HomeMy WebLinkAboutMiscellaneous - 805 FOREST STREET 4/30/2018i
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North Andover Board of Assessors Public Access
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Town of North Andover
]3taaFd of Assessors
Parcel ID: 210/105.D-0018-0000.0
SKETCH
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Page 1 of 1 '
Property
Record Card
Community: North Andover
PHOTO
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t05
STREET
Location: 805 FOREST STREET
Owner Name: DUMALAC, JOHN M & GRACE C
Owner Address: 805 FOREST STREET
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 6 - 6 Land Area: 1 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2556 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 739,600 676,300
Building Value: 508,700 466,300
Land Value: 230,900 210,000
Market Land Value: 230,900
Chapter Land Value:
LATESTSALE
Sale Price: 602,500 Sale Date: 10/30/2002
Arms Length Sale Code: Y -YES -VALID Grantor: MARCHAND, JACQUES
Cert Doc: Book: 07224 Page: 0007
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&LinkId=990625 4/27/2007
Lot & Street 1 Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: ES NO Permit# 6
Plan Approval: Date: �14W* Approved by:��
Designer: Plan Date:_aa
Conditions:
Water Supply: own Well
Well Permit: Driller:
-Well Tests: Chemical Date Approved
Bacteria I Date Approved
``Bacteria 11 Date Approved
Plumbing Sign -Off: Wiring Sign -off:
Comments:
Form °Un Approval: Approval to Issue�YES j NO, -
Date Issued /o? / By:
Conditions:
Final Approval:
All Permits Paid? YES" NO
Well Construction Approval? YES NO
Septic System Construction Approval? YES' NO,
Certification? YE'S',' NO
Other? YES NO
Any Variance Needed? YES NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
CONDITIONS:
Date:. K5 516 It'-,
Dater
Final Construction Approval: Date:,
Certificate of Compliance: Approval:
M
By: e '
Date:
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
�M
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.
A. Facility Information
1. System Location: eft front o , right front of house, left side of house, right side of house, Left
rear of house, righ rear o house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner: C,\j -A
Name `1
Address (if different from location)
City/Town State t-7l(l ZiVaqde
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date
Cesspool(s)
— 2. Quantity Pumped:
eptic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes lo— If yes, was it cleaned? ❑ Yes ❑ No
5. Condition pfSem:
I'�v
�Ct�(
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
F5821
Vehicle License Number
r
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1
N Ew ]ENGLkND IENGINEIEMG SERVICES, INC.
B00 Osgood Street
uilding 20 Suite 2-64
North Andover, MA 01843
Ifel: (978) 686-1768 • Fax: (978) 327-6138
Benjamin C. Osgood, Jr., P.E. —RE CdEIWED
President
APR 2 4 2006 1 April 20, 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
RE: TITLE V REPORT: 805 Forest Street North Andover, MA
Dear Ms. Sawyer:
Enclosed is the Title 5 Report for the above referenced property. The system PASSES
the inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely,
z:)
—�
Benjatvdn C. Osgood
Certified Title 5 Inspector
s y
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
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Owner's Address: 805 Forest Street North Andover, MA 01845
Date of Inspection: April 19, 2006
RECEIVED
APP 2 4 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 STATEMI+.NT
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:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
Z-.
The system inspection shall submit a copy of this Rection 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 does
not address how the system will perform in the future under the same or different conditions of use.
2of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 2006
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
j / 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:
JVO 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_
3 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 2006
C. Further Evaluation is Required by the Board of Health:
90 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: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 2006
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an 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
K Liquid depth in cesspool is less than 6" below invert or available volume is less than'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times
pumped
x Any Portion of the SAS, cesspool or privy is below high ground water elevation
N Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
7 Any portion of a cesspool or privy is within a Zone 1 of a public well.
>1� Any portion of a cesspool or privy is within 50 feet of a private water supply well.
T- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for
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.)
_(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 b onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You m tate either `yes" or "no" to each of the following:
('The followingcWerp apply to large systems in addition to the criteria above)
Yes No
The system is within 400 fa surface drinking water y
The system is within 200 feet of a tributary surface drinking water supply
The system is located in a p)xon sensitive area
of a public water suppPfkell
Protection Area — IWPA) or a mapped Zone R
If you answered "yes" to question in Section E the system is considered a significant thr r answered "yes" in Section D above
the large system }�a ailed The owner or operator of any large system considered a significant under Section E or failed under
Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should con ct the appropriate regional
office of the Department.
6of11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 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) y L1 0 &—Q P
Number of current residents:_ —
Does residence have a garbage grinder (yes or no): N`
Is laundry on a separate sewage system (yes or no): N [if yes separate inspection required]
Laundry system inspected ( yes or no):
Seasonal use: (yes or no):)fl
Water meter readings, if available (last 2 years usage (gpd): Tn Lo Af
Sump Pump (yes or no):IVD
Last date of occupancy &j,tT-
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft, 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: Z Do 3 QEiZ o,-- 6L
Was system pumped as part of the inspection (yes or no): IV 0
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 (describe):
Approximate age of all components, date installed (if known) and source of information:
2003 YCf7, Ar ?��, C—V
Were sewage odors detected wen arriving at the site (yes or no): 0
7of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 2006
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of construction: cast iron_C 40 PVC_ other�ea:plain)
Distance from private water supply well or suction line: N
Comments (on condition of joints, venting, evidence of leakage, etc.):
�lisc Me.nE i✓t tsl (G'rr� lam/ ��L: iy y +J,sr ( 6
SEPTIC TANK: (locate on site plan)
Depth below grade: 0
Material of construction: 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:rS �<.� �,.q ti AJ.S
Sludge depth: - i
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: .4
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:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
TAgX/ik IN e-V')�, ('dhjr,,111,).J, -156 K 44z) P;C //� C -U,30 r0,y1)r-(?4A-,
GREASE TRAP: �✓ f� (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.
8of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 2006
TIGHT OR HOLDING TANI :24_(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:
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.): (� n !
&X L,A),De� rC� }FGfi �JnJc'FJ' l- L.("'rj-XL'i y
CUE- 2
PUMP CHAMBER: /V (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.):
9of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 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
$ leaching trenches, number in length
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)
.a Ac -,/9 y F `/L L Q -,y 0 Al 1 A L. /,/ => E✓ ID e,- (- L` 6 F-- t�G� � � ,v � 0A'1 -1P
SG'�b G;2 U/t:UcC-- /-A7A) C, �Le it
CESSPOOLS: .,v d (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: l� (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.
10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 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.
aG
11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest Street North Andover, MA 01845
Owner's Name: Grace Dumalac
Date of Inspection: April 19, 2006
SITE EXAM
Slope & 0l1
Surface water v j v
Check cellar N> s"AA r� �Dr2y
Shallow wells
Estimated depth to ground water __fa 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:
J?�1SiPv✓� D�S�ac�r 7 � � �gt?.1C „✓ � ��'�i4Y
tel' 2 3 2002
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a
DEPARTMENT OF ENVIRONMENTAL PROTECTION
yt
l v\y
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 805 Forest Street
North Andover, DQ --01845
Owner's Name: daequs—larch—QnA
Owner's Address:
—80S Ferest Street
Date of Inspection: —Nerth Andover—, P4A 01845
Name of Inspector: (please print) James Wright
Company Name: R_,T_ TnsnPrtio s, Inc.
Mailing Address: nnP 0Gaond r-eet
MPt-hUeP MA 01 R44
Telephone Number: q 7 tI _ h p 1_ 8 7 5 q
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
Needs Further Evaluation by the Local Approving Authority
Fails
j
Inspector's Signature: � ate:01
The system inspector shall' Submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of
completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****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 I
Page 2 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 805 Forest Street
North Andover MA 01845
Owner: 1a� =1�Ps Marchand'
Date of Inspection: 1 n / 1 5 /Q.2
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. Sysstt 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:
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 Healtb):
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
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 805 Forest Street
North Andover MA 01845
Owner: Jacques Marchand
Date of Inspection: 1 0/ 15 / 0 2
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.
System will pass unless Board of Health duet ines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner ich will protect public health, safety and the environment:
_ Cesspool or privy is with 0 feet of a surface water
Cesspool or privy is in 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 i hin a Zone I of a public water supply.
The system has a septic tank and SAS the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**, thod used to determine distance
**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.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 805 Forest Street
North Andover 01845
Owner: Jacques Marchand
Date of Inspection: _j.Q 15 / 0 2
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
tackup 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
_ ZMgged SAS or cesspool
o
atic liquid level in the distribution box above outlet invert due to an overloaded or clogged gg SAS or
cesspool
`Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow
— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
ones pumped
�y 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.
�y portion of a cesspool or privy is within a Zone 1 of a public well.
�y 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.]
, V V (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�oof
ce drinking water supply
— _ the system is within 200butary to a surface drinking water supply
the system is lo�d 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.
4
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 805 Forest Street
Nnrth AnhnvPr MA 01845
Owner: , a-c„'�s Marchand
Date of inspection:_ 1 0'/jS,i0 -)
Check if the following have been done. You must indicate `yes" or "no" as to each of the following:
/eNo Pu
ping 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 there '
p vtous two week period .
,-./--'Have large volumes of water been introduced to the system recently or asart of this inspection ?
P P
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out ?
Were all system components, excluding the SAS, located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
�of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner (and occupants if different from owner provided with information ormadon 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 n
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)]
Page 7 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest St.
North Andover MA 01845
Owner: JLqques Marchand
Date of Inspection: 10/1 Z02
BUILDING SEWER (locate on site plan)
Depth below grade: L ' -
Materials of construction: —cast iron 40 PVC _other (explain):
Distance from private water supply well or suction line: /✓ /�i` ' _
Comments (on condition of joints, venting, evidence of leakage, etc.):
re
SEPTIC TANK: — (locate on site plan)
,�
Depth below grade: _,
�
Material of construction: 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: �/ S X Q
Sludge depth: '�
Distance from top of s udge to bottom of outlet tee or baffle:
Scum thickness:— `/
b
Distance from top fscum to top of outlet tee or baffle: r r
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments (on pumping recommendations, inlet and outlet tee or affle condition, structural integrity, liquid levels
as related to outlet invert, evide ce of leakage, etc.):
ti C-1�� vj 1'�/ r �L.
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 of outlet tee or baffle:
Distance from bottom o um to bottom of outlet tee or baffle:
Date of last pumpi .
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
I
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest St
North Andover MA 01845
Owner: Ta c Marchand
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: ns/day
Alarm present (yes or no):
Alarm level: Al 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:
Comments (note if box is level and distri uti tion to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.)-
dl,-
tc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes o
Comments (note conditio pump chamber, condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest St.
N.Andover MA 01845
Owner: Jacques Marchand
Date of Inspection: 10 1 r,/02
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:
✓teaching trenches, number, length: / Zj
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.):
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 cons ion:
Indication of undwater inflow (yes or no):
Comments ote 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 ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest St.
N. Andover MA 01845
Owner: Jacques Marchand
Date of Inspection: 10/15/02
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.
10
Page 11 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 805 Forest St.
N.Andover MA 01845
Owner: Jacques Marchand
Date of Inspection: _ 10/15/02
SITE EXAM
Slope
Surface water
Check cellar
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:
_,,__C-hecked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established t e high ground water elevation:
�T
11
Page 6 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: -N. Andeve:r M. -A 01845
Date of Inspection: , „ L- ,,
v 7 F
RESIDENTIAL LOW CONDITIONS
Number of bedrooms (design): �'-f Number of bedrooms (actual):
DESIGN flow based on 310 CIv l 5.203 (for example:110 gpd x # of bedrooms):
Number of current residents:_
Does residence have a garbage grinder (yes or no): A10
Is laundry on a separate sewage system (yes or no): o�a[if yes separate inspection required]
Laundry system inspected (yes or no): —
Seasonal use: (yes or no): f mac'
Water meter readings, if available (last 2 years usage (gpd)): Z = ,
Sump pump (yes or no): /V G
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/,sgft,etc.):
Grease trap present (yessr po)`
Industrial waste hol4i g tank present (yes or no):
Non -sanitary waste discharged to *e Title 5 system (yes or no): —
Water meter readings, if available�-
Last date of occupancy/use: f ;�
OTHER (describe): i
Pumping Records GENERAL INFORMATION
Source of information: 0 Gw/,.- /=�
Was system pumped as part of the inspection (yes or no): �j _
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping: IIIA -41
TYTY E 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 _ Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components date installed (if known) and sour e of informat'on:
S /f/L�7� C71 -G G G
Were sewage odors detected, when arriving at the site (yes or no): —
6
11
i ) l` I o f, y oar, ��) -t�
AS -BUILT CHECKLIST
LOT NUMBER, STREET NAME
ASSESSORS MAP & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
r/ TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
_lz_ LOCATIONS OF DEEP HOLES & PERC
TESTS
t� ELEVATIONS OF DISPOSAL SYSTEM
-- TOP OF FDN ELEVATION
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
&6f rJ
.411
i�dm,A-
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Dispos.al System ( constructed;
( ) repaired; `.
by
located at OTS.
was installed in conformance with the North Andover Board of Health approved plan,
System Design Pe. -,, t u 109b, dated with an approved design
flow of 44-6 gallons per day. The materials used were in conformance with those
specified on the approved plan; the system was installed in accordance with the provisions
of 310 Cti1R 15.000, Title 5 apd local regulations, and the final grading agrees
substantially with the approved plan. A.11 work is accurately represented on the As -built
which has been submitted to the Board of Health.
Bed inspection date:
,. Engineer Reor6entative
Final inspection date: 5 - ( 6 - 2 Q0o '6
Engineer Represe native
Inst 1ALica: Date:
Design Engineer:
ANDOVgR down TAM- INM
1MT RIVER 0"1
MUEN, MA\061I,844
Date:
AS -BUILT CCUIST
�_--
LOT NUMDER. STREET NAS L/- �0 v
ASSESSORS. MAP & PARCEL NVN:BER
LOT LINES &; LOCATION OF DWELLINGS
LOCATIONS & DIMENNSIONS OF SYSTEM.
INCLUDING RESERVE
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANX
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAI'JS, WATERCOURSES
WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF IfOUSE TO CENTER OF
TANK & D -BOX
ORIGINAL STAMP & SIGNATURE
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
LOCATION & ELEVATIONS OF BEN"GI MARK I SED
Town of North Andover
OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLIAM J. SCOTT
Director
(978)688-9531
September 15,1999
Andover Consultants, Inc.
1 East River Place
Methuen, MA 01844
RE: 805 Forest Street
27 Charles Street
North Andover, Massachusetts 01845
Dear Mr. Jordan:
This letter is to inform you that the proposed septic plan for 805 Salem Street,
North Andover has been disapproved for the following reasons:
Fax(978)688-9542
• The foundation drain is missing. (NA 8.02y)
• Please. label existing well and add a note stating that this well is to be abandoned
according to accepted standards prior to any construction.
Please do not hesitate to call the office at the number below if you have any
questions.
Sincerely,
Sandra Starr, KS.
Health Administrator
Cc: William Hamel
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
4
INSPECTION CHECKLIST FOR SEPTIC SYSTEMS
t ,r
Yes
A. Bottom of Bed
1. Excavation to proper depth
2. With trenches, sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation, etc. rl
Comments:
B. Retaining Wall
1. Wall height and width as specified
2. Waterproofed
3. Wall minimum 10' to leaching facility
4. Wall meets specifications of plan
Comments:
NO Initials
f
C. Building Sewer
ice,
1. Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Watertight joints
4. Inlet to tank cemented
5. Slope minimum 0.01 or 1/8" per foot minimum
6. Pipe properly set on compact firm base
7. Pipe laid on continuous grade in straight line
8. Cleanouts precede all change in alignment and grade
9. Manholes at any 90° change
10. 10' minimum offset to water line
Comments:
14. Tank is watertight
Comments:
D. Septic Tank
1. Level
2. 1,500 gal minimum
v
3. Gas baffle present on outlet
4. Manhole to grade
5. Manholes over center and each tee
6. 3-20" manholes
v
7. Inlet tee minimum 12" under invert
8. Outlet tee minimum 14" under invert
r
9. Outlet line cemented
,'/
10. Air space 3" above tees
11. 2" - 3" drop from inlet to outlet
12. Pipe set
13. Compact base with 6" of 1/4" crushed stone under tank
✓'
14. Tank is watertight
Comments:
Yes NO
E. Pump Chamber
1. If separa1e�from tank, compact base with 6" of '/4" stone underneath
2. Minimum 2 ',Ripe to d -box if gravity system
3. 20" access m%with
4. Tank level
5. Watertight
6. Tank size agrspecification
7. Manhole to grade
8. Check valve and bleeder ho
9. Alarm in building on separate
10. Alarm functions
11. Manual operating switch
12. Pump delivers liquid to d -box
Comments:
F. Distribution Box
1. D -box level
2. Minimum 0. IT' (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
Comments:
G. Soil Absorption system
1. All stone double -washed -'/4" = 1 '/2"
- pea stone
Bucket test done?
2. Minimum 2" of pea stone above distribution lines _
3. Minimum 6" stone beneath pipe _
4. Distribution lines capped or connected together _
5. Grading meets 3:1 slope _
6. Minimum of 9" of fill graded over system
7. Toe of slope stops minimum 5' from edge of property; if not, then swale.
Comments:
H. Leach Trenches
1. Minimum 2 trenches
2. Length of trenches agree with plan. (Max. length 100')
3. Width of trenches agree with plan - Minimum 2'; maximum - 4'.
Vent present if <50 feet or specified
'5. Distance between trenches minimum 4' and maximum of 6'
6. Minimum distance between trenches 10'
7. Pipe slope minimum 0.005 or 6" per 100'
8. Depth of trenches below outlet invert minimum of 6".
;f
w
Yes NO
9. Pipes set on stable base.
Comments:
1. Leach Field
1. Maximum length of field 100'
2. Pipe slope minimum 0.005 or 6" per 100'
3. Separation between pipe 6' maximum
4. Pipes connected at end
5. Separation between adjacent fields 10' minimum
6. Pipes set on stable base
7. Maximum 4' separation from edge of field to first line
8. Minimum two distribution lines
9. Maximum perc rate 20 mpi
Comments:
I Leaching Pits
1. Minimum inlet pipe 4"
2. Pits of concrete
3. Sidewall between 12" and 48" wide
4. Access manholes on each pit
5. Pipes cemented with hydraulic cement
Comments:
K. Final Grade
1. Slope over soil absorption system minimum 0.02
2. All system components covered by at least 9" soil
3. Cover soil free of stones larger than 6"
4. Grading slopes away from dwelling
5. No areas over system that may pond
m
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0
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the property
at eO_')� i aF��S' S7 relative to the application of -7}+-omP-5 M.
dated y- 2 o -ao for plans by %u,o '� -:Y*-P by and dated with
revisions dateds;'
I understand and agree to 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 Title 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 BOH 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.
Undersig d Licensed Septi aller
- Date:
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERtNHT
DATE: �' �y CTJRRENT rNSTALLER'S LICENSE, / `—<f>
LOCATION: rre s /V6r �A 1�,n alti u r
LICENSED INSTALLER: �"! Gw►A5��
SIGNATURE
CHECK ONE:
REPAM:
'TELEPHONE, / 76 V3
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
575.00 Fee Attached?
Foundation As -Built?
Fioor Plans?
Approval
Administrative Use Only
Yes No
Yes N o
Yes: No
Date:
WILLIAM I SCOTT
Director
(978)688-9531
i
Town of North Andover NORTH
OFFICE OFO�Og 4, �t0 ,0 ,10
COMMUNITY DEVELOPMENT AND SERVICES z
.
27 Charles Street
North Andover, Massachusetts 01845
September 29, 1999
Mr. Jordan
Andover Consultants, Inc.
1 East River Place
Methuen, MA 01844
Re: 805 Forest Street
N. Andover, MA 01845
Dear Mr. Jordan:
This is to inform you that the proposed septic plans to construct a maximum of nine (9)
rooms have been approved for the site referenced above.
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.
Health Administrator
SS/sc
cc: William Hamel
File
Fax(978)688-9542
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Town of North Andover, Massachusetts Form No. 2
pORTN BOARD OF HEALTH
A
� �r' DESIGN APPROVAL FOR
SACNU`+Et�
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
ApplicantdweL Test No. l�
Site Location
Reference Plans and Specs.
ENGINEER
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee_
CHAIRMAN, BOARD OF HEALTH
Site System Permit No.
Town of North Andover, Massachusetts
BOARD OF HEALTH
F >,
APPLICATION FOR SITE TESTING/INSPECTION
Form No. 1
19
Applicant
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
CHAIRMAN, BOARD OF HEALTH
F1
S.S. Permit No. IQ 0' D.W.C. No. C.C. Date
Test No.
Plbg. Permit No.
SEPTIC PLAN SUBMITTAL FORM
i
LOCATION: lfa 5 i'is %'2 j S?
NEW PLANS:
$125.00/Plan
REVISED PLANS: YES $ 60.00/Plan V/
SITE EVALU TION FORMS INCLUDED: YES NO
DATE:
1
DESIGN ENGINEER: ' Zil d 144ydoe4r C�07 Su.
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans to Port
Engineering.
When the submission is all in place, route to the Health Secretary.
2 7 ,�
andover
consultants
inc.
1 East River Place
Methuen, Massachusetts 01844
Tel. (978) 687-3828
Fax (978) 686-5100
IN ORDER TO EXPEDIATE MATTERS, I AM
SENDING THE ATTACHED LANS OCUMENTS
WITHOUT A FORMAL LETTER RANSMITTAL.
Civil Engineers • Land Surveyors e Land Planners
Sep -10-99.08:04A Paul D. Tuvbide, PE/PLS
PTOR
ENGINEERING
Civil Engineers &
Land Surveyors
One Harris Street
Newburyporl, WA
01950
(978) 465-8594.
September 10, 1999
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
30 School St.
North Andover, MA 01845
508-465-0313 P-02
RE: Title V review for 805 Forest Street (revised)
Dear Sandra,
Enclosed find the "Checklist for North Andover Septic System Plans" for the above-
mentioned site. The following is a list of all the `Problem' areas and deficiencies Port
Engineering has found. (Because the list is just for minor problems, I do not necessarily
have to review the plans a second time if the following items are changed or added.)
u The location and elevation of the foundation drain (if there will be one) is not
shown. NA 8.02y
❑ 310 CMR 247(2) states that a minimum of 2" of 118 to'/z inch stone is to be placed
on the top of the leaching bed. The plan design calls for a layer of filter fabric to be
laid on top this stone. There is no regulation that I could find that allows filter fabric
to be laid over the peastone, and therefore I would recommend that the filter fabric
be removed from the design.
❑ There is an existing drilled well on the lot (shown on the plan as a faint 1132 inch
circle about 15 feet northeast of the northeast corner of the proposed foundation). It
is my understanding that this well will be abandoned in favor of tying in to the new
proposed municipal water main to be constructed on Forest Street. However, the
existing well should be shown on the plan, and should be described as "to be
abandoned".
If you have any questions or comments please feel free to contact me.
Sincerely
Carlton A. Brown, PE/.PLS
Forest805.doc
FORM 1 I - SOIL EVALUATOR FORM
Page 1 of 3
Date: June 28, 1999
Commonwealth of Massachusetts
North Andover, Massachusetts
Soil Suitability Assessment for On-site Sewage Disposal
Performed By: David Jordan Date: June 24,1999
Witnessed By: Carlton Brown
Location address or Lot # Owner's Name, Address, and Tel. #
805 Forest Street William J. & Deana J. Hamel
Town Map 105D, Lot 18 805 Forest Street North Andover, MA
978-686-9054
New Construction N Repair ❑
Office Review
Published Soil Survey Available: No ❑ Yes
Year Published 1981 Publication Scale 1:15,840 Soil Map Unit CbC
Drainage Class WD Soil limitations Permeability, stones ,
Surficial Geologic Report Available: No ® Yes ❑
Year Published Publication Scale Soil Map Unit
Geologic Material (Map Unit)
Landform
Flood Insurance Rate Map: - A - _.� ._ -.-- •---
TC
Above 500 year flood boundary No ❑ Yes
Within 500 year flood boundary No ® Yes ❑ - 3
Above 100 year flood boundary No ❑ Yes ® ,
Wetland Area:
National Wetland Inventory Map (map unit}
Wetlands Conservancy Program Map (map unit)
Current Water Resource Conditions (USGS):
Range: Above Normal ❑
Other References Reviewed:
Month May
Normal ❑ Below Normal
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No: 805 Forest Street
On-site Review
Deep Hole Number 1 Date: 6/24/99 Time: 9:30 AM Weather: 80° Sunny
Location (identify on site plan)
Land Use: Residential lot Slope (%) 10-15 Surface Stones none
Vegetation: Grass
Landform: Ground moraine
Position on landscape (Sketch on back)
Distances from:
Open Water Body: >100 Feet
Possible Wet Area: >100 Feet
Drinking Water Well: 57 Feet
Drainage Way: >100 Feet
Property Line: 35 Feet
Other:
DEEP OBSERVATION HOLE LOG
Depth from
Soil Horizon
Soil Texture
Soil Color
Soil Mottling
Other
Surface
(USDA)
(Munsell)
(Structure, Stones, boulders,
(inches)
Consistency, % Gravel
0-7
A
Fine Sandy
10YR4/3
Loam
7-96
C
Very
5Y6/4
massive, friable to very firm,
Gravelly
35% gravel, 15% cobbles
Sandy Loam
Parent Material (geologic) Basal Till Depth of Bedrock >96"
Depth to Groundwater: Standing Water in Hole: none Weeping from Pit Face: none
Estimated Seasonal High Ground Water: 7 96"
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. 805 Forest Street
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole inches
❑ Depth weeping from side of observation hole inches
Depth to soil mottles �9to inches
❑ Ground water adjustment feet
Index Well Number Reading Date Index well level
Adjustment factor Adjusted ground water level
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? Yes
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on Fall 1996 (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above
analysis was performed by me consistent with the required training, expertise and
experience described in 310 CMR 15.017.
Signature Date
FORM 11 - SOIL EVALUATOR FORM
Location Address or Lot No: 805 Forest Street
Ott -Site Review
Deep Hole Number 2 Date: 6/24/99 Time: 10:15 AM Weather: 80° Sunny
Location (identify on site plan)
Land Use: Residential lot Slope (%) 10-15 Surface Stones none
Vegetation: Grass
Landform: Ground moraine
Position on landscape (Sketch on back)
Distances from:
Open Water Body: >100 Feet
Possible Wet Area: >100 Feet
Drinking Water Well: 55 Feet
Drainage Way: >100 Feet
Property Line: 21 Feet
Other:
Page 2 of 3
DEEP OBSERVATION HOLE LOG
Depth from
Soil Horizon
Soil Texture
Soil Color
Soil Mottling
Other
Surface(USDA)
(Munsell)
(Structure, Stones, boulders,
(inches)
Consistency, % Gravel
0-41
A & B
Fine Sandy
not
in varying
Loam
colored
layers
41-108
C
Very
2.5Y5/4
massive, friable
Gravelly
35% gravel, 15% cobbles
Sandy Loam
Parent Material (geologic) Basal Till Depth of Bedrock >108
Depth to Groundwater: Standing Water in Hole: none Weeping from Pit Face: none
Estimated Seasonal High Ground Water: > 108"
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. 805 Forest Street
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole inches
❑ Depth weeping from side of observation hole inches
Depth to soil mottles � I Q3 inches
❑ Ground water adjustment feet
Index Well Number Reading Date Index well level
Adjustment factor Adjusted ground water level
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? Yes
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on Fall 1996 (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above
analysis was performed by me consistent with the required training, expertise and
experience described in 310 CMR 15.017.
Signature / �" L/`-� Date
Location Address or Lot No. 805 Forest Street
Commonwealth of Massachusetts
North Andover, Massachusetts
Percolation Test*
Date: June 24, 1999
Observation Hole #
1
2
Depth of Perc
36"
60"
Start of Pre-soak
10:50
11:20
End of Pre-soak
11:07
11:36
Time at 12"
11:07
11:36
Time at 9"
11:14
11:40
Time at 6"
11:22
11:45
Time (9"-6")
8
5
Rate (Min./Inch)
3
2
*Minimum of 1 percolation test must be performed in both the primary area AND
reserve area.
Site Passed
Performed By
Site Failed ❑
David Jordan
Witnessed By: Carlton Brown
Comments:
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SEPTIC PLAN SUBMITTAL FORM
LOCATION: ads —eW /6
NEW PLANS: . YES
REVISED PLANS: YES
$125.00/Plan
$ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES NO
DATE: 9113A?2
y
DESIGN ENGINEER: /
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans
Engineering.
When the submission is all in place, route to the Health Secretary.
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LOCATION
NORTH ANDOVER BOARD OF HEALTH
AUTHORIZATION FOR SOIL TESTS
ENGINEER TEL # PAID
DATE TO PORT
805 Forest St Andover Consultants 978-687-3828 Yes 6/15/99
BOARD OF HEALTH
NORTH ANDOVER, MA 01845
APPLICATION FOR SOIL TESTS
DATE:
LOCATION OF SOIL TESTS
ASSESSOR'S MAP & PARCEL
NUMBER:
OWNER-
ADDRESS:
WNER
ADDRESS:
ENGINEER:
CERTIFIED SOIL EVALUATOR:
INTENDED USE OF LAND:
RESIDENTIAL SUBDIVISION,
SINGLE FAMILY HOME,
COMMERCIAL:
CONSERVATION COMMISSION
APPROVAL:
May ll, 1999
805, Forest St.
Map 105D, Parcel 18
William & Deanna Hamel
805 Forest St., N. Andover, MA
fit/ 5T/�U6 /-lo MC TU
E I -R I9L Es.D
TEL NO.: 686-9054
Andover Consultants Inc. TEL NO.: 687-3828
David Jordan
Repair Testing: Undeveloped
Lot Testing:
X
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
1. Proof of land ownership (tax bill, deed, or letter from owner permitting tests).
2. Plot plan.
3. Fee of $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 disposal area.
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.
86-4f?o Th
QF�tIcALTBI/�R/
MAY
171999
William & Deana Hamel
805 Forest Street
No. Andover, MA 01845
Andover Consultants
1 East River Place
Methuen, MA 01844
May 11, 1999
To Whom it May Concern:
We give Andover Consultants permission to start septic testing on our land located on 805 Forest Street.
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B -LAIR, Robert
805 Forest St.
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
805 Forest Street . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of 1000 Gal.* in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open" jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of _ 180 lineal (ff4LWiW feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
the line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
DATE SEP "" 9 1963
ded below, and to incorporate any additional requirements
permit. Plot Plans must be submitted with application.
ignature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE
a�n s, 9 '963
Si nature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature of Inspecting Officer
Percolation Test 5 min. Soil: Sandy -clay
Garbage Grinder No
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BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
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1. NAME -:'1 rX�1 `t .: t /.J +rte DATE
2. ADDRESS `� :+ .n LOT NO. TEL.
3. NO. OF BEDROOMS -7� -- DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
Ao
g. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
► . _ -�1;4-Robert Belair
Forest St.
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APPLICATION FOR SEWAGE DISPOSAL INSTALLATION � � z; L {
HEALTH DEPARTM ET --NORTH ANDOVER, MASS.
I hereby make apptlication►for a permit for a sewage disposal installation at
Forest S 1 will install this system in
accordance with all the laws of the Commonwealth of Massachusetts and regulations
of the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 10 until 10 feet
preceding the septic tank# where the grade shall not exceed 2%. I will install a
concrete septic tank of 1000 gal._ in size. A manhole (s) permitting easy
cleaning will be provided with removable cover (s) of iron or concrete within 3.2
inches of the ground surface. I will provide subsurface disposal, field with open
jointed bell and spigot Ackron pipe at least 4 inches in diameter and laid in a
series of trenches, the bottom of which will provide a minimum of 200 lineal
() feet of effective absorption area. The pipes will be laid on a 6 inch
layer of washed gravel or crushed stone ranging in size from 3/4 to 1.1/2 inches
(dia.) and the pipes will be surrounded by similar material to a height of 2 inches
above the crown of the pipe. The joints of these pipes will be protected from
clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4"
(dia.) will be placed over the course gravel or stone. The disposal field will be
installed at a grade of 4 to 6 inches/lOO feet. No single the line will. exceed
100 feet in length and in any case, two lines of the will be installed. A minimum
of 6 feet will be maintained between the center lines of the disposal field trenches
and the average depth of trench shall not exceed 36 inches. No part of the in—
stallation will be less than 100 feet from any private water supply, 25 feet from
any stream, 20 feet from any dwelling or 10 feet from any property line. I further
officers, as provided below, and to incorporate any additional requirements tha
may be attached to the permit. Plot Plans must be submitted with application.
DATE VL=;&_
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE _T_� r�
i
gnaturg of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature of Inspecting Officer
Pereolation Test 5 min. sandy -clay
Garbage Grinder
May 9, 1959
Miss Mary Sheridan R. N.
Health Agent
Board of Health
North Andover, Mass.
Dear Miss Sheridan;
An examination was made as requested in order
to determine the suitability of the soil for the
subsurface disposal of sewage on the proposed
Forest Street building site of Robert Belair.
The subsoil in the area was a sandy clay content
and a 5 -minute percolation test was conducted.
The land in general is high.
It is recommended that a 1,000 gallon concrete
septic tank be installed together with 200 lineal feet
of drain pipe.
Very truly yours,
as
` ` , r,•_,
lilliam J. 11c 11
BOARD_ OF HEALTH
-- / TOWN OF -NORTH ANDOVER, MASS.
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1. NAME_-44�p �/
�,� �D�Gl.�ot i DATE �2, 7- a1-/ "
2. ADDRESS y�-�u�.�j_T LOT NO. TEL.
3. NO. OF BEDROOMS DEN YES NO
4. GARBAGE GRINDER YES NO �-
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
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BOARD OF HEALTH
TOWN OF NOWH ANDOVER' AMASS.
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1. NAME �3' (�.L"i�-.— ... DATE
2. ADDRESS . LOT NO~ , �, .- :1: (%a.� . TEL
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3. NO. OF BEDROODS DEN YES . NO.
!�. GARBAGE GRINDER YES . . N0.
5. SHOW DITlENSIONS OF HOUSE %/ X L
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 33J/
7. SHOW DI1,00IORTS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
k, 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREA16p DITCHES, LEDGE OUTCROP, ETC.
11. SHOVE DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
`
NOTE: LOCAL REGULAT IOALS SHOULD BE READ CAREFULLY.
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