HomeMy WebLinkAboutMiscellaneous - 80 LACONIA CIRCLE 4/30/2018Commonwealth of Massachusetts
rj"City/Town of
g System Pumping Record
„ Form 4
information must be substantially the same as that provided here. Before using this form
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
use only the tab
z
SO L0,
��
key to move your
Address ` "
cursor - do not
}�
use the return
—_Y` �na\%r
key.
City/Town
VQ�2. System Owner:
_ Jame_boke_ -,J en l�cj r� 5
N
ZU15
State Zip Code
Address (if different from location)
City/Town-----...
— ---- ... State -----...---
._____
Zip Code
-617'91` `�OC)0
Tmb
elephone Nur —------- --- - -- - --
B. Pumping Record
1. Date of Pumping _— /�
— 2. Quantity Pumped. -
Date _
,�/Gallons
3. Type of system: ❑ Cesspool(s) L� Septic Tank
❑ Tight Tank ❑Grease Trap
❑ Other (describe): - - - - - ------- -------
4. Effluent Tee Filter present? 1/yes ❑ NoIf yes 1/
wa �vJ
5. Condition of System:
s I 't cleaned? Yes ❑ No
6. System Pumped By:
Name
—�' S57a� a
- -----
}� ,,/ Vehicle License Number_Erl)(i�w_nvJ4(Company
7. Location
where contents were disposed -
Signature of Hauler
Signature of Receiving Facility
Dale -._.._
Date -. _.... .
t5form4.doc• 03/06
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts JUL f 2014
VCity/Town of JTOWN OF MORTHANDOVER
7. System pumping Record NORTH ANDOVEEA,THDPART; .:-NT
Form 4
DEP has provided this form for use by local Boards of Health.
lt here. Before using his form, check with your
ther forms may be used. but the
information must be substantially the same as thatp Record must be submitted to
local Board of Health to determine the form they use. The System Pumping in date to
the local Board of Health or other approving authority within 14 days from the pumping
accordance with 310 CMR 15.351.
Important:
When fil5na out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
A. Facility Information
1. System Location:
Address
CityrTown
2. System Owner:
_.-
State Zip Code
o
c
Name
Address (if different from location)
City/Town — ---
State Zip Code
Telephone Number—_
B. Pumping Record
2, Quantity Pumped: Gallons
1. Date of Pumping pate
3. Type of system: s) �ep tic Tank E] Tight Tank ❑ Grease Trap
❑ Cess oof P �
❑ Other (describe) ----
sent? ❑ Yes [9 -no if yes, was it cleaned? ❑ Yds ❑ No
4. Effluent Tee FAer pre
5. Condition of System:
6. System Pumped By
Name
Company
7. Location where contents were disposed:
t5form4.doc• 03106
Vehicle License- Number
jn
D.
140A W a!p oM MA.
Date
Signature of Hauler
__ __
Signature of Receiving _Facility
System Pumping Record • Page i of t
North Andover Board of Assessors Public Access
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Property
Record Card
Parcel ID: 210/105.D-0156-0000.0 Community: North Andover
SKETCH PHOTO
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I
80 LACONIA CIRCLE
Location: 80 LACONIA CIRCLE
Owner Name: BOULLIE, JOHN W
C/O DALE JENKINS
Owner Address: 80 LACONIA CIRCLE
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 7 - 7 Land Area: 1.8 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 3008 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 657,800 686,500
Building Value: 427,000 443,600
Land Value: 230,800 242,900
Market Land Value: 230,800
Chapter Land Value:
LATEST SALE
Sale Price: 299,000 Sale Date: 01/29/1997
Arms Length Sale Code: Y -YES -VALID Grantor: MIDDLETON, RICHARD C
Cert Doc: Book: 04682 Page: 0041
http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=1180987 1/17/2008
I,. of 11
COMMONWEALTH OF MASSACHUSETTS.
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
RECEIVED
Property Address: 80 Laconia Circle North Andover, MA 01845 LVHEACLTCH
6 2006
Owner's Name: John Boullie
Owner's Address: 80 Laconia Circle North Andover, MA 01845
Date of Inspection: November 30, 2006 PARTM DEWN OF NORTH PARTMENT
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 01845
Telephone Number: 978-686-1768
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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (3 10 CMR 15.000). The system:
Inspector's Signature:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Z
The system inspection shall submit a copy of thisinspection report to the Approving Authority ( Board of Health or DEP) within 30
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and
the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system
owner and copies sent to the buyer, if applicable, and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection
not address how the system will perform in the future under the same or different conditions of use.
26f 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
!}� I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR
15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
NO 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):
Broken pipe(s) are replaced
Obstruction is removed
ND explain:
3ofll
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
C. Further Evaluation is Required by the Board of Health:
1%0 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect
public health, safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is
not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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 (SAS) Soil Absorption System and the (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 the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well* *. Method used to determine distance
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organize 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 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other:
4of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
v 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 overload or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times
pumped
✓ Any Portion of the SAS, cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
-� Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.)
/Vo (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
The sy is within 400 feet of a surface drinking water suppl
The system is wit . 00 feet of a tributary to a_sw,ace drinking water supply
The system is located in a nitro nsitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II
of a public water supply we
If you answered "yes" to ide
any ion in Section E the system is c red a significant threat, or answered "yes" in Section D above
the large system has fa' he owner or operator of any large system c idered a significant threat under Section E or failed under
Section D shall upgrade the system in accordance with 310 CMR 15.304. The tem owner should contact the appropriate regional
office of the Department.
5of1'1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
✓ Pumping information was provided by the owner, occupant, or Board of Health
✓' Were any of the system components pumped out in the previous two weeks-?
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of an inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
f Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for sign of break out?
Were all system components, excluding the SAS, located on site?
V- Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum?
✓- Was the facility owner ( and occupants if difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
%/' Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [3 10 CMR 15.302(3)(b)]
6 of 1'1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design) Number of bedrooms (actual):
DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms) G p G 1''i T>
Number of current residents:_
Does residence have a garbage grinder (yes or no):�3 F5,
Is laundry on a separate sewage system (yes or no): N0 [if yes separate inspection required]
Laundry system inspected ( yes or no):
Seasonal use: (yes or no): W 0 )
Water meter readings, if available (last 2 years usage (gpd): i75- GF Cf t 2) a 6
Sump Pump (yes or no): A,10
Last date of occupancy --C � 4, ^ e -n t
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: S " �-+ 2
Was system pumped as part o the inspection (yes or no): .n./o
If yes, volume pumped: gallons — How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_( Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from
system owner)
Tight tank Attached a copy of the DEP approval
Other (
Approximate age of all components, date installed (if known) and source of information:
Jc186 jPcA A -.s- aji_T ?LAr-J
Were sewage odors detected wen arriving at the site (yes or no): /Vy
• 7of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
BUILDING SEWER (locate on site plan)
Depth below grade: .3(0
Materials of construction:Xcast iron 40 PVC_other (explain)
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: 2 4
Material of construction: Y concrete metal fiberglass polyethylene
Other (explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate)
Dimensions: /Sa -;k Cs-AL""JS
Sludge depth: 4. Z
Distance from top of sludge to bottom of outlet tee or baffle: 2 8
Scum thickness: G Z
Distance from top of scum to top of outlet tee or baffle: "
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined: 2e7 r, T7 e.X
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
1-5400L l A-) cr=a D cow/ D t7�4 • Go Ai c ed k O IA. Gv des
iuco n.ticnrX 19 Vi o* wv 06 ,2 &S /� r tf 9--C 7- .4 -✓a
G� t.t c orgF- /- 5A .
GREASE TRAP: (locate on site plan)
Depth below grade:
Materials 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 sludge 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.
8bf11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
TIGHT OR HOLDING TANK: A/ & (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials of construction: concrete metal fiberglass polyethylene 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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O
Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or
out of box, etc.):
009 tti Goofl C6N0,170.v PIW rISu?J,-. Gc` .41-. 1;C01to Or
I. FRA4&-E rAj a d..— 0,2 .sDI-cos c,g/Z/2V
J
PUMP CHAMBER:&21,j= _(locate on sire 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.):
9 of 1'1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required
If SAS not located explain why
TYPE
leaching pits number
leaching chambers, number
leaching galleries number
beaching trenches, number in length — 2 '7—�nc� '?4 G•�J N fir- �� „�, . p c
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc)
4(WA_ n F:� iG! ¢c.a 1.-0.7 I" A.It A.rt,4- .v0 or --
37
i=
37 AAA f -.Go i L o 4 O N %1$ u,4C- V C-' &-4;F 7 4-T?0 A-).
CESSPOOLS: N I 1a (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of Construction:
Indication of groundwater inflow (yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: N )/-V _(locate on site plan)
Material of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 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 excavator, installers — (attach documentation)
_ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
V>(60 w,vlc arta Nam'Ag
.5re "N FFAZA. 15 r -t l(r)4 Eel TH 4v w C"J' A -&c -t+5
42 EWb
.,' sysr c vn cc, s cke 4 pHgt,
10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 80 Laconia Circle North Andover, MA 01845
Owner's Name: John Boullie
Date of Inspection: November 30, 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate
all wells within 100 feet. Locate where public water supply enters the building.
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
PIZ
DATE: 11:3 4C CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTA LER: `9
SIGNATURE: L TELEPHONE#
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
S
$75.00 Fee Attached?
Foundation As -Built?
Administr 've Use Only
Yes No
Yes No
Approval t Date: /4 l_zl
f
Town of North Andover, Massachusetts Form No. 3
t NpRTN BOARD OF HEALTH
(_1 19�,�
DISPOSAL WORKS CONSTRUCTION PERMIT
CHuS�t
Applicant U L)j Uucyr— LYI , ( Y1
NAME ADDRSSS TELEPHONE
Site Location_ CA-
Permission is hereby granted to Construct ( ) or Repair (1-,j/an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
,,��MAN,-BOARD OF HEALTH
Fee D.W.C. No.
C
NORTH s
m
o �
CO
�SSACHO
North Andover Health Department
Community Development Division
Date: July 25, 2011
Dale and Tiffany Jenkins
80 Laconia Circle
North Andover, MA 01845
Re: Denial of Application for the addition of a garage and a grand room at 80 Laconia
Circle, North Andover
Dear Mr. and Mrs. Jenkins,
Your building permit application for an addition, submitted on July 22, 2011, has been reviewed
by the Health Department. Unfortunately, the application cannot be approved by the Health
Department for the following reasons found below in bold and in red:
1. ❑ Missing information
2. ❑ Passing Title 5 inspection of septic system required
3. ❑ Location of structure not acceptable
4. x Undersized septic system
To address the problem(s):
If #1 is checked, please supply: A floor plan of the existing home and proposed addition —
please label all rooms
a. Draw in the project on the As -built at the Health Dept. showing house, septic
system and proposed project in scale (this can be done in the Health Dept)
If #2 is checked:
a. Once the Health Director reviews the room count and gives the approval, have the
septic system inspected by a certified Title 5 inspector to determine whether it is
operating properly: A list of licensed inspectors can be found at
httn://www.townofnorthandover.com/PaQes/NAndoverMA Health/nermitsandresrs
b. Tie-in to municipal sewer
80 Laconia Circle July 25, 2011
If #3 is checked: NO
a. Relocate the project
If #4 is checked:
a. The subsurface disposal system is currently designed for a 4 -bedroom
(maximum 9 room) home. Floor plans submitted indicate the current home is
11+ rooms, which exceeds the MA DEP Environmental Code 310 CMR 15.204
(see attached). Room numbers include all habitable rooms, excluding bathrooms,
hallways etc. The system must be upgraded to a fully compliant Title V system.
This application has been denied. It is recommended that you contact a professional engineer,
who is proficient in the MA State code Title 5: Minimum Requirements for the Subsurface
Disposal of Sanitary Sewage, if you wish to move forward in this project. The engineer can
guide you through the options available to you and the process as set forth in the code. Please
feel free to call the Health Office at 978-688-9540 with any questions you may have.
Stisl an Sawye'
Public Health Director
Cc: Building Department
Conservation Department
Tom Cassidy, TnT Consulting
File
Encl: excerpt of Title V
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Sawyer, Susan
From: Golden, Claire (DEP) [claire. golden @state. ma. us]
Sent: Monday, July 25, 20112:38 PM
To: Sawyer, Susan
Subject: Deed Restriction for Number of Bedrooms
Susan,
Please see if the following adequately addresses your questions:
When an addition is planned to a structure, especially a dwelling, it is reasonable to assume that the addition
constitutes new construction and that construction of a new septic system conforming to new construction
standards is mandated. This assumption may be overcome on a case-by-case basis and with the agreement and
concurrence of the local approving authority.
310 CMR 15.002 provides definitions of terms used in Title 5 of the State Environmental Code. Of note should be
the definitions of bedroom and new construction.
If an addition is planned to a dwelling and it is reasonable to assume through the very definition of bedroom, that
the addition results in an increase in design flow, an applicant may overcome this presumption through imposition of
a deed restriction on the property. This deed restriction would limit the number of bedrooms in the dwelling. This
deed restriction cannot be imposed upon the property by the applicant without the review and approval/rejection
by the local approving authority. Local approving authorities are advised to consider wisely the circumstances
under which they would be willing to accept such a deed restriction. I have already forwarded to you a copy of
MassDEP's proposed deed restriction for bedrooms. Acceptance of this deed restriction by the local approving
authority does not require a variance to be granted unless required under a local bylaw or regulation.
In rare cases, an applicant may apply for a variance for increased flow to an existing system, see 310 CMR 15.414.
The requirements for applying for and for granting such a variance are extensive. Please note that the Northeast
Regional Office has only received one application for such a variance since 1995.
I hope this clarifies the matter.
Claire
Claire A. Golden
Environmental Engineer IV
Watershed Permitting Program
MaSSt)EP/NERD/BRP
2058 Lowell Street
Wilmington, MA 01887
direct: 978-694-3244
fax: 978-694-3498 or 978-694-3499
claire.golden@state.rna.us
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WWlam F. Weld
Goiwrnor
Ary*o Paul C*Iluccl
U. Gowmor
Commonweafth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Trudy Cox*
David S. Struhs
Commbsiornr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _
CERTIFICATION
Property Address: 90 e -ACO IVI'/9 Address of Owner.
Date of Inspection: De C t I l9 5 L (If different)
Name of Inspector. (,v i // "q- k..' C✓fOUL)
Company Name, Address and Telephone Number-
CERTIFICATION
umber
CERTIFICATION STATEMENT
I 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 "wage disposal systems. The system:
v Passes ,
_ Conditionally Passes
_ Needs s Further Evaluation By the Local Approving Authority
Fail ' :.
Inspector's signature: .Ci��""" (� Date,
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
J inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater; the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
I
Al SYS ASSES:
i
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.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes
inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, 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.
(revised 11/03/95)
One Winter Street • Boston, Massachusetts 02108
1
• FAX (617) 556-1049 • Telephone (617) 292.5500
0 A
Pnnted on Recycled Paper
4
Type: Emergency
Cesspool: Irlo
Cate of Pumping: 04--C�
System Pumped By:
Contents transferred to:
Contents Disposed at:
Date:
Commonwealth of
Routine
Yes
-- System Pumping
Location I AN o— .,s
MAY 16 2005
TOWN ur Nb.,_. H AdDJV
HEATH DEPARTMENT
Septic tank: W F-jYe, ED
Quantity Pumped:( 0 6(J --d Gallons
Wind River Envimmmnfni, LLC Permit #:
of System/Other Comments
Pumper Signature: (SFIQ
Dep Approved Form - 12/07/95
-
NORTH `r
� 9
• Town of North Andover
` '• ' ,` HEALTH DEPARTMENTS ,/,o
CHusst �'7
CHECK #:
LOCATION:
H/O NAME:i�9��!—�c�C.
COLT-- AGT -N'A'i' -
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5Inspector $
itle 5 Report $
❑ Other. (Indicate) $
2058 ao,
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Commonwealth of Massachusetts
City/Town of --
= System Pumping Record NORTH ANDOVCbe!�7sed,�but
Form 4
DEP has provided this form for use by local Boards of Health. Other forminformation must be substantially the same as that provided here.Beforelocal Board of Health to determine the form they use. The System Pumpi
the local Board of Health or other approving authority within 14 days from the pumping date In
accordance with 310 CMR 15.351.
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping z4ho--
2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) U Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o
5. Condition of System:
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
of Hauler
Signature of Receiving Facility
If yes, was it cleaned? ❑ Yes ❑ No
to
x''62 ----
vehicle License Number
Date
Date
<o
t5form4.doc• 03106 System Pumping Record • Page 1 of 1
A. Facility Information
Important:
When filling out
1. System Location:
forms on the'0
A4—pC(Q
`.. (1
computer, use
only the tab key
to move your
— - —�— — — -- ---__
Address
, V a/�
cursor - do not
City/Town State
use the return
key.
2. System Owner:
�°
Name
- - -----
Address (if different from location)
Cityfrown —_ ---- — — — State
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping z4ho--
2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) U Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o
5. Condition of System:
6. System Pumped By:
Name
Company
7. Location where contents were disposed:
of Hauler
Signature of Receiving Facility
If yes, was it cleaned? ❑ Yes ❑ No
to
x''62 ----
vehicle License Number
Date
Date
<o
t5form4.doc• 03106 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MAlky-AVEbl %J
- System Pumping Record
�.i
Form 4 OCT 0 4 2009
DEP has provided this form for use by local Boards of He�lfbwN� p: tS.h� t> &fflvf 9 t Record must
5. Condition of System.-
Good
ystem:Good
6. System Pumped By:
Na e Vehicle Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
be submitted to the local Board of Health or other approvihgUtMhp . E ARTMENT
A. Facility Information
Important:
When filling out
1. System Location:
forms on the
computer, use
o 1_Q Con t G C',rd -C,
only the tab key
ss
to move your
L' DOOM
cursor - do not
use the return
City/Tow
State
Zip Code
key.
2. System Owner:
Name
Address (if different from location)
City/Town
State
Zip Code
_b)q_!Lj-
000a
Telephone Number
B. Pumping Record
9-1 L4- 09
1. Date of Pumping
Date
2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s)
[v"'Septic Tank ❑
Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [No
If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System.-
Good
ystem:Good
6. System Pumped By:
Na e Vehicle Number
Company
7. Location where contents were disposed:
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
CommonwealthWofassacbusetts
City/Town of :OCT- 7 200
o
System Pumping Recor
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use �G CZO Y) 10 CI r ClIc,
only the tab key Address ` /� �/
to move your No��h j'I��OYe� 6G c))�'L��
cursor - do not City/Town State Zip Code
use the return
key. 2 System Owner:
Jenkin S
Name
!L Address (if different from location)
City/Town S to Zip Code
-q74-0ooa
fstephode Number
B. Pumping Record
�-
1. Date of Pumping Date a6 -o8' 2. Quantity Pumped: Iyao
Gallons
3. Type of system: ❑ Cesspool(s) [+Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes [j No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Good'
6. System Pumped By:
Jty,n -760
Name Vehicle License Number
wiyl)j E10v►ro�n
Company
7. Location where contents were disposed:
Ipswich water
Treatment Plant
Signature of Hauler Ipswich, MSR 01938 Date
Signature of Receiving Facility
t5form4.doc• 03/06
Date
System Pumping Record • Page 1 of 1
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Type: Emergency
Cesspool: No
Date of Pumping:
System Pumped By:
Contents transferred to:
Contents Disposed at:
Commonwealth of Massachusetss
: Massachusetts
System Pumping Record
Location
,aa
AI,, i lit. , e 4 5 ;
Routine
4x Yes Septic tank: No Yes
Quantity Pumped: Ikms
Wind River Environnnentoi, LLC Permit #:
L S,
Date: Pumper Signature:
Condition of System/Other Comments
Dep Approved from - 12/07/95
41::'
NdI�TN /JtiI�U�I�, MA,
�jpPU CAti j F-1045-
(JT,�� Sv�?Ly - - TbWnl ❑ WELL- ,�� oycD1YJTC
SS �' SEPTIc Sy S i ,_..�.
EMS
4PP�avt-v
(fOUJPITiays =
DI PPP4 v5p
�EASoNS
p r6'
1A 1-6
C- X4V4T(o,0 ),A.)'-, f? GTO & J
FINAL WSP6:�:jIoo
4 PPROOED
5C'PF(('- 5'y STENt W STA t LAT IOA J
Arc
QJ13T6,T-16 -kG
AVPITjoJAL I)�j5Fbc: jo^'S (j}= -,may)
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0 ►3,155 E] F-4►L-
APFr�avJ,vG AUTHOI�� zy �ZV
FML /J PPFZ(jVA L
BOARD OF HEALTH
No.Andover, Mass. t X(7 1
SUBSURFACE DI5POSAL DFMGN CHECK LIST
• J id
LOT # /,4CO�Q a Gs K -
APPROVED DATE 7-/ Z %
DISAPPROVED DATE
Provided:
Reasons: �' L
—Y
Title V
FAIL
OK
Reg 2.5
The submitted plan must show as a mi.nimu:.:
a) the lot to be served -area, dimensions Int Cabutteris
b location and log deep observation ),Z( ;-distance to ties
c location and results percolation t 3t -•distance to ties
d design calculations & calculations shoT'ng required leaching area
(e) location and dimensions of system-includsng reserve area
f) existing and proposed contours
(g) location any wet areas within 1001 of sewage disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board files
(j) known sources of water supply within 2001 of sewage disposal d .
system or disclaimer
(k) location of any proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
-
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, c stribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan mast be prepared by a Professions Engineer or other
professional authorized by law to p eptre such plans
Reg 6
Septic Tanks
(a) capac t es- 50,% of flow, water table, tnei, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or iuground sximmi.ng pool
(d) 251 from subsurface drains
Reg 10.2
7 Distribution Boxes
Reg 110.4
(b) �e greater 0.08
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Thursday, January 17, 2008 10:50 AM
To: 'gfuller@wrenvironmental. com'; 'jganong@wrenvironmental. com'
Subject: 80 Laconia Circle - Copy of File
Importance: High
Here is the copy of the file that we have.
-----Original Message -----
From: noreply@yourcopier.com [maiIto: noreply@yourcopier.com]
Sent: Thursday, January 17, 2008 11:38 AM
To: DelleChiaie, Pamela
Subject: Message from KMBT 600
EaN
SKMBT 600080117
11370.pdf
�L Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. - -
WN OF NORTH ANDOVER
State z HEALTH DEPARTMENT
State ZipCode
q-� 86e -
Te pnone Number
B. Pumping Record
1. Date of Pumping e3L-�� — 2. Quantity Pumped-
Dal
3. Type of system: [j Cesspool(s)Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe).
4. Effluent Tee Filter present? ❑/ Yes57` O If yes, was it cleaned? ❑ Yesj*�o
5. Condition of System
& Syste u ped By:
Name vehicle License Number
Company .4.dpacr`
7. Location where contents were disposed: 'tea•
Signature or Hauler Date
Signature of Receiving Faolity Date
t5fomt4 doc• 03106 System Pumping Record - Page I of t
A. Facility Information
Important:
When filling out
forms on the
1. System Location:
QQ 1 Ci rt
eomputer,use
only the tab key
to move your
Ad ress/1
ji.�.
cursor . do not
use the return
C ly(fo wn
key
2. System ^Owner:
Name - -
Address (if different from location)
cbyrro— -
WN OF NORTH ANDOVER
State z HEALTH DEPARTMENT
State ZipCode
q-� 86e -
Te pnone Number
B. Pumping Record
1. Date of Pumping e3L-�� — 2. Quantity Pumped-
Dal
3. Type of system: [j Cesspool(s)Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe).
4. Effluent Tee Filter present? ❑/ Yes57` O If yes, was it cleaned? ❑ Yesj*�o
5. Condition of System
& Syste u ped By:
Name vehicle License Number
Company .4.dpacr`
7. Location where contents were disposed: 'tea•
Signature or Hauler Date
Signature of Receiving Faolity Date
t5fomt4 doc• 03106 System Pumping Record - Page I of t
Commonwealth of Massachusetts
City/Town of
System Pumping Record NORTH ANDOVER
- Y ��-�a
Form 4 A,:�
h DEP has provided this form fqr use by local Boards of Health. Other forms may be' used, but the
as that provided here. Before using this form, check with your
information must be substantially the same
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor _ do not
use the return
key.
1. System Location:
Address
City(Town
2. System Owner:
71- �, r
_. - . ....
State Zip Code
- -
Name
Address (if different from location) -
-
State Zip Code
City(rown
Telephone Number _
B. Pumping Record
/So 0
2. Quantity Pumped: Gallons1. Date of Pumping
Date
3 T e of s stem ❑ Cesspool(s) Septic.Tank ❑ Tight Tank ❑ Grease Trap
yP Y
❑ Other (describe): -- — — -
4. Effluent Tee Filter present? ❑ Yes [4S
5. Condition of System:
6. System Pumped By.
Name
Company
7. Location where contents were disposed:
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
----- ------- — — - Date
Signature of Hauler 0 ..D
-- --- ---- ---- - ._..dV MA Date
Signature of Receiving Facility
System Pumping Record • Page 1 of 1
15form4.doc• 03/06