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HomeMy WebLinkAboutMiscellaneous - 835 CHESTNUT STREET 4/30/2018 (2)t � w 1 s Lot & Street 1-3Jf �#0 T-A1L17- ;5 Map/Parcel SOV ACS CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: 63 Approved by: Designer: Conditions: Water Supply: Town Well Well Permit: Driller: Well Tests: Chemical Bacteria I Bacteria II Plumbing Sign -Off: Comments: Form "U" Approval: Date Issued Conditions: Final Approval: Plan Date:A�1'6 Date Approved Date Approved Date Approved--, Wiring Sign -off: Approval to Issue By:_ YES NO All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed?_ YES --�, Type of Construction: NEW REPAIR New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: NO DWC Permit Paid? DWC Permit# /�2�/�, Installer:UG)( nYRES----� NO Begin Inspection: YES NO Excavation Inspection: Needed: Passed: 711,71 Cj S By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: Final Grading Approval: Date: Final Construction Approval: Date: a M By: Certificate of Compliance: Approval: Date: i;1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: John J. Souc Name of Inspector Soucy's Sewer Service Inc. Company Name 78 North Broadwav Company Address Salem City/Town 603-898-9339 Telephone Number B. Certification NH State 13397 License Number 03079 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority zx-), 1/1 A 03/11/16 /h9spectVStSignature Date em inspector shall subm' a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts RECEIVED N F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments APR U 4 2016 835 CHESTNUT STREET TOWN OF NORTH ANDOVER Property Address MEAtTM DEPARTMENT I 'y DIANNA DEOSSIE GAUDET ' 14 ^J�4'l Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/11/16 page. City/Town State Zip Code Date of Inspection Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: John J. Souc Name of Inspector Soucy's Sewer Service Inc. Company Name 78 North Broadwav Company Address Salem City/Town 603-898-9339 Telephone Number B. Certification NH State 13397 License Number 03079 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority zx-), 1/1 A 03/11/16 /h9spectVStSignature Date em inspector shall subm' a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/11/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owners Name N. ANDOVER MA 01845 03/11/16 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner's Name N. ANDOVER MA 01845 03/11/16 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts N - Title 5 Official Insp o Subsurface Sewage Disposal System For 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. City/Town B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or ection Form ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. m - Not for Voluntary Assessments Any portion of cesspool or privy is within 100 feet of a surface water supply or the system is within 200 feet of a tributary to a surface drinking water supply tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, MA 01845 03/11/16 and chain of custody must be attached to this form.] State Zip Code Date of Inspection ❑ ® 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 the system is within 200 feet of a tributary to a surface drinking water supply tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. Cityrrown C. Checklist MA 01845 State Zip Code 03/11/16 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. Cityrrown D. System Information Description: MA 01845 State Zip Code 03/11/16 Date of Inspection Water meter readings, if available (last 2 years usage (gpd)): Detail: SEE ATTACHED Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ® Yes ❑ No CURRENT Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: SEE ATTACHED Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ® Yes ❑ No CURRENT Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET OwnerOww nePs Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: State 01845 03/11/16 Zip Code Date of Inspection CURRENT Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Soucy's Sewer Service Inc 1500 gallons Gauoe on truck Maintenance and Inspection Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ® Yes ❑ No ❑ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o M yve 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. CityT town D. System Information (cont.) MA 01845 03/11/16 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC El other (explain): D' t f t t 1 II t' I' 24" feet Is ance rom peva a wa er supp y we or au" Ion Ine. feet Comments (on condition of joints, venting, evidence of leakage, etc.): APPEARS TO BE WATERTIGHT. ❑ Yes ® No Septic Tank (locate on site plan): Depth below grade: 10"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 6'X 10.5' Sludge depth: 0 ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/11/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 38" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? TAPE & SLUDGE TOOL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PUMP TANK ANNUALY. ALL TEES ARE IN PLACE. TANK APPEARS TO BE WATERTIGHT. Grease Trap (locate on site plan): Depth below grade: Material of construction: feet ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. Cityrrown MA 01845 State Zip Code 03/11/16 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) MA 01845 03/11/16 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Flow checked good Pump Chamber (locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): EVERYTHING LOOKS NORMAL * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM , 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. Cityfrown D. System Information (cont.) MA 01845 State Zip Code 03/11/16 Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 30'X44' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins - 3/13 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/11/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Insp a Subsurface Sewage Disposal System Fo 835 CHESTNUT STREET D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately ection Form rm - Not for Voluntary Assessments — -- o, Property Address TIES TP 1 DIANNA DEOSSIE GAUDET ..- Owner Owner's Name information is required for every N. ANDOVER MA 01845 03/11/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately t5ins ° 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 / � I — -- o, SYSTEM TIES TP 1 ..- 3 TO TANK 13.5' �N 4 TO TANK .' 6 DISTRIBUTION BOX ( 0 .�' '� 3 TO PUMP 1113 9.6' �► 1 TO PUMP 68.1' 1 TO D BOX 2 TO D BOX 85.4' 97,1' PT 1 1 TO A74.1' 1 TOG 72.9' 2 TO A BBI: 2 TO G 74.1' 1 TO F 2 TO F 97.5' 107.9' 1 TO L 2 TO L 96.9' 99.1' �y r1•, a_ BENCHMARK 2: SPIKE IN PINE TREE. 105.25 CELEV d �....I 4' CAST IRON SLEEVE EXISTING THREE BEDROOM HOUS F.rl SILL ELEV 104.! BENCHMARK 1: TOP OF 'ONE BOUND. ELEV 100.00 (ossumed) 1n C, v 2' SCH 40 PVC p FORCE MAIN a Czlf� 1.7. 1000 GALLON PUMP CHAMBER o c 1500 GALLON PUMP CHAMBER PRESSURE WATER SERVICE 120.58' 3 S09. 30 CHESTNUT STREI t5ins ° 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts F - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: MA State 01845 Zip Code 5' feet 03/11/16 Date of Inspection Please indicate all methods used to determine the high ground water elevation: -/ 0 7 0 Obtained from system design plans on record If h kddt f i 1 d' 2/6/03 c ec e, a e o U0 V" p an reviewe . Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: 107-101.95 = 5.05' FROM TOP OF S.A.S. LOCATION. ALSO DUG TEST HOLE WITH AUGER, APPROXIMATELY 30' FROM REAR OF S.A.S. AT DOWN SLOPE. WATER AT T EXISTING GRADE. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 835 CHESTNUT STREET Property Address DIANNA DEOSSIE GAUDET Owner Owner's Name information is N. ANDOVER required for every page. Cityfrown MA 01845 State Zip Code E. Report Completeness Checklist 03/11/16 Date of Inspection ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 311201610:39:15 AM by Keren Hanlon Town of North Andover Tax Map # 210-107.0-0026-0000.0 Parcel Id 18309 835 CHESTNUT STREET DEOSSIE, DIANNA C 835 CHESTNUT STREET N. ANDOVER, MA 01845 Page 1 Class 10i Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.04 Acres FY 2016 UB Mailina Index Name/Address Type Loan Number Activellnact. From Until DEOSSIE, DIANNA C Payor 835 CHESTNUT STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 13624.0 - 835 CHESTNUT STREET Last Billing Date 2/812016 1090301 01 Cycle 01 Active UB Services Maint. Account No. 1090301 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 41.80 /1 UB Meter Maintenance Account No. 1090301 Serial No Status Location Brand Type Size YTD Cons 16802324 a Active 00 METE METE W Water 0.63 0.63 638 Date Reading Code Consumption Posted Date Variance 1/21/2016 1506 aActual 11 2/19/2016 -23% 10/21/2015 1495 aActual 14 11/20/2015 .6°% 7/23/2015 1481 a Actual 15 8/14/2015 36% 4/23/2015 1466 a Actual 11 5/19/2015 -8% 1/22/2015 1455 aActual 12 2/20/2015 1% 10/23/2014 1443 aActual 12 11/14/2014 8% 7/23/2014 1431 a Actual 11 8113/2014 8% 4/23/2014 1420 a Actual 10 5/15/2014 -14% 1/24/2014 1410 aActual 12 2114/2014 -7% 10/24/2013 1398 aActual 13 11/18/2013 -35% 7/23/2013 1385 aActual 19 8/15/2013 30% 4/25/2013 1366 a Actual 15 5/20/2013 18% 1/24/2013 1351 aActual 13 2/13/2013 -8% 10/23/2012 1338 a Actual 14 11/9/2012 -37% 7/23/2012 1324 a Actual 22 8/14/2012 5% 4/23/2012 1302 a Actual 21 5/9/2012 22% 1/23/2012 1281 aActual 18 2/13/2012 -30% 10/20/2011 1263 aActual 25 11/14/2011 -46% 7120/2011 1238 a Actual 45 8/15/2011 112% 4/22/2011 1193 a Actual 21 5/16/2011 8% 1/2412011 1172 a Actual 21 2/11/2011 -16% 10/21/2010 1151 aActual 24 11/12/2010 -14% 7122/2010 1127 a Actual 28 8/16/2010 -1% 4122/2010 1099 a Actual 28 5/1212010 13% 1/22/2010 1071 a Actual 25 2/12/2010 -7% 10/23/2009 1046 aActual 27 11/11/2009 -3% 7/24/2009 1019 a Actual 27 8/12/2009 20% 4/27/2009 992 a Actual 24 5/13/2009 24% 1/2312009 968 a Actual 19 2/10/2009 39% COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS h DEPARTMENT OF ENVIRONMENTAL PROTECTION K TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property .Address: .v_ Hnno�Pr MA 01 R45 Owner's Name: ni ana Deossie FU -- Owner's ECEIVED Address:835 Chaci-nit St.AA" ter.-.Mn.,_-0-a4l5Date of Inspection: L ` 5 2005 Name of Inspector: (please print) James Wright TOWN �FNQRTHAP�ppV Company Name: R.J. Inspections,Inc. HEALT!ip�pARTMENTER Mailing Address: One Osgood St Methuen MA 01844 Telephone Number: 978-681-8759 CERTIFICATION STATEMENT . 1 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 ZS7' 15.340 of Title 5 (310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:,. -__.._.Date: �r A The system inspector shA"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 bpd 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 Conunents ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 835 Chestnut St N. Andover MA 0-vvnet: Diana Deossie Date of Inspection: 6113/05 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. Systn Passes: have not found any information which indicates 15.,0, or in 510 CMR 15.304 exist. Any failure ct ria not aevaluated are indicated below. t any of the failure criteria cribed m,10 CMR 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 determin explain. ed (Y,N,ND) in the for the following statements. If "not determined" please 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 existilg 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: N—c3of11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 835 Chestnut St. N. Andover MA 01845 Owner: Diana Deossie Date of inspection: 6/13105 C. Further Evaluation is Required by the Board of Health: ____ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health dote mines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a mannex 4icb will protect public health, safety and the environment: _ Cesspool or privy is wi n Cesspool or privy 50 feet of a surface water tthin 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 t00 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SA -9 -is 1. within a Zone 1 of a public water supply. The system has a septic tank anPAS^and the SAS is within 50 feet of a private water supply well. _ The system has a septic.,tahk 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 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: PaCre 4 of 1 I OFFICIAL INSPECTION FORM —� NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 835 Chestnut St, N. Andover MA 01845 Owner: Diana Deossie Date of Inspection: 6 11 _I (l r, D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No �cl up of sewage into facility or system component due to overloaded or clogged SAS or cesspool `Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or .cesspool iquid depth in cesspool is less than 6" below invert or available volume is less than % day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number �cft 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. __ 1y portion of a cesspool or privy is within a Zone 1 of a public well. any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) /Ka(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. C. 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 uo the system is wit ' 400 feet of a surface drinking water supply tfie syst ►s within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well if you have answered "yes" to any question in Section E the system is considered a significant threat, or. answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 835 Chestnut St N. Andover MA 01845 Owner: Diana Deossie Date of Inspection: -6/13/05 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks ? .Has the system received normal flows in the previous two week period ? - — — Have large volumes of water been introduced to the system recently or as part of this inspection '? Were as built plans of the system obtained and examined? (If they were not available note as N/A) r — Was the facility or dwelling inspected for signs of sewage back up _�. Was the site inspected for signs of break out ? — Were all system components, excluding the SAS, located on site ✓_ — Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? _ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes,` __ f! _ Existing information. For example, a plan at the Board of Health. ✓ — Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]pp Paoe 6 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 835 Chestnut St, N.Andover MA 01845 Owner: Diana Deossie Date of Inspection:(/ 1 3 � p .RESIDENTIAL FLOW CONDITIONS Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents,;2,4"' Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system(yes or no): _ [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): LGA Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15 �): gpd Basis of design flow (seats/per s/sgft,etc.): Grease trap present (yes o): — (ndustrial waste ho g 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): Pumping Records GENERAL INFORMATION Source of information:. Was system pumped as part of the inspection (yes or no): _ If yes, volume pumped:/S��alIons -- How was quantity pumped determined? Reason for pumping: TYP , )F 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 Oource of i A/r• T. Were sewage odors detected, when arriving at the site (yes or no): /1�/ 6 iI'age7ofll OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contiltued) Property Address: 835 Chestnut st. N. Andover MA 01845 Owner: Diana Deossie Date of Inspection: 6/ 1 3 / 05 BUILDING SEWER (locate on site plan) / Depth below grade: Materials of construction: _cast on _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: 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: -'%-y Sludge depth: / Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: / Distance from top of scum to top of outlet tee or baffle: s Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: _(fl-CIZ& ,o! Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP: _(locate on site plan) Depth below grade.- Material rade:Material of construction (explain): concrete _polyethylene _other Dimensions: Scum thickness: Distance from top o to top of outlet tee or baffle: Distance from tom of scum to bottom of outlet tee or baffle: Date ofla , ump.ing: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Paoe 8 of l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 835 Chestnut St N- [anan ver MA 01845 Owner: Di ,na DP ssie Datc of Inspection: 6111-4105 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: _ Material of construction: concrete metal fiber _polyethylene other(explain): Lnmensions: Capacity: gall Design Flow: __ allons/day Alarm present (yes or no Alarm level: Alarm in working order (yes or no): Date of last pu mg: 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 evidence of solids carryover, any evidence of leakage into,�;out of box, etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): 4—L - Comments (note condition of 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: 835 Chestnut St N Andover MA 01845 Owner: Diana Deossie Date of Inspection: 6,11 3.105 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, length: _ileaching fields, number, dimensions: _ overflow cesspool, number: innovative/alternative system Type/name of tet hnology: Con-mients (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 inl vert: Depth of solids layer: Depth of scum lay 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: (locate on site plan) Materials of construction: Dimensions: Depth of solids: / Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): M r`� 113:e 10 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 835 Chestnut St N Andover MA 01845 Owner: Diane Deossie Date of Inspection: F 113 / 0 r, SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or • P e 11 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 835 Chestnut St N. Andover MA 01845 Owner: _i ana DeOSSle Date of Inspection: _6.113 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water t 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: s wrecked with local excavators, installers- (attach documentation) __ 4ccessed USGS database -explain: Yougust describe how you-Qstablished the high ground water elevation: �l _.�' ,> _ _ _ MASSACHUSETTS ACTON 158 * TS 1965 http://ma.watei-.usgs.gov/current-cond/data//-()u..) -U4.t) SUMMARY OF GROUND -WATER LEVELS APRIL 2005 PROVISIONAL + (NO'T'E: Wells with * also available in real-time at top of Ground -Water Data page; OWc, monthly measured value used in high ground -water level estimation report, USGS Open -File Report 80-1205.) 0.18 13.99 WELL L START NET CHANGE DEPARTURE WATER LEVEL T I YEAR IN MONTH IN ONE FROM BELOW LAND - 0 T OF YEAR MONTHLY SURFACE P H RECORD + MEDIAN DATUM 0 0 21.82 26 BARNSTABLE 247 (OWc) 1962 + (FEET) (FEET) (FEET) (FEET) DAY MASSACHUSETTS ACTON 158 * TS 1965 + 0.46 + 0.89 + 2.26 15.46 30 ANDOVER 462 VS 1968 + 0.30 + 0.10 + 0.18 13.99 22 ATTLEBORO 83 VS 1964 - 1.07 - 0.11 + 0.11 3.34 29 BARNSTABLE 230 FS 1957 ----- + 1.24 + 1.00 21.82 26 BARNSTABLE 247 FS 1962 + 0.45 + 0.93 + 0.68 22.93 26 BECKET 12 TS 1986 - 0.62 + 0.20 + 0.34 2.82 29 BLANDFORD 9 VS 1986 - 0.31 + 0.10 + 0.40 1.72 > 29 BOURNE 198 FS 1962 + 1.16 + 2.29 + 1.10 31.09 26 BREWSTER 21 FS 1962 + 0.60 + 0.91 + 0.80 9.01 26 BREWSTER 22 * FS 1962 + 0.54 + 1.64 + 1.64 28.98 30 CHATHAM 138 FS 1962 + 0.24 + 0.99 + 1.71 21.56 26 CHESHIRE 2 HT 1951 - 1.22 - 1.26 - 1.81 3.92 28 CHICOPEE 95 TS 1984 + 0.86 + 0.39 + 0.32 20.84 28 COLRAIN 8 VS 1965 + 0.97 + 1.01 + 1.08 15.46 28 CONCORD 165 TS 1965 + 1.12 + 1.83 + 0.84 40.70 25 CONCORD 167 TS 1965 + 0.32 + 0.17 + 0.44 5.64 25 CUMMINGTON 13 VS 1986 - 0.37 + 0.37 + 0.10 3.44 28 DEDHAM 231 ST 1965 - 0.57 - 1.09 + 0.00 4.64 25 DEERFIELD 44 VS 1965 - 0.05 - 0.01 + 0.65 1.94 28 DOVER 10 TS 1965 + 0.91 + 0.32 + 0.58 31.15 5/4 DUXBURY 79 * VS 1965 - 0.90 - 0.15 + 0.18 7.68 30 DUXBURY 80 VR 1965 - 0.73 - 0.16 + 0.48 20.98 28 EAST BRIDGEWATER 30 HT 1958 - 1.67 - 1.20 - 0.34 5.35 25 EDGARTOWN 52 VS 1976 + 1.42 + 1.75 + 2.12 15.59 27 FOXBOROUGH 3 TS 1965 - 0.54 - 0.64 - 0.41 18.35 29 FREETOWN 23 TS 1964 + 0.54 + 1.30 + 1.34 11.50 28 GEORGETOWN 168 VS 1965 - 0.34 - 0.36 + 0.10 3.81 22 GRANBY 68 VS 1954 + 0.67 + 0.22 + 0.46 5.78 28 GRANVILLE 5 TS 1965 + 1.03 + 0.29 + 1.05 31.47 29 GRANVILLE 6 SS 1965 - 0.25 + 0.32 + 0.77 2.68 29 GREAT BARRINGTON 2 VT 1951 - 1.43 - 1.17 - 0.77 8.69 28 HANSON 76 VS 1964 - 0.84 + 0.22 - 0.02 4.30 28 HARDWICK 1 TS 1965 - 0.64 - 2.28 - 0.24 12.48 26 HAVERHILL 23 TS 1960 + 2.15 + 0.11 + 0.97 8.44 22 HAWLEY 8 ST 1986 + 0.01 + 0.00 + 0.44 2.49 28 LAKEVILLE 14 * TS 1964 - 1.48 + 0.32 + 1.99 10.92 30 LEXINGTON 104 VS 1965 + 0.02 + 0.12 + 1.18 1.05 > 25 MASHPEE 29 FS 1976 + 0.66 + 1.42 + 1.45 6.42 26 MIDDLEBOROUGH 82 VT 1965 - 2.41 - 0.32 + 0.20 4.70 26 MONTGOMERY 19 SS 1986 + 0.05 + 0.06 + 0.30 0.32 29 NANTUCKET 228 FS 1976 + 0.46 + 2.32 + 2.47 22.02 28 NEW BEDFORD 116 VS 1964 - 0.58 - 0.06 - 0.17 4.02 28 NEWBURY 27 VT 1965 - 0.42 - 0.22 + 1.53 3.54 22 NORFOLK 27 * VS 1965 - 0.69 - 0.17 + 0.18 5.64 30 NORTHBRIDGE 54 VS 1984 + 0.54 - 0.15 + 0.37 3.39 20 NORTON 37 FS 1964 - 2.99 - 0.66 + 0.25 5.7'7 29 ORANGE 63 TS 1985 + 0.57 + 0.46 + 0.91 5.52 25 OTIS 7 VS 1965 - 0.90 - 0.06 - 0.08 7.34 29 PELRAM 23 * SR 1984 + 0.35 + 0.90 - 1.92 13.97 30 PELHAM 24 SS 1984 - 0.26 + 0.43 + 0.65 2.38 25 PETERSHAM 16 ST 1984 - 1.29 - 0.31 + 1.50 9.75 25 nLip:i/ma.watei-.usgs.gov/currt:iii_4.;uitui uiuiv.Lvu-pv r.L+t PITTSFIELD 51 * VS 1963 + 0.76 - 0.33 - 0.47 14.79 30 PLYMOUTH 22 TS 1956 + 1.27 + 1.69 + 1.51 21.75 28 PLYMOUTH 494 SS 1985 + 1.30 + 0.66 + 0.68 28.83 28 SANDWICH 252 FS 1962 + 0.45 + 0.93 + 0.75 46.22 26 SANDWICH 253 FS 1962 + 0.99 + 0.82 + 0.12 49.41 26 SEEKONK 275 VS 1964 - 0.38 - 0.14 + 0.72 5.34 28 SHEFFIELD 58 FS 1987 + 0.60 + 0.68 + 1.58 11.33 28 SOUTHBOROUGH 12 HT 1990 - 0.17 - 0.52 + 0.75 2.16 25 SOUTHWICK 95 TS 1986 + 0.42 + 0.50 + 0.62 1.83 29 S'T'ERLING 1 ST 1947 + 0.03 - 0.01 + 0.59 2.48 25 STERLING 177 SS 1995 + 0.28 - 0.64 - 0.09 13.84 25 SUNDERLAND 7 SS 1957 + 0.58 + 0.00 - 0.12 10.09 25 SUNDERLAND 68 VS 1983 - 0.21 + 0.11 + 0.69 1.50 25 TAUNTON 337 TS 1964 - 1.72 - 0.27 + 0.45 7.68 29 TEMPLETON 3 VS 1957 - 0.46 + 0.50 + 0.53 2.79 25 TOPSFIELD 1 HT 1936 - 2.77 - 2.40 - 1.12 10.38 22 TOWNSEND 13 TS 1965 + 1.86 + 0.04 + 0.90 10.98 25 TRURO 1 TS 1950 + 0.32 + 0.82 + 0.68 9.82 26 TRURO 89 TS 1962 + 0.18 + 0.65 + 0.44 11.20 26 WAKEFIELD 38 * FS 1965 - 0.47 - 0.04 + 0.41 5.58 30 WARE 43 VS 1965 + 1.24 + 1.43 + 2.28 6.45 26 WAREHAM 51 TS 1959 - 0.78 + 1.23 + 0.15 5.93 26 WAYLAND 2 TS 1965 + 0.66 - 0.10 + 0.27 14.79 25 WEBSTER 1 HS 1958 - 2.55 - 0.59 + 0.18 12.90 20 WELLFLEET 17 VS 1962 + 0.70 + 1.28 + 0.44 9.38 26 WENHAM /6 VS 1965 - 0.42 - 0.29 + 0.26 1.96 22 WEST BOYLSTON 26 SS 1995 + 2.08 - 0.65 + 0.53 2.99 25 WEST BROOKFIELD 2 TS 1959 + 0.77 + 1.15 + 1.15 17.23 26 WESTHAMPTON 20 SS 1986 + 2.17 + 0.22 - 1.26 9.20 29 WESTFIELD 62 SS 1957 - 0.02 - 0.55 - 0.24 6.08 29 WESTFIELD 152 TS 1986 - 0.45 + 0.08 + 1.03 2.16 > 29 WESTFORD 160 VS 2001 - 0.98 - 0.17 ----- 10.54 29 WEYMOUTH 2 FT 1965 - 2.33 - 0.95 + 0.11 7.70 25 WEYMOUTH 3 VS 1965 + 0.38 - 0.28 + 0.13 4.50 25 WEYMOUTH 4 TS 1965 - 2.71 - 0.54 + 0.25 6.05 25 WILBRAHAM 55 TS 1965 + 4.63 + 3.76 + 1.59 33.81 28 WILMINGTON 78 * FS 1951 - 0.46 - 0.40 - 0.15 6.77 30 WINCHENDON 13 ST 1939 + 0.11 - 0.09 + 0.48 3.11 25 WINCHESTER 14 ST 1940 - 1.87 - 3.00 - 1.50 10.43 22 RHODE ISLAND BURRILLVILLE 187 TS 1968 + 0.67 - 0.35 - 0.31 14.27 26 BURRILLVILLE 395 UT 1992 + 0.13 - 0.09 + 0.28 5.79 28 BURRILLVILLE 396 VT 1992 + 0.02 + 0.15 + 0.53 4.30 > 27 BURRILLVILLE 397 HT 1992 ----- ----- ----- ----- BURRILLVILLE 398 HT 1992 + 0.06 - 1.32 + 0.04 6.80 28 CHARLESTOWN 18 FS 1946 + 0.39 - 0.81 + 1.48 14.12 26 CHARLESTOWN 586 VT 1992 - 0.32 - 0.02 - 0.05 3.63 26 CHARLESTOWN 587 ST 1992 - 3.14 - 3.40 - 1.87 7.50 < 27 COVENTRY 342 VS 1991 + 0.99 - 1.26 + 0.07 7.40 26 COVENTRY 411 SS 1961 + 1.54 + 0.41 + 0.44 19.72 26 COVENTRY 466 VT 1992 - 0.20 + 0.07 - 0.10 2.63 25 CRANSTON CITY 439 ST 1992 - 0.85 - 0.41 - 0.40 8.56 25 CUMBERLAND 265 SS 1946 - 0.45 - 1.39 + 0.25 11.68 26 EXETER 6 VS 1948 + 0.63 - 0.05 + 0.57 4.28 26 EXETER 158 ST 1991 + 0.71 - 0.93 + 0.63 5.56 26 EXETER 238 FT 1991 - 1.15 - 0.16 - 0.02 11.50 26 uup.ruua.waLci.Un63.gwi�u,,.,,, .. .« �- EXETER 278 HT 1991 - 3.45 - 1.74 - 0.78 8.80 26 EXETER 475 VS 1981 + 1.15 + 0.19 + 0.38 12.47 26 EXETER 554 SS 1988 - 0.58 - 0.30 - 0.19 9.10 26 FOSTER 40 HT 1991 + 0.02 + 0.49 + 0.50 3.32 26 FOSTER 290 HT 1992 - 0.48 - 0.36 + 0.11 4.09 25 HOPKINTON 67 ST 1991 + 1.97 - 2.41 - 0.54 12.39 26 LINCOLN 84 VS 1946 + 0.92 + 0.54 + 1.40 3.03 26 LITTLE COMPTON 142 ST 1992 - 5.10 - 2.20 - 2.44 12.14 25 NEW SHOREHAM 258 UT 1991 ----- ----- ----- ----- NORTH KINGSTOWN 255 VS 1954 - 2.03 - 0.52 + 0.69 6.45 26 NORTH SMITHFIELD 21 TS 1947 - 0.22 - 0.69 + 0.10 6.45 26 PORTSMOUTH 551 HT 1992 10.79 - 4.42 - 2.78 34.40 26 PROVIDENCE 48 TS 1944 - 0.10 + 0.07 + 2.54 3.57 27 RICHMOND 417 VS 1976 - 0.47 - 0.25 + 0.36 5.68 26 RICHMOND 600* TS 1917 + 0.99 - 0.42 + 0.78 32.25 30 RICHMOND 785 FS 1989 + 1.16 + 1.95 + 1.61 21.35 26 SOUTH KINGSTOWN 6 VS 1955 - 0.08 + 0.27 + 0.95 9.87 26 SOUTH KINGSTOWN 1198FS 1988 - 0.37 - 0.40 + 0.22 6.55 26 TIVERTON 274 TT 1990 ----- ----- ----- ----- WARWICK 59 ST 1991 - 0.70 - 0.32 - 0.17 4.92 27 WESTERLY 522 FS 1969 - 0.64 - 0.46 + 0.03 11.38 26 WEST GREENWICH 181 US 1969 + 0.25 - 1.55 + 0.05 14.98 26 WEST GREENWICH 206 ST 1991 + 0.16 + 0.52 + 0.51 3.27 > 26 ------------------------------------------------------------------------------- >> SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR PERIOD OF RECORD > SET NEW HIGH OR EQUALED HIGHEST RECORDED WATER LEVEL FOR END OF APRIL << SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR PERIOD OF RECORD < SET NEW LOW OR EQUALED LOWEST RECORDED WATER LEVEL FOR END OF APRIL ------ - DATA NOT AVAILABLE TOPOGRAPHIC (TOPO) SETTING: F=FLAT, G=FLOOD PLAIN, H=HILLTOP, S=HILLSIDE, T=TERRACE, U=UNDULATING, V=VALLEY, W=UPLAND DRAW LITHOLOGY (LITHO): G=GRAVEL, R=ROCK, S=SAND, T=TILL CONTENTS OF MAJOR RESERVOIRS (ESTIMATED END OF MONTH READINGS) (MILLIONS OF CUBIC FEET) RESERVOIR BORDEN BR + COBBLE MTN RES, MA QUABBIN RESERVOIR, MA SCITUATE RESERVOIR, RI MONTH-END PERCENT OF PERCENT CONTENTS AVERAGE FULL 3218 107 95 55470 --- 101 5047 105 103 STREAMFLOW FOR SELECTED INDEX STATIONS (CUBIC FEET PER SECOND) MONTH-END PERCENT MAXIMUM DATE MINIMUM DATE STREAM MEAN MEDIAN FOR MONTH FOR MONTH CHARLES RIVER, MA 869 160 1580 05 369 23 E. BR. HOUSATONIC RIVER, MA 341 157 2140 03 71 22 PAWCATUCK RIVER, RI 490 153 896 04 287 23 WARE RIVER, MA 672 ------------------------------------------------------------------------------- 176 ---- -- ---- -- A MONTHLY REPORT PREPARED BY THE U.S. GEOLOGICAL SURVEY MASSACHUSETTS -RHODE ISLAND WATER SCIENCE CENTER 10 BEARFOOT ROAD, NORTHBOROUGH, MA 01532 IN COOPERATION WITH THE MASSACHUSETTS DEPT. OF CONSERVATION AND RECREATION, CAPE COD COMMISSION, RHODE ISLAND DEPT. OF ENVIRONMENTAL MANAGEMENT, AND THE Un D **'' raw CD fD CD .a C t y ►, • `w r> ��w0 N O w \^ z CDNCD D C37rn 3 N r v+ r+ O O O O � r" � =3O � � `` O O O �-* r D CD s n D ^ p O a D 7 0 Do --� m m 7p D O CD W D X Z c 3 -p CND z o 0:33 D a .� o °- Z -M c o . D �0 D -� � r o 3 0 c nw ` Tc - — - – s-. 3 703 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: S - f r -g-3 CURRENT INSTALLER'S LICENSE# LOCATION: !R -3 S- /V"1 14J4 LICENSED INSTAkUER: SIGNATURE: CHECK ONE: TELEPHONE# REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $175.00 Fee Attached? Yes V No Foundation As -built? Yes No Floor plans on file? Yes No Approval Date: \-I .-� INSTALLER PROJECT MANAGEMENT OBLIGATIONS - - I - As the North Andover licensed installer for the construction of the septic systemfor; tlib ?r)qJ property at relative to the application of A'�. dated d for plans by . E .D and dated^�0►�03 with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the, system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Septic Installer Date: 5 13--0 Disposal Vforks Construction 4anit # +V ' NUMBER NUMBER FEE COMMONWEALTH OF MASSACHUSETTS North Andover Board of Health DE OSS IE, DIANNA ------------------------------------------------------------------------------------------------------- NAME 835 CHESTNUT STREET ------------------------------------------- ------------------------------------------------------------ ADDRESS IS HEREBY GRANTED A PERMIT Disposal Works Construction This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ---------------------------------------------------- unless sooner suspended or revoked. ----------------------------------------------------------------- May 13, 2003 --------------------------------------------------------------- Board ---------------------------------------------------------------- of Health COMMONWEALTH OF MASSACHUSETTS North Andover Board of Health DE OSSIE, DIANNA ----------------------------------------------------------------------------------------------------------------------- NAME 835 CHESTNUT STREET --------------------------------------------------- ---------------------------------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Disposal Works Construction This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ---------------------------------------------------- unless sooner suspended or revoked. ----------------------------------------------------------------- May 13, 2003 FEE $175.00 --------------------------------------------------------- Board --------------------------------------------------------- of -------------------------------------------------------- Health --------------------------------------------------------- NORTF �- Applicant Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 APPLICATION FOR SITE TESTING/INSPECTION Site Location Engineer Test/Inspection Date and Time0,(, CHAIRMAN, BOiDFHEALTH Fee Test No.'&4e-*7 S.S. Permit No./--"// D.W.C. No. C.C. Date Plbg. Permit No. J� f VkORTN O F Town of North Andover, Massachusetts BOARD OF HEALTH DESIGN APPROVAL FOR ss"�M�St� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant %v:_ �!G%� -�-c-� Test No. Site Locations Form No. 2 Reference Plans and SpecsL—�Y2 '- Z' � ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee - C AIRMAN, BOARD OF HEALTH Site System Permit No. �v2l CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS Job The following is a checklist that incorporates all Title 5 and local regulations for septic plans.. Name of Applicant- J 1 cj rl rtq ,�—Do `UPJ%� Name of Designer: -, U t Plan Date: O9�95 Revision Date: Date of Review: Property Address: (��74442 Map: Lot: BOH Reviewer: Type of Plan (new or upgrade):_ Number of Bedrooms in Assessor's Records: gpd) Garbage Disposal Allowed: General Information: N.A. = North Andover Septic Regulations Other numbers refer to Title 5 OK Problem N/A Street number and map/lot - 220(4)(u) Maximum scale of 1 "=40' for plot plan - 220(4) Maximum scale of 1 "=20' for profile and component details - 220(4) Legal boundaries of the facility being served - 220(4)(a) Names of abutters from recent tax map - NA 8.02j Number of bedrooms, design calcs., - NA 8.02i V , Name & address of record owner & applicant - NA 8.02k Name & address of designer - NA 8.021 Holder and location of all easements - 220(4)(b) Date plan drawn & any revision date - NA 8.02m t/ All dwellings and buildings, existing and proposed - 220(4)(c) Location of all existing or proposed impervious areas - 220(4)(d) ✓ All distances on site plan — NA 8.03a -c ✓� Elevation of proposed driveway - NA 8.02t ✓' Location and elevation of foundation drain - NA 8.02y t✓ Location and dimensions of the system incl. reserve (new const.) - 220(4)(e) Limits of excavation of leach area on site plan - NA 8.02z Locus plan - 220(4)(t) (Not to scale) North arrow - 220(4)(g) Existing and proposed contours - 220(4)(g) Locations and logs of deep holes - 220(4)(h) Locations and logs of percolation tests - 220(4)(i) Date(s) of soil testing - 220(4)(h) & (i) Existing grade elevation of each deep hole - 220(4)(h) Elevation of percolation tests — N.A. 8.02n Name of approving authority representative - 220(4)(h) & (i) ✓ Name of soil evaluator - 220(4)0) Soil logs and perc test logs match BOH records ✓ Locations of waterlines, drains, and subsurface utilities - 220(4)(m) Observed and adjusted g.w. elevation in the vicinity of the system - 220(4)(n) ✓ Complete profile of the system to scale - 220(4)(o), NA 8.02c ✓'' Cross section of leaching facility - NA 8.02w (Not to scale) L Location of benchmark(s) within 50-75 feet of facility - 220(4)(q) Note listing all variance requests with proper citations - 220(4)(p) ti Local upgrade approval request form submitted - 403(1) 2 On-site Soil and Groundwater Review OK Problem N/A V-1, Proper deep observation hole logs on plan - 220(4)(h) " Original R.S./P.E. stamp, signature & date - 220(1) & (2) ✓ P.E., discipline specified within stamp. MGL C. 11.2 s. 8 1 M / sfc. supplies (w/in 400'), pub. wells (w/in 250'), pvt. wells (w/in 150') - 220(4)( refusal el. Location of watercourses, wetlands, wells, etc. w/in 150' of system – NA 8.02r Wetland disclaimer – NA 8.02s t✓ RLS plan reference & certification required (prop line setbacks) - 220(3) Plan contains designer's certification statement Use approvals / standards checked for I/A system - DEP docs., ✓ Perc rate >30 MPI - not allowed for new, LUA for upgrade - 245(1)&('3) Perc rate > 60 MPI - must use modified tight tank or UA technology - 245(4) Proposed system qualifies as "shared" system - 002 (definitions) Flow is over 2,000 gpd - No R.S. allowed - 220(1) ✓ Design flow was set in accordance with code - 203 x Existing system location and note on proper abandonment - 354 Leaching facility at least F above Base Flood elevation – NA 9.05 All piping Sch 40 minimum – NA 10.01 Basement floor minimum P above groundwater elevation – NA 5.04 Foundation drain present with elevation – NA 8.02y On-site Soil and Groundwater Review OK Problem N/A V-1, Proper deep observation hole logs on plan - 220(4)(h) acceptable soil el. All deep holes and peres shown, including aborted tests – NA 8.02n ✓ Soil evaluation forms submitted within 60 days of field work - 018(2) ground water el. Proper percolation test log - 220(4)(i) refusal el. Ample deep observation holes in primary disposal area (minimum 2) - 102(2) Ample deep observation holes in secondary disposal area (minimum 2) - 102(2) Ample perc testing (one in each disposal area, 3 in prim. > 2,000 gpd) - 104(4) Deep hole testing conducted within two years – NA 7.05 Hole Identification Numbers: ground elevation el. acceptable soil el. Leach facilitv invert el. A7 / , 17 _ ground water el. refusal el. bottom of leach facility el. thickness of acceptable soil -1 767 _ before & after soil R&R f separation to groundwater separation to refusal soil class ILI— _ a perc rate loading rate septic tank below g.w. table pump tank below g.w. table l.f in fill 7� r• (yes or no) (yes or no) - 255(1) Setback Distances (Given in feet)15.21 1. YES NO OK Problem N/A Is the lot in the Lake Cochiewick Watershed? NA 6.00 & 5.02 Septic Tank Leach Facility Property line 10 10 20 10 20 Cellar wall 10 Inground pool 10 10 Slab foundation 75 100 75 100 75 Deck, on footings, etc. 400 400 Waterline 150 v Private drinking well Irrigation well Wetlands �/Public well ✓ Wetlands bordering surface water Supply or trib. (in Watershed) Trib. To Surface Water supply Reservoirs Tributaries to reservoirs 1/ Drains (wat. supply/trib.) :. Drains (intercept g.w.) Foundation drains "/ rains (Other) Drywells Downhill slope Septic Tank Leach Facility 1.0 10 10 20 10 20 10 10 5 10 10 10 75 100 75 100 75 100 400 400 150 150 325 325 400 400 200 200 50 1.00 25 50 10 20 5 10 20 25 15' to 3:1 slope 3 3 w/o barrier Building Sewer OK Problem N/Aj / Tank is accessible - 228(3) Grease trap required for certain uses (check 230 for details) Pipe diameter listed (4" minimum) - 222(1) Pipe schedule listed - 222(3) ✓ Pipe cast iron or Sch 40 PVC — NA 11.02 Watertight joints specified - 222(3) & (4) Pipe laid on compact, fin base - 222(5) 2-3" drop from inlet to outlet - 227(5) Pipe laid on continuous grade in straight line - 222(7)@ Cleanouts precede all changes in alignment and grade - 222(8) Cleanout provided every 100 feet - 222(8) __ Manhole at any 90 degree alignment change - 222(8) c/ Invert elevation at building: ✓ Invert elevation at septic tank: Tees are not to be replaced by baffles - 227(1) Length of run: 16Y Slope: 8 , O Z (minimum of 0.01 - 0.02 desired) - 222(6) ✓ 10' offset to private well or suction line - 222(2) Septic Tank OK Problem N/A 4 ✓ Tank is accessible - 228(3) c/ No structures above tank — (228(3) �--- Tank can accommodate both primary & reserve — NA 9.04 h-� 200% of flow (required & provided given. 1.500 min.) - 220(4)(f) & 223)(1)(a) 2-3" drop from inlet to outlet - 227(5) ✓ Minimum of 4' liquid depth - 223(2) 3" air space above tees/baffles (minimum) - 227(4) �^ 9"air space above flow line (minimum) - 227(4) ✓ Tees are not to be replaced by baffles - 227(1) Tees extend 6" above flow line - 227(1) Inlet tee extends 10" below flow line (minimum) - 227(6) Outlet tee extends 1.4" below flow line (more for deeper tanks) - 227(6) t/ Gas baffle installed on outlet - 227(4) �✓ Access manhole cover above center of tank & each tee (except 2 compart) 228(2) t/ 3-20" manholes - 228(2) 1 childproof, 24" riser/manhole w/in 6" of final grade if <1.000gpd- 228(2) �r Inlet and outlet tees on center line - 227(1) -� Soil compaction below tank specified (if soil is non-native) - 221(2) t/ 6" of <=3/4"stone beneath tank specified - 221(2) & 22 8(1) Ci- If > 1,000 gpd AND not a single fam. dwell. must be 2 tks or 2 comp. - 223(l)(b) If plan specifies disposal must be 2 tanks in series or 2 compart. tank - 223(l)(c) Buoyancy calcs. required if tank at or below water table - 221(8) ✓ Tank is watertight - 221 (1) 9" of cover over tank - 228(1) i�. =H-20 H- 10 loading (min.)affc - 226(3) Top of tank <=36" below grade - 221(7) All pumping to tank (if applies) in accordance with - 229 Tank is set to keep old system in service during install if possible 4 Tijjht Tank (Check here if not present: ✓ ) OK Problem N/A 500% of design flow or 2000 gallons provided — 260(2)(a) 3- 20" manholes — 228(2) Soil compaction below tank specified (if soil non-native) — 221(2) 6" of <=3/4" stone beneath tank specified — 221(2) & 228(1) Buoyancy calcs. Required if tank at or below water table — 221(8) Tank is watertight — 221(1) 9" of cover over tank specified (minimum) — 228(1) H-10 loading (min.) — H-20 if traffic — 226(3) Top of tank <= 36" below grade — 221(7) All pumping to tank (if applies) in accordance with — 229 AN alarm set at 3/5 tank capacity — 260(2)(c) Min. 1-24" frame w/cover at finished grade — 228(2)(f) Year round access for pumping — 228(2)(g) Distribution Box (Check here if not present: ) OK/ Problem N/A Inlet elevation: Outlet elevation: i 0.1.7' drop from inlet to outlet (minimum) - 232(3)(b) 6" sump (minimum) - 232(3)(e) All outlets at same elevation - 232(3)(b) LZ Outlet pipes laid level for first 2 ft. - 232(3)(c) Pipe Sch 40 - NA 10.011 14)IL Number of outlets: Number of laterals: 17 Size of outlets: c/ " Inlet.baffle/tee min. 1" over outlet invert for all d -boxes - 232(3)(a), Soil compaction below distribution box specified (if soil is non-native) - 221(2) 6" of stone beneath distribution box specified - 221(2) Box is watertight - 221 (1) Top box below 221(7) of <=36" grade - Buoyancy calculations required if box is at or below water table - 221(8) Pump Chamber (Check here if not present: ) OKE Problem N/A Volume specified: 220(4)(r) Pump on elevation- 220(4)(r) Pump off elevation: q3, 90 220(4)(r) Alarm on elevation: 96-1-5 P, 220(4)(r) Number of cycles per day - 220(4)(r) (also 254(1)(d) if gravity from d -box) Minimum 2" delivery line to d -box if gravity - 254(1)( c) ✓- Pressure dosed Lf. if flow >= 2,000 gpd - 254(1)(a) & 254(2)(a) Cycles per day is consistent with chamber volume - 23 1 Volume calculations include flowback volume - 2') 1(2) Leaching Facility (general - complete for all designs) OK Problem N/✓ 50% larger if garbage disposal - 240(4) Trenches to be used whenever possible - 240(6) No vehicle or imperv. area above l.f. unless unavoidable - 240(7); NA 13.02 Vented if under impervious cover - 241 (1) Vented through same pipes as distribution system - 241 (1)(a) �i Vent protected from precipitation/animal entry - 241 (1)(b) t/ Vent is placed beyond traffic or impervious area - 24 1 (1)(c) All lines connected to vent if bed or trenches - 241(1)(d) 9" cover over peastone - 240(9) L/ Reserve area provided (new construction) - 248(1) Reserve 4' from primary leach area — NA 9.04 1✓ 4' (5' if pere rate <=2 MPI) separation to g.w. - 212(a) & (b) 4' (down to T with variance or I/A - upgrades only) of natural soil under 11 ✓ GW separation is adjusted to highest existing grade if facility cuts into a hillside f✓ Pipe slope minimum of 0.005 - 251(9) Require 5' removal and replacement if in fill - 255(5) Top of leach facility <= 36" below grade - 22] (7) Final grade over l.f. minimum 0.02 ft/ft -240(1 0) y Surface & subsurface drainage away from l.f. - 240(1 1) & 245(5) Minimum design flow 440 gpd without deed restriction — NA 13.01 ✓ 3:1 slope where grading required - 255(2) f Toe of fill slope stops 5' from property line or Swale installed - 255(2) f Impermeable barrier if < 3:1 slope or < 15 feet to —3: 1 slope - 255(2) Impermeable barrier/retaining wall poured concrete — NA 9.02 Retaining wall stamped by P.E. - 255(2)(b) Top of retaining wall >= top of peastone elevation - 255(2)(f) 10' offset from edge of leach facility to edge of ret. wall - 255(2)(g) Pere test(s) done in most restrictive layer - 104(2) Pere test 4' below leaching elevation — NA 7.06 �✓ Design flow listed and required/provided leach area given - 220(4)(f) Leach pipes SCH40 PVC — NA 10.01 Leach pipes minimum 4" diameter except for dosed system — NA 14.04 24 hour storage capacity above pump on elevation - 231(2) Number of pumps: 1 2 if system serves >2 dwelling units - 231(6) ' Capacity of pump(s) - -�VZ gpm @ 26 ' TDH - 220(4)(r) Pump can pass ] 1/4 "solids (minimum) - 231(7) Pump controls specified - 220(4)(r) Alarm equipment specified - 231(2) 1/ Alarm is in building and powered on separate circuit from pump - 2') 1(9) t/ Pump sequence correct (off-lead on-lag on-alan-n on) - 231(8) Pump performance curves included - 220(4)(r) 4� Manual operating switch - NA 12.01 '-� Check valve, bleeder hole - NA 12.01. ✓ 1 childproof, 24" riser/manhole to final grade - 2'31(5), �✓ Soil compaction beneath pump chamber specified (if soil is non-native) - 221(2) 6"of <=3/4"stone beneath chmbr. specified - 22] (2) & 228(1), Buoyancy calculations if chamber is at or below water table - 221(8)@ 9" of cover over cha mmum) - 228(1) v H- 10 loading (min.) LU-2D J traffic - 226(')), ✓ Chamber is watertight - 221 (1) Top of chamber <=36" below grade - 221(7) Leaching Facility (general - complete for all designs) OK Problem N/✓ 50% larger if garbage disposal - 240(4) Trenches to be used whenever possible - 240(6) No vehicle or imperv. area above l.f. unless unavoidable - 240(7); NA 13.02 Vented if under impervious cover - 241 (1) Vented through same pipes as distribution system - 241 (1)(a) �i Vent protected from precipitation/animal entry - 241 (1)(b) t/ Vent is placed beyond traffic or impervious area - 24 1 (1)(c) All lines connected to vent if bed or trenches - 241(1)(d) 9" cover over peastone - 240(9) L/ Reserve area provided (new construction) - 248(1) Reserve 4' from primary leach area — NA 9.04 1✓ 4' (5' if pere rate <=2 MPI) separation to g.w. - 212(a) & (b) 4' (down to T with variance or I/A - upgrades only) of natural soil under 11 ✓ GW separation is adjusted to highest existing grade if facility cuts into a hillside f✓ Pipe slope minimum of 0.005 - 251(9) Require 5' removal and replacement if in fill - 255(5) Top of leach facility <= 36" below grade - 22] (7) Final grade over l.f. minimum 0.02 ft/ft -240(1 0) y Surface & subsurface drainage away from l.f. - 240(1 1) & 245(5) Minimum design flow 440 gpd without deed restriction — NA 13.01 ✓ 3:1 slope where grading required - 255(2) f Toe of fill slope stops 5' from property line or Swale installed - 255(2) f Impermeable barrier if < 3:1 slope or < 15 feet to —3: 1 slope - 255(2) Impermeable barrier/retaining wall poured concrete — NA 9.02 Retaining wall stamped by P.E. - 255(2)(b) Top of retaining wall >= top of peastone elevation - 255(2)(f) 10' offset from edge of leach facility to edge of ret. wall - 255(2)(g) Pere test(s) done in most restrictive layer - 104(2) Pere test 4' below leaching elevation — NA 7.06 �✓ Design flow listed and required/provided leach area given - 220(4)(f) Leach pipes SCH40 PVC — NA 10.01 Leach pipes minimum 4" diameter except for dosed system — NA 14.04 Leach lines capped, vented, or connected together - 251(9) Pressure dosing guidance followed if pressure distribution - 254(2)(c ), Pressure dosing required over 2,000 gpd or with I/A remedial use - 231(1) Leaching Trenches (Check here if not present: OK Problem N/A Number of trenches: Minimum of 2 trenches - NA 9.01(2) Depth of trenches (max eff. 2'): -247(l) Width of trenches (2' min., 4' max.): - 251 (1)(b) Length of trenches (100' max.): - 25 1 (1)(a) Trenches are vented (when > 50') - 251 (11) Trenches follow contour lines - 251(2) Trench spacing 3 times effective width or depth minimum- 251 (1)(d) In fill or reserve between trenches, 10' min. - NA 1.4.01 & 14.03 Available leach area given (Min. 500 s.f.) - NA 9.01(2) Bottom = L x W x # — s.f. Sidewall = L x D x# x 2= s. f. Effective leach area given Loading factor: Effective area = total area s.f. x LTAR = g/day Effective area is >= design flow of facility being served 2"of 1/8"- 1/2" 2x washed peastone.- 247(2) Trench depth of 3/4" to 1 1/2" double washed stone - 247(1) Leaching Pits (Check here if not present: OK Problem N/A # of pits/pit systems: (dosing chamber if>1, 231 (1)) Dimensions of each pit or system: L W D Depth of pits (max eff. 2'): - 253(1)(a) Available leach area given Bottom = L x W x # of systems = s.f. Sidewall = L+ W x D x 2 x# of systems = s.f. Total area = bottom + sidewall — s.f. Effective leach area given Loading factor: Effective area = total area s.f. x LTAR = —g/day Effective area is >= design flow of facility being served Minimum of 2 pits at least 13'X16' — NA 9.01(3) Distribution for galleries/chmbrs. in trench config. - pipe every 20'- 253(6) Distribution for galleries/chmbrs. in bed config.-ea.pipe serves <= 40 s.f.-253(6) Spacing - 2 times the effective width or depth (the greater) - 253(1)(c) 2"of 1/8"- 1 /2" 2x washed peastone.- 247(2) 3/4" to 1 1/2" double washed stone - 247(1) Each pit has at least one 20" access cover. 24" CI to grade over 2,000 gpd -253(3) Surrounding aggregate thickness between 1' (min.) and 4' (max.) - 253(1)(b) Vents, if necessary, extend under covers of pit(s) - 241 (e) Leach Fields (Check here if not present: ) OK Problem N/A J/ Number of fields: (need dosing chamber if > 1, 231 (1)) Final Grading OK/ Problem N/A d V 5/24/01 Length (100' rim �.): - 252 (2)(b) Width: Total area: L x W _s. f. Minimum 900 squ e feet - NA 9.01(1) Distribution lines connected with solid pipe — NA 15.01 Effective leach area give Loading factor: Effective area = total area s.f x LTAR _g/dav Effective area is >= design flow of facility being served Minimum of two distribution lines - 252(2)(a) 6' line separation (max.) - 252(2)(d) 4' maximum separation from edge of field to line - 252(2)(e) 10' minimum separation between adjacent leach fields - 252(2)(f) Between 6" and 12" of 3/4 - 1 1/2" stone beneath field - 252(2)(g) & 247(2) 2"of 1/8"-1/2" 2x washed peastone.- 247(2) Slope over leach area minimum of 0.02 feet/foot — 240(10) Grading shall divert drainage away from leach area — 240(l 1) Grading slopes away from dwelling NEW ENGLAND ENGINEERING SERVICES INC February 11, 2003 Sandra Starr, Administrator North Andover Health Department - Town Hall Annex - 27 Charles Street 2003 North Andover, MA 01845 j 9 Re: 835 Chestnut Street, North Andover, Septic system design Dear Sandra: Enclosed are the following documents for the above referenced property. 1. 5 copies of septic system design plans, one with an original stamp. 2. Application for approval and required fee. 3. Copy of soil evaluator sheets. This plan is being submitted for approval. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, �. C 0, Ben3a�C. Osgoocor., EIT President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 SEPTIC PLAN SUBMITTALS LOCATION: 253s- G� ��%� 5�2� < < Map & Parcel—Z5–5- - 6 NEW PLANS: YES $225.00/Plan +-' Check #: 5-733 REVISED PLANS: YES $ 60.00/Plan Check #: SITE EVALUATION FORMS INCLUDED: YES NO LOCAL UPGRADE FORM INCLUDED: YES NO DATE: 'th4J DATE TO CONSULTANT: DESIGN ENGINEER:,,)/' NGINEER: Telephone #: When the submission is complete (including check), date stamp plans, COPY for Conservation, and place in existing file with green Design Approval form. V, TOWN OF NORTH ANDOVER ;aIEALT � 1)E,?A7tU"? 1!,:NT 27 CHARLES STREET NORTH ANDOVER, !MASSACHUSETTS 01845 Sandra Starr Public Health Director April 1, 2003 Ben Osgood, Jr. New England Engineering Services, Inc. 60 Beechwood Drive North Andover, MA 01845 Re: 835 Chestnut Street Dear Mr. Osgood: Telephone (978) 688-95.10 FAX (978) 688-9512 This is to notify you that the proposed plans dated February 6, 2003 for the repair of the septic system at 835 Chestnut Street, North Andover have technical deficiencies which must be addressed before the plans can be approved. They are: • The existing system location is missing. • The emergency storage capacity appears to be less than 24 -hours. • Vent is missing devices to protect from animals, weather, etc. If you have any questions, please call the office at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: BOH Homeowner File NEW ENGLAND ENGINEERING SERVICES lk INC Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 835 Chestnut Street, North Andover, Septic system design Dear Sandra: April 7, 2003 FC:_. APR - 92003 L -_ Enclosed are 5 copies of revised septic system design plans, one with an original stamp for the above referenced property. The following corrections were made to the plan. 1. The vent detail has been revised to indicate the installation of a charcoal filter/animal screen. 2. The existing system locations have been added. 3. A thrust block detail and a note indicating that thrust blocks shall be installed at all force main bends has been added. This plan is being submitted for approval. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, Benjamin C. Os ood, Jr., EIT President Cc Owner 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 INSPECTION CHECKLIST FOR SEPTIC SYSTEMS � 1��,� Yes NO A. Bottom of Bed 1. Excavation to proper depth t� 2. With trenches, sides of excavation are beneath B horizon -�- 3. Edge of excavation specified distance from foundation, etc. "--` Comments: � J� JA) 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: C. Building Sewer / 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: D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20" manholes_ 7. Inlet tee minimum 12" under invert 8. Outlet tee minimum 14" under invert 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/." crushed stone under tank 14. Tank is watertight Comments: Initials F. Distribution Box 1. D -box level 2. Minimum 0.1 T' (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 %" - 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.-,7- 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'. 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". NO Yes E. Pump Chamber 1. If separate from tank, compact base with 6" of 1/4" stone underneath / 2. Minimum 2" pipe to d -box if ga+tits�eEr► 3. 20" access manhole 4. Tank level_ 5. Watertight �- 6. Tank size agrees with plan specification_ 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d -box Comments: F. Distribution Box 1. D -box level 2. Minimum 0.1 T' (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 %" - 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.-,7- 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'. 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". NO 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 r Comments: I Leaching Pits 1. Miniinum 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 En W 0 0 ;' ooz 0 Cl N N b Ob A h to Oil x N z 0 0 o• i h. b N O O �A. O O i BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR SOIL TESTS DATE: n _j o 2 -MAP & PARCEL: 107C, 2 0 LOCATION OF SOIL TESTS: E 3 S s i t = e i OWNER: Y), ,9, j v t4 P E-0_" S, E TEL. NO.: ADDRESS: CKC3, k) v 1 ENGINEER: NELAJ �•L,EC�AN,� 4- )61W Z�RW6- TEL. NO.: q70 -6&(,--/ ) 4 g� CERTIFIED SOIL EVALUATOR: Be, C�)sjoj,9i 2 �.cH. 2t 40 Intended Use of Land: Residential Subdivision ,Single Family Hom> Commercial Is This: Repair Testing: `� Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No X THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $200.00 per lot for repairs or Lipgrades. (If time is not critical, fee for repairs is $75.00) GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. 20 Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount:7,5" Checkate: yid � WME 6-1 00 IP tP - ' N 16°9230 `��73 O p 04 r e 0 � o w 00 o •p 0 ,p�� alo PO 0 •� H- 00 J IP • f�f y y ?y , leapt, a WME LOCA. TIONCP�1. .= 1 -OL=. i ION i i =G 7-1 OivI 'J�: T-' Clf -INE l..'F tai = i ILIEA T6" 101Igo dr- f.5 mo�ff653 FORM 11 - SOIL EVALUATOR FORM i p.G Page 2 of 3 s�O Location Address or Lot No. On-site Review / �0 7— Time:: . -�f Weather//�`��0 Deep Hole Number .::::. Date:..:,>l�.. .:.../ .�,:.. c %.._ ....::�. Location lidentif on site plan) ..:....... ..../�� Land Use ::.::..: a�..:....:,...:Qg... Slope (%) `..'...... Surface Stones Vegetation- Landform egetation:Landform ..... ..:::.. . , .. Position on landscape (sketch on the back) ...:...� ..�' Distances from: Open Water Body feet Drainage wey:.:.:..:. feet Possible Wet Area feet Property Line .:::.::......:.:.. feet Drinking Water Well :: :.:::::,:._ . feet Other DEEP OBSERVATION HOLE LOG` Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) �f�yyf ` q MINIMUM OF Z HULtb htUUIMLLJ Al cvcni rnvrvvw vw Parent Material (geologic) DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: -- DEP APPROVED FORhi • 12/07/95 0 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. R On-site Review Deep Hole Number ...:. Date `::/.Time:../`r'°3:`� Weathe_/'?' Location (identify on site plan) .:.:...::.:.:....:.v`.�,.::::.. :::.::::::::..::-.::... Land Use :,:...:.:..:..::. Slope (%) ...,-, .... Surface Stones Vegetation, Landform .... Position on landscape (sketch on the back) Distances from: Open Water Body .:.. .. feet . Drainage way. feet Possible Wet Area .:... feet Property Line .::.:.:..::..:.,. feet Drinking Water Well :::.::..::.:.. feet Other DEEP OBSERVATION'HOLE LOG' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % f7 P6 Parent Material (geologic) DepthtoBedrock: Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: -- kiDEP APPROVED FOU11 • 12107195 , .. ►A • dYi�i�_i �/J t b �pp I I /I JaM-1 MWAMM N owl �, d ap E� • / �fffim