years — NA 7.05 ground elevation el. acceptable soil el. Leach facilitv invert el. ground water el. refusal el. bottom of leach facility el. thickness of acceptable soil before & after soil R&R separation to groundwater separation to refusal soil class perc rate loading rate og •�/C�� septic tank below g.w. table Sump tank below g.w. table l.f in fill Hole Identification Numbers: i H NO /N ✓ � (yes or no)�-�cis aS(yes r no) /N ✓ ;7,5 .a° v (/eVt5.&=O - 255(1) Setback Distances (Given in feet) 15.21 1 YES NO Is the lot in the Lake Cochiewick Watershed? NA 6.00 & 5.02 OK Problem N/A Septic Tank Leach Facility ^y Property line 10 10 !/ Cellar wall 10 20 02 2 Building Sewer OK Problem N/A w/o barrier Grease trap required for certain uses (check 230 for details) Pipe diameter listed (4" minimum) - 222(1) / Pipe schedule listed - 222(3) Pipe cast iron or Sch 40 PVC — NA,M Watertight joints specified Pipe laid on compact, ,fi ase - 222(5) Pipe laid on conti u6us grade in straight line - 222(7)@ Cleanouts pr a all changes in alignment and grade - 222(8) Cleano rovided every 100 feet - 222(8) Ma ole at any 90 degree alignment change - 222(8) vert elevation at building: Invert elevation at septic tank: Length of run: Slope: (minimum of 0.01 - 0.02 desired) - 222(6) 10' offset to private well or suction line - 222(2) 3 3 Inground pool 10 20 Slab foundation 10 10 Deck, on footings, etc. 5 10 / Waterline 10 10 Private drinking well 75 100 Irrigation well 75 100 Wetlands 75 100 Public well 400 400 Wetlands bordering surface 150 150 water Supply or trib. (in Watershed) Trib. To Surface Water supply 325 325 Reservoirs 400 400 Tributaries to reservoirs 200 200 j-- Drains (wat. supply/trib.) 50 100 c/ Drains (intercept g.w.) 25 50 Foundation drains 10 20 Drains (Other) 5 10 Drywells 20 25 f Downhill slope 15' to 3:1 slope Building Sewer OK Problem N/A w/o barrier Grease trap required for certain uses (check 230 for details) Pipe diameter listed (4" minimum) - 222(1) / Pipe schedule listed - 222(3) Pipe cast iron or Sch 40 PVC — NA,M Watertight joints specified Pipe laid on compact, ,fi ase - 222(5) Pipe laid on conti u6us grade in straight line - 222(7)@ Cleanouts pr a all changes in alignment and grade - 222(8) Cleano rovided every 100 feet - 222(8) Ma ole at any 90 degree alignment change - 222(8) vert elevation at building: Invert elevation at septic tank: Length of run: Slope: (minimum of 0.01 - 0.02 desired) - 222(6) 10' offset to private well or suction line - 222(2) 3 3 --may 06— Septic Tank OK Problem N/A Tank is accessible - 228(3) No structures above tank - (228(3) Tank can accommodate both primary & reserve - NA 9.04 200% of flow (required & provided given. 1500 min.) - 220(4)(f) & 223)(1)(a) 2-3" drop from inlet to outlet - 227(5) Minimum of 4' liquid depth - 223(2) 3" air space above tees/baffles (minimum) - 227(4) 9"air space above flow line (minimum) - 227(4) Tees are not to be replaced by baffles - 227(1) Tees extend 6" above flow line - 227(1) Inlet tee extends 10" below flow line (minimum) - 227(6) Outlet tee extends 14" below flow line (more for deeper tanks) - 227(6) Gas baffle installed on outlet - 227(4) Access manhole cover above center of tank & each tee (except 2 compart) 228(2) 3-20" manholes - 228(2) 1 childproof, 24" riser/manhole w/in 6" of final grade if <1000gpd- 228(2) Inlet and outlet tees on center line - 227(1) Soil compaction below tank specified (if soil is non-native) - 221(2) 6" of <=3/4"stone beneath tank specified - 221(2) & 22 8(1) If > 1,000 gpd AND not a single fam. dwell. must be 2 tks or 2 comp. - 223(1)(b) If plan specifies disposal must be 2 tanks in series or 2 compart. tank - 223(1)(c) Buoyancy calcs. required if tank at or below water table - 221(8) Tank is watertight - 221 (1) 9" of cover over tank (minimum) - 228(l) H- 10 loading (min.) - H-20 if traffic - 226(3) Top of tank <=36" below grade - 221(7) All pumping to tank (if applies) in accordance with - 229 Tank is set to keep old system in service during install if possible Distribution Box (Check here if not present: ) OK Problem N/A Inlet elevation: Outlet elevation: �- �� 0.17' drop from inlet to outlet (minimum) - 232(3)(b) 6" sump (minimum) - 232(3)(e) L" All outlets at same elevation - 232(3)(b) Outlet pipes laid level for fust 2 ft. - 232(3)(c) Pipe Sch 40 - NA 10.01 Number of outlets: Number of laterals: Size of outlets: -"���n�LInlet baffle/tee min. 1" over outlet invert for all d -boxes - 232(3)(a), Soil compaction below distribution box specified (if soil is non-native) - 221(2) 6" of stone beneath distribution box specified - 221(2) �^ Box is watertight - 221 (1) Top of box <=36" below grade - 221(7) Buoyancy calculations required if box is at or below water table - 221(8) Pump Chamber (Check here if not present: ) OK Problem N/A - "' Volume specified: 220(4)(r) Pump on elevation- 220(4)(r) Pump off elevation: 220(4)(r) Alarm on elevation: 220(4)(r) Number of cycles per day - 220(4)(r) (also 254(1)(d) if gravity from d -box) Minimum 2" delivery line to d -box if gravity - 254(1)( c) �4 4 V Pressure dosed Lf. if flow >= 2,000 gpd - 254(1)(a) & 254(2)(a) (� Cycles per day is consistent with chamber volume - 23 1 C Volume calculations include flowback volume - 2') O 1 2 24 hour storage capacity above pump on elevation - 231(2) Number of pumps: 2 if system serves >2 dwelling units - 231(6) Capacity of pump(s) - gpm @ ' TDH - 220(4)(r) Pump can pass 1 1/4 "solids (minimum) - 231(7) Pump controls specified - 220(4)(r) Alarm equipment specified - 231(2) Alarm is in building and powered on separate circuit from pump - 2') 1(9) Pump sequence correct (off -lead on -lag on-alan-n on) - 231(8) Pump performance curves included - 220(4)(r) Manual operating switch - NA 12.01 Check valve, bleeder hole - NA 12.01 1 childproof, 24" riser/manhole to final grade - 2'31(5), Soil compaction beneath pump chamber specified (if soil is non-native) - 221(2) 6"of <=3/4"stone beneath chmbr. specified - 221(2) & 228(1), Buoyancy calculations if chamber is at or below, water table - 221(8) @ 9" of cover over chamber (minimum) - 228(1) H- 10 loading (min.) - H-20 if traffic - 226(')), Chamber is watertight - 221 (1) Top of chamber <=36" below grade - 221(7) Leaching Facility (general - complete for all designs) OK Problem N/A 50% larger if garbage disposal - 240(4) t/ Trenches to be used whenever possible - 240(6) No vehicle or imperv. area above 11 unless unavoidable - 240(7); NA 13.02 Vented if under impervious cover - 241 (1) Vented through same pipes as distribution system - 241 (1)(a) Vent protected from precipitation/animal entry - 241 (1)(b) Vent is placed beyond traffic or impervious area - 24 1 (1)(c) All lines connected to vent if bed or trenches - 241(1)(d) �— 9" cover over peastone - 240(9) Reserve area provided (new construction) - 248(1) Reserve 4' from primary leach area — NA 9.04 �- 4' (5' if perc rate <=2 MPI) separation to g.w. - 212(a) & (b) 4' (down to 2' with variance or I/A - upgrades only) of natural soil under 11 1� GW separation is adjusted to highest existing grade if facility cuts into a hillside (�— Pipe slope minimum of 0.005 - 251(9) Require 5' removal and replacement if in fill - 255(5) Top of leach facility <= 36" below. grade - 221(7) Final grade over l.f. minimum 0.02 ft/ft -240(10) Surface & subsurface drainage away from 11 - 240(1 1) & 245(5) V- Minimum design flow 440 gpd without deed restriction — NA 13.01 3:1 slope where grading required - 255(2) G Toe of fill slope stops 5' from property line or swale installed - 255(2) Impermeable barrier if < 3:1 slope or < 15 feet to—3:lslope - 255(2) Impermeable barrier/retaining wall poured concrete — NA 9.02 Retaining wall stamped by P.E. - 255(2)(b) Top of retaining wall >= top of peastone elevation - 255(2)(f) 10' offset from edge of leach facility to edge of ret. wall `f 255(2)(8) Perc test(s) done in most restrictive layer - 104(2) Perc test 4' below leaching elevation — NA 7.06 Design flow listed andrequired/provided leach area given - 220(4)(f) Leach pipes SCH40 PVC — NA 10.01 �� ✓' Leach pipes minimum 4 diameter except for dosed system — NA 14.04 �-- Leach lines Capp , vented, o connected together - 251(9) Pressure dosing guffawed if pressure distribution - 254(2)(c ), �� Pressure dosing required over 2,000 gpd or with I/A remedial use - 231(1) Leaching Trenches (Check here if not present: OK Problem N/A Number of trenes: Minimum o trenches - NA 9.01(2) Depth o enches (max eff. 2'): -247(l) Wi of trenches (2' min., 4' max.): - 251 (1)(b) ngth of trenches (100' max.): - 25 1 (1)(a) Trenches are vented (when > 50') - 251 (11) Trenches follow contour lines - 251(2) Trench spacing 3 times effective width or depth minimum- 251-( In fill or reserve between trenches, 10' min. - NA 14.0 4.03 Available leach area given (Min. 500 s.f.) - NA 9<0 (2) Bottom = L x W x # _ Sidewall = L x D x# x 2 =_ Effective leach area given Loading factor: Effective area = to area s.f. x LTAR —_ Effective area is >— esign flow of facility being served 2"of 1/8"- 1/2" washed peastone.- 247(2) Trench de sof 3/4" to 1 1/2" double washed stone - 247(1) Leach Fields (Check here if not present: ) OK Problem N/A c/ Final Grading OK Problem N/A )(d) s.f. —s.f. g/day Number of fields: _ (need dosing chamber if > 1, 231 (1)) Length (100' max.): ��- 252 (2)(b) Width: 2Q Total area: L x W = s. f. Minimum 900 square feet - NA 9.01(1) Distribution lines connected with solid pipe — NA 15.01 Effective leach area given Loading factor: Effective area = total area s.f x LTAR = g/dav Effective area is >= design flow of facility being served Minimum of two distribution lines - 252(2)(a) 6' line separation (max.) - 252(2)(d) 4' maximum separation from edge of field to line - 252(2)(e) 10' minimum separation between adjacent leach fields - 252(2)(f) Between 6" and 12" of 3/4 - 1 1/2" stone beneath field - 252(2)(g) & 247(2) 2"of 1/8"-1/2" 2x washed peastone.- 247(2) G— Slope over leach area minimum of 0.02 feet/foot — 240(10) Grading shall divert drainage away from leach area — 240(l 1) J Grading slopes away from dwelling 5/24/01 f./office/forms/tonackltr.doc a Rl NORTH . ACMUSE�� Applicant its NAM Site Location Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 DISPOSAL WORKS CONSTRUCTION PERMIT A Permission is hereby granted to Construct ( ) or Repair (✓jean Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. .1,1 . Fee .� ✓+ !I �..,. yam, CHAIRMAN, BOARD OF HEALTH D. W.C. No. 1,223 F' Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH slifpi�r)9 I CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorptio ge Disposal System constructe ( or repaired y 'TN -STA L L E R r S .� re- SITE eSITE LOCATION has been installed in accordance with Board of Health Regulafions as described in the Design Approval Site System Permit No. � L? dated 3ei a Cc' I The issuance of this certificate shall not be construed as :a guarantee that, the,.aystem will „. function satisfactorily. �',V'B'CJA REr 0F -N TWW BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: / r CURRENT INSTALLER'S LICENSE# LOCATION: -'f �. �`/ LICENSED INSTALLER: SIGNATURE: CHECK ONE: REPAIR: NEW CONSTRUCTION: r- IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $160.00 Fee Attached? Foundation As -Built? Administrative Use Only Yes ` . No Yes No Floor Plans? Yes No Approval Date: U INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at 97,6 7,7 "V, y. ., relative to the application of C crr% / dated , ! r se' `` for plans by C. �l and dated/01 with revisions dated h/a I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with 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. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Se is Installer Date: Disposal Works Construction Permit # 1"',.. I, t .. ✓t:,..,"1'"�...h•+ .\rgPTr.: �.I�9' ^ — . .'1-1.1.. .. . . . y , ' . tin.. " — . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9'K ND Owner's Name: / 2 Owner's Address: TOvVN OF FORTH ANDOVER/ Date of Inspection: BOARD OF HEALTH Name of Inspector: (Please rint)norel) Vl 'l� C Cevz.0 k Company Name: r r iY", Mailing Address: 2 ,5 T ;45 .< r Telephone Number: �27 F=�Z 2 Q —? c2 / CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes j meds Further Evaluation by the Local Approving Authority Inspector's Signature: Date: G/—/,q — O/ The system inspector shalt. submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of c6mpleting this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments Wo + elL 61&) A/ 1,V PO (Ae O'S 0 44' -5 Cl�t L /Cfiku ha C-�L ��j �'� 141c G� GvG� ��✓� /G '` ,06l ****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 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:0 ! T 2 S/ 1V ie -- Owner: %//•/t Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: 9 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in'310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ND explain: broken pipe(s) are replaced obstruction is removed - 2 r Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -2Y( v Owner: ball/ U ✓" Date of Inspection: 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. o 4, a. r_ 4, . -. • 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 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, peffoimed at a"DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: w " Page 4 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: N �i!% /V rt,(1L0 OVA S% Owner: / < o ►Ccf Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Ye No,, Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level 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 . Any portion of the SAS, cesspool or privy is below high ground water elevation. . Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] .�(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. 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• You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Z 6 Owner: /! D ✓� Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Y�evs . No, d. �..., r \ - V _ Pumping information was provided by the owner, occupant, or Board of Health _ VWere any of the system components pumped out in the previous two weeks _ Has the system received normal flows in the previous two week period ? V/ Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) V _ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out ? ✓ _ Were all system components, excluding the SAS, located on site ? VWere 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 ? VWas 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: Yes no ff _ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: G &/A/T-(-K- s- b(it.Q02— Owner: l! / <U rza Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): A DESIGN flow based on 310 C15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: r Does residence have a garbage' 'grinder (des or -no): ] ,j PCG Nit Q Is laundry on a separate sewage system (yes or no)•/Lp [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): WO Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): 0 Last date of occupancy: () C4�,U_Ck COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Q Ike (k e ( Was system pumped as part of the inspection (yes or n ): If yes, volume pumped:/00# gallons ---How was quantity. pumped determined? 51 �. _1(1 q�yC Reason for pumping: fW S rp p�`3fvr� V lj TYPE F SYSTEM eptic tank, distribution box, soil absorptian system _ Single cesspool _ Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval _ Other (describe): age of all components, date installed (if known) and source of information: ea rS Were sewage odors detected when arriving at the site (yes or no):/L,0 r , ,.fir ._. �. + ..},Vs.. v -• .. -1.r•. �- .aw. ...• ..'IM.'\�.w �.Y.A\.. �„ �h-V• �-\...�r.^�., w ice. Y. ��r ... �r SAW,.. , Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2V (' h) g— 5r /V Gt-F1r�C- Owner• Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: /,V— Materials of construction: _,ast iron X40 QVC,•other (explain): Distance frob private water supply well or suctibn line: Y j Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: 010cate on site plan) Depth below grade: Material of construction: oncrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 3` = S Kf Sludge depth: Distance from top of sedge to bottom of outlet tee or bathe: b �� Scum thickness: Distance from top of scum to top of outlet tee or baffle:Ou'Ar ha r*r c a Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: GC/ -f Atea-c.ye Z Comments (on pumping recommendations,inletoutlet tee or baffle condition, structural integrity, liquid levels as re yed to .utlet invert, evidence o leakage, etc.): / , D2iYW/ ," ao-ev AYu ve o z-er 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 (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): S: Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address•�ICIK Owner• 4 / U 2 Date of Inspection: 5--,70-01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: a Material of cgnstructioq: &ncrete + metal �� fiberglass _po(§ethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: i/ (if present must be opened)(locate on site plan) o� Depth of liquid level above outlet invert:9"' ©&&Q r Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakinto of box, tQu�CI^J 8 Q)( S S T e rn e af PUMP CHAMBER ocate on site plan) Pumps in working r (y s or no):, . Alarms in working i (yes or no): ;t Comments (note c dition of pump chamber, condition of pumps and appurtenances, etc.): 8 'Page 9 of 11 r ,R OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: i/I I v erz— sf o O Fl- fe' Owner: �� 1 Q Date of Inspection: D"Dl SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: y Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: eaching fields, number, dimensions: 0 A 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, j ,,/ etk CA Cl V'CcvL- c -�-'ct t 1. u �a Roti C:� l�� liTCt .5 -Ci / 'L 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 infldw ('yes or no):, i 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.): 9 er •.". Pagb10of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: / <b /V N . [J Owner: _4a/ / /I 2 Date of Inspection: —O 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;, hin-100 feet. Locate %%here public water supply enters the building. 140, �t CO' �e� 10 Page 11 of Ilk + It , OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:,A11YI r /VO N O t Owner: Ka - Date of Inspection:ld r d� SITE EXAM Slope Surface water 'T Check cellar a Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how y established the high groun water elevatipn: gq S r� a LP i cor.� r,c G�/ a I / Town of North Andover, Massachusetts Form No. 1 N0RT1y A BOARD OF HEALTH Q��SLEo-19 \Rp°°° °w°•�" APPLICATION FOR SITE TESTING/INSPECTION Rgreo Ppa.45 �r Applicant. NAME ADDRE;J(?�L- - A Site Location �� �f�f''�=�r-�'�..� ,yf_` !-11 Engineer!` �1-1..�. �:•:tir'�+.,G�.G�f 1- cL� L NAME /) ADDRESS TELEPHONE Test/Inspection Date and Time Y` Z d7— CHAIRMAN, BOARD OF HEALTH Fee / Test N o. •� S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR SOIL TESTS _ a. r.r . APR I 8 2001 j. n J DATE: _ �� � i MAP & PARCEL: / 01/ Z? LOCATION OF SOIL TESTS: '1 �1(,• 1A�� r� i r!� `�ir��'�t- ��' • fI ;� OWNER: C� c r��n 4. V.: ,11 �� �2�� TEL. NO.: ADDRESS: 1 L Lu ; rv-i ire STrzee ; 'AL" r ENGINEER: P a t'- >~� ���i/lr'C". ',��� TEL. NO.: CERTIFIED SOIL EVALUATOR: gic y X217 C —i4,j&-AP-9. 'a C'A C 0,-6-06 -0 �Tj Intended Use of Land: Residential Subdivision Single Family 'Home Commercial Is This: Repair Testing: ( Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No �( THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. 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 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 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. Please Do Not Write Below This Line � '�`r�' of NORTH A'NDC , BOARD OF HEALTH N.A. Conservation Commission Approval: P 5 Date Received: Check Amount: Check Date: s w Z00o MOMAGE lt4sp CTipN pLAN NDZTH ANl)ovvz,,t- P"4d DEC. 14, i m JOHN Z. SN LUNG ASSOCIATE'S PWFFSSI.ONAL LAM SuPvcyM 4? ARIA? RA LINCocN,MAsS, RI�;31� H F rP 4 9 ^ — 3Za fa.-- ?c,stI� T 5 c,c C l.r Si LoT 43,SR1 5Q,FT \ f_ 1 pre M r A` o ti ^ 9 V/ rZr.oS I PLAN REFERENCES: -PLAN NUMBER 758e, LOT 6WINTER STREET . -PLAN RUMLER 11671, DRAIN EASEMENT, THIS MORTCAGE INSPECTION PLAN AND CFRTLFICATIONS ARE MADE FOR THE USE OF THE PRINCIPAL FINANCIAL GROUP, FOR MORTGAGE PURPOSES ONLY, THE OFFSETS SHCWN OR THIS PLAN ARE NOT THE RESULT OF AN INSTRUMENT SURVET AND UNDER NO CIRCUMSTANCES ARE TREY TO BE USED FOR DETERMINING THE LOCATION OF PROPERTY LINES OR ESTABLISHING THE rOCATION OF ADDITIONS, RASED ON MT RNOVLEDGE, INFORMATION AND EELIEF, i CERTIFY THAT: THE DUILDING CONFORMS TO THE FRONT, SIDE AND REAR YARD SETBAcR REgU1REMENTS AND THE LOT CONFORMS TO THE AREA AND FRONTAGF. REQUIREMENTS OF THE ZONING BY -LANs AND THE TOWN OF NORTH ANDOVER, HASS. OF TH9 STRUCTURE IS ROT SITUATED WITHIN THE SPEr,IAL FLOOD HAZARD ZONE A5 SHOWN ON THE FEDERAL FNERGENCt MANAGEMENT AGENCY MAP OF THF. TOWN OF.MORTIf ANDOVER, MASS, 1COMMUNITY-PANEL NUMBER 250098, FLOOD INSURANCE RATE• MAP EFFECTIVE DATE JUNE 15, 1983), N ,! FL ZK 1 Si+EIlAhli �F S�AI«- FILE 0 LO4Df . ZZZ99LtEL6 YVJ Zt:2T Al TO/ZT1tO D_ll -C�p..,�a Yg"2 d-4,4, T -et "4 9 R -I- 'I 'I bv "�t. ZIL'I'Di o FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 No. / �--- Commonwealth of Massachusetts Massachusetts a.. t - - r- -- fl-- 't - 0 -- — . ( - Performed By: �'! .........��. `....;...... `....�'% 7 Witnessed By: ........... ... ........................................... Date: Date:// Laation Address «��--�—� Owrsr's NaI�J�� �ie� Address, iL01 # end -7q( �� /Z Tc`�717,�AF r �p r— kphone / MCIMA u/'���/ .414Dvdd,0-1 rYl14 � vew Construction ❑ Repair _Office Review Published Soil Survey Available: No ❑ Yes Year Published�•••• ••••..•.••.. Publication Scale/ .................. Soil Map Unit �b ......._.... .. Drainage ClassL, �Pi..�'+p/�.,r.../��,Q� .................. Soil Limitations .......... .........�.. Surficial Geologic Report Available: No � Yes ❑ Year Published Publication Scale -....,...... Geologic Material (Map Unit) ................................. ................................... ....................................... ...... ..... ........... _....... ...... .. Landform................................................................................................................................................................................ ... ...._.... Flood Insurance Rate Map: Above 500 year flood boundary No [.]Yes 5Q Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No []Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) ............................ ................ :.......................... .................. .......... . ,F` ,T ....................................................................... Current Water Resource Conditions (USGS): Month >/ Range :Above Normal ❑Normal ®Belau Normal ❑ Other References Reviewed: _ DEP APPROVED FORM • 12/07/95 I FORM 11 - SOIL EVALUATOR FOIZM Page 2 of 3 or Lot leo. �9r� xlmoo ' Location Address / On-site Review Deep Hole Number / Date:... ;�1� � Time:.: /' . Weather Location (identify on site plan) Land Use �s�Ti�L Slope (%) Surface Stones Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Line :2-�. feet Drinking Water Well 7/.5'Z:;� feet Other ...:...- DEEP OBSERVATION HOLE LOG' Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, Gravel) 49 9 Z- s MINIMUM OF 2 HO/Lt�S, HtUUIHtU AAI ttVtNT rnuruz-tu uiarv3/AL Parent Material (geologic}_ d57i L L DeF Depth to Groundwater: Standing Water in the Hole: J r' Estimated Seasonal High Ground Water: —� kiDEP APPROVED FORM - 12/07/95 r, Bedrock: Weeping from Pit Face: r FORM 11 - SOIL EVALUATOR FORM Page 2of3 Location Address or Lot No. 7 - On-site Review Deep Hole Number Date:.�eQ� Time:. %'. �S Weather[/SAP/ �© Location (identify on site plan) C'7 L nd Use -�`/x� Slope (%) Surface Stones Vegetation Landform Position on landscape (sketch on the back)�'Gm'7�� Distances from: Open Water Body 2 feet Drainage way feet Possible Wet Area feet Property Line .....:....... feet Drinking Water Well 77:L't feet Other :..::..:: ............. :. DEEP OBSERVATION HOLE LOG` Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, Gravel) IVr P i MINIMUM OF Z HULLb HLUUIHtU--Ai ttvtnr rnvrvaw vi�rva ! Parent Material (geologic) _ L��� / L L Depth to Groundwater: Standing Water in the Hole: Estimated Seasonal High Ground Water: DEP APPROVED FORA-) • 12/07/95 rancm Weeping from Pit Face: _ c7 FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. _7f("O' /.�i,T jz �T �� ffxiZ-� Method Used: ❑ Depth observed standing in observation hole ................... inches ❑ Depth weeping from side of observation hole ................. inches Depth to soil mottles ...,.,:.( inches zB ❑ Ground water adjustment ................... feetZ_ Index Well Number .................. Adjustment factor ................... Reading Date .................. Index well level .............. Adjusted ground water level Del2th of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in I areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? -- Certification I certify that on/�5—(date) 1 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 15.017. __---_ Signature �� / ate —Z// DEP APPROVED FORM • 22/07/95 =�0L4.. TI 0 N i i TWE C. i iNl_ 7 j NIE. T I IV i� S Tr. i^7 E �I N `,v- u y ,, i - - I II`/iE.`.T I!I T i i` I E i h w -- v TO: FROM: NORTH ANDOVER, MASS BOARD OF HEALTH DESIGN ENGINEER :%DEC /2- 19 = Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at IZC.7`6 f1(Z/A/-1 . R ST> North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 V,,<< VPI-6VEngineer/ ' . Sanitarian i a�`s�\�G o W1 1v VC) ��Syvr- 20 L o,`._.1' 43 a�`s�\�G o W1 1v VC) ��Syvr- 20 L