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Home My WebLink AboutMiscellaneous - 855 WINTER STREET 4/30/2018 (2)North Andover Board of Assesso s Public Access - NORTH F T • 9SSACHU`+�� Click Seal To Retum Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial I Page 1 of 1 roperty Record Card Parcel ID :210/104.B-0041-0000.0 FY:2010 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO Location: 855 WINTER STREET Owner Name: GREEN, DAVID S & GREEN, KITTY Owner Address: 855 WINTER STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6 - 6 Land Area: 2.00 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1960 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 342,300 364,900 Building Value: 127,800 148,600 Land Value: 214,500 216,300 Market Land Value: 214,500 Chapter Land Value: http://csc-ma.us/PROPA PP/display. do?linkId=1517830&town=NandoverPubAcc r 12/8/2010 T Lot & Street �� Lis`//1��G/c /� Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: l `/ Approved by: t Designer: /1%� Plan Date: g 13 2 d0a Conditions: Water Supply: \ Town Well Well Permit: Driller: Well Tests: Chemical Bacteria I Bacteria II Plumbing Sign -Off: Comments: Date Approved Date Approved Date Approved Wiring Sign -off: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: 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 3 'tD 19 t--) 3 ��room�• FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? YES NO 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: YES NO DWC Permit Paid? YES NO DWC Permit # Installer: Begin Inspection: Excavation Inspection: Needed: Passed: By: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Final Grading Approval Date: Date: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: YES NO WATER SUPPLY: WN WELL WELL PERMIT -_ DRILLER_._-_____.__._....__._._�._...._...._.....- WELL TESTS: EMICAL UAIE Al`NfZUVEU_._..__ BACTERI UATE fI'PROVED BACTERIA II 1E APPROVEU_�`_„_ COMMENTS FORM U APPROVAL: APPROVAL TO ISSUE” YE5 NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL NU .SEPTIC SYSTEM CONSTRUCTION APPROVAL ES NO OTHER _ NU ANY VARIANCE NEEDED YES NU FINAL BOARD OF HEALTH APPROVAL: :,A46 x 'S T�KOI .�i r WATER SUPPLY: WN WELL WELL PERMIT -_ DRILLER_._-_____.__._....__._._�._...._...._.....- WELL TESTS: EMICAL UAIE Al`NfZUVEU_._..__ BACTERI UATE fI'PROVED BACTERIA II 1E APPROVEU_�`_„_ COMMENTS FORM U APPROVAL: APPROVAL TO ISSUE” YE5 NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL NU .SEPTIC SYSTEM CONSTRUCTION APPROVAL ES NO OTHER _ NU ANY VARIANCE NEEDED YES NU FINAL BOARD OF HEALTH APPROVAL: :,A46 x 'S T�KOI - r MAP # LOT # PARCEL #d STREET CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? S NO KLAN APPROVAL: DATE 1-17 APP. BY DESIGNER:� PLAN DATE: CONDITIONS WATER SUPPLY: WN WELL WELL PERMIT -_ DRILLER_._-_____.__._....__._._�._...._...._.....- WELL TESTS: EMICAL UAIE Al`NfZUVEU_._..__ BACTERI UATE fI'PROVED BACTERIA II 1E APPROVEU_�`_„_ COMMENTS FORM U APPROVAL: APPROVAL TO ISSUE” YE5 NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL NU .SEPTIC SYSTEM CONSTRUCTION APPROVAL ES NO OTHER _ NU ANY VARIANCE NEEDED YES NU FINAL BOARD OF HEALTH APPROVAL: :,A46 ' Y . E ` CLARK TITLE V SEPTIC SYSTEM PROFESSIONALS INC. October 21, 2016 D.F CLARK, INC. Mr. & Mrs. Patrick Spain 855 Winter Street North Andover, MA 01845 RE: Title 5 Inspection 855 Winter Street, North Andover Dear Patrick & Anna: RECEIVED OCT 3); Z-01 �6 TOWNOF NO!"' «,,NDWER HM DEPARTMENT 443,10 Please find enclosed the Subsurface Sewage Disposal System Inspection Report for the above referenced property. As noted on Part B (Certification) of the report, the system Passes the inspection criteria. This inspection is good for the next two (2) years; you may extend the life of the inspection to three (3) years by having the septic tank pumped annually (before anniversary date of inspection). Thank you for allowing us to be of service to you on this project. Please contact us if you have any questions regarding this matter. Sincerely, D.F. Clark, Inc. 0� � George F. Norris Title 5 Inspector Enclosure cc: North Andover Board of Health D.F. Clark, Inc. PO Box 265 24A Mitchell Road Ipswich, MA 01938 978-356-5638 Fax 978-356-5500 Toll Free 888 -DF -CLARK Commonwealth of Massachusetts Title 5 Official Inspection Form McEivEn a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments OCT 3 11016 wM 855 Winter Street MM OF NORTH ANDOVER Property Address HEALTH DEPARTMENT Patrick & Anna Spain Owner Owner's Name nformationis equined fofor every _North Andover MA 01845 October 12, 2016 page. City/Town State Zip Code Date of Inspection 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. i require Important: When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor - do not George F. Norris use the return key. Name of Inspector D.F. Clark, Inc. Company Name 22 Mitchell Road, PO Box 265 Company Address �I Ipswich City/Town (978) 356-5638 Telephone Number B. Certification MA State S14051 License Number 01938 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 � (; F la 1al1� Inspector's `Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 855 Winter Street Property Address Patrick & Anna Spain Owner Owner's Name information is required for every North Andover MA 01845 October 12, 2016 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: Cleaned effluent filter in the septic tank at time of inspection Manufacturer recommends filter be cleaned on a yearly basis to prevent filter from clogging and possibly backing sewerage into residence. 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 - 3113 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 855 Winter Street Property Address Patrick & Anna Spain Owner's Name North Andover MA 01845 October 12, 2016 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 • 3113 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 855 Winter Street Nroperty Address Patrick & Anna Spain Owners Name North Andover MA 01845 October 12, 2016 CityfTown 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® 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 855 Winter Street Property Address Patrick & Anna Spain Owner information is Owner's Name required for every North Andover MA 01845 October 12, 2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 W Title 5 Official Inspection Fora o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 855 Winter Street C. Checklist in MA 01845 State Zip Code October 12, 2016 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Property Address ❑ ® Patrick & Anna Sp Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist in MA 01845 State Zip Code October 12, 2016 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 W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 855 Winter Street in D. System Information Description: As Der desian olan MA 01845 State Zip Code October 12, 2016 Date of Inspection Number of current residents: Property Address 3 Patrick & Anna SI Owner Owner's Name information is required for every North Andover page. Citylrown in D. System Information Description: As Der desian olan MA 01845 State Zip Code October 12, 2016 Date of Inspection Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 187 gpd Detail: September 17, 2014 - September 12, 2016 = 136,000 gallons divided by 726 days = 187 gallons per day 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 Currently occupied Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 855 Winter Street Property Address Patrick & Anna Spain Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: R A n n 1 n l r General Information Date October 12, 2016 Date of Inspection Source of information: According to owner, system was last pumped one year ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: gallons Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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): Septic tank, pump chamber, distribution box, soil absorption system t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 855 Winter Street Property Address Patrick & Anna Spain Owner Owner's Name information is required for every North Andover MA 01845 October 12, 2016 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Svstem as -built is dated October 21, 2010 per Board of Health file. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: El cast iron ® 40 PVC El other (explain): Distance from private water supply well or suction line' ❑ Yes ® No 1.42 feet N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer pipe is in the slab floor. Unable to inspect pipe. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal .75 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'Wx10.5'Lx4'D Sludge depth: t5ins • 3/13 1St Compartment = 2", 2nd Compartment = 1" Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 855 Winter Street Property Address Patrick & Anna Spain Owner Owner's Name information is required for every North Andover MA 01845 October 12, 2016 page. Cityrrown 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 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 33" 0" in both compartments N/A N/A How were dimensions determined? Tape measure and Sludge Judge Comments (on pumping recommendations, inlet and outlet.tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees are in place. Liquid level is normal. Pumping is not required at this time Cleaned effluent filter in second compartment at time of inspection. Septic tank is in good condition. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 • 3113 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 855 Winter Street Property Address Patrick & Anna Spain Owner Owner's Name information is required for every North Andover MA 01845 October 12, 2016 page. Cityrrown State Zip Code 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 855 Winter Street Property Address Patrick & Anna Sr Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 41 October 12, 2016 Date of Inspection 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.): Distribution box ("d -box") is 5" below grade. Distribution is equal. There are no signs of leakage or solids carryover. Ran pump and observed good flow into the d -box. D -box is in good condition. 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.): Pump and all three (3) floats are working properly. Pump chamber is in good condition * 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 855 Winter Street D. System Information (cont.) leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system 01845 October 12, 2016 Zip Code Date of Inspection number: number: number: number, length: number, dimensions number: 1 leach field - 12.82' W x 32'L Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil absorption system ("SAS") is under the front yard. There are no signs of ponding or hydraulic failure. Inspected leach field with inspection camera and found it working properly. 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 t-roperty Address Patrick & Anna Spain Owner Owner's Name information is required for every North Andover MA page. City/Town State D. System Information (cont.) leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system 01845 October 12, 2016 Zip Code Date of Inspection number: number: number: number, length: number, dimensions number: 1 leach field - 12.82' W x 32'L Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil absorption system ("SAS") is under the front yard. There are no signs of ponding or hydraulic failure. Inspected leach field with inspection camera and found it working properly. 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 855 Winter Street n D. System Information (cont.) MA 01845 State Zip Code October 12, 2016 Date of Inspection 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 Property Address Patrick & Anna S Owner Owner's Name information is required for every North Andover page. City/Town n D. System Information (cont.) MA 01845 State Zip Code October 12, 2016 Date of Inspection 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 Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 855 Winter Street Property Address Patrick & Anna Spain Owner Owner's Name information is required for every North Andover MA 01845 October 12, 2016 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 A-1 = 16'6" #1, #2 & #3 have covers to grade B-1 = 31'3" A-2 = 15'6" B-2 = 39'3" A-3 = 19'5" B-3 = 49'5" A-4 = 27'2" B-4 = 35'9" Garage Water Sewer • A #2 — Septic Tank (Outlet) #1 - Septic Tank (Inlet) # - Pump Chamber • • B=4" Paved 4" Vent line L32nfiltrator Driveway #4ch Field Distribution Box 14sw ch, D. E. CLARK TITLE V 'EPTIC SYSTEM PROFESSIONALS INC. �—"'8) 356.0b ' Winter Street t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 855 Winter Street Property Address Patrick & Anna Spain Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 5 feet October 12, 2016 Date of Inspection Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: July 7, 2010 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: Greg Saab performed soil testing on June 24, 2010 and observed ESHGW in both holes @ 60". According to design plan the bottom of SAS is 4' above the ESHGW in hole DH1. At time of of inspection a site exam was made, site was level, no surface water was observed, house is on a slab, and no shallow wells were located. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 855 Winter Street Property Address Patrick & Anna Spain Owner Owner's Name information is required for every North Andover MA 01845 October 12, 2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® 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 .. V6 L, I (. LV I U I , VVI Is1 ouuunniy Record Card generated on 1 011 712016 12'59:54 PM by Tara Hurley Town of North Andover Tax Map # 210-1043-0041-0000.0 Parcel Id 16366 855 WINTER STREET SPAIN, PATRICK Since Jan 2012 NGUYEN, ANNA 855 WINTER STREET NORTH ANDOVER, MA 01845 Page 1 Class 101 Singla Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 2 Acres FY 2017 UB Mailing Index Name/Address PATRICK SPAIN 855 WINTER STREET NORTH ANDOVER, MA 01845 GREEN,HENRY 855 WINTER STREET N. ANDOVER, MA 01845 BANK UNITED, FSB 7815 N.W. 148 STREET MIAMI LAKES, FL 33016 UB Account Maint. Account No Cycle Bldg Id. 18034.0 - 855 WINTER STREET 3180063 03 Cycle 03 UB Services Maint, Account No, 3180003 Service Code MISGFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3180063 Type Loan Number Owner Previous Customer Previous Customer Active/Inact. From Inactive 9/8/2008 Inactive 2/28/2011 Occupant Name Activellnacttve Last Billing Date 10/13/2016 Active Rate Charge Multiplier/Users 0.63518 7.82 1/ 01 ALL METER SIZE 60.60 /1 Serial No Status Location 13242152 a Active 00 Date Reading Code 9/12/2010 954 a Actual 6/17/2016 938 a Actual 3/1412016 919 aActual 12/14/2015 904 aActual 9/11/2015 887 a Actual 6/11/2015 870 aActual 3/18/2015 855 a Actual 1211512014 837 aActual 9/16/2014 818 a Actual 6/12/2014 800 aActual 3/13/2014 776 a Actual 12/13/2013 762 a Actual 9/13/2013 747 a Actual 6/14/2013 733 a Actual 3/20/2013 722 a Actual 12/13/2012 710 a Actual 9/19/2012 698 a Actual 6/18/2012 683 aActual 3/20/2012 672 a Actual 12/19/2011 662 aActual Brand Type METE METE w Water Consumption Posted Date 16 10/24/2016 19 8/2/2015 15 4/2212016 17 1/20/2016 17 10/16/2016 15 7/24/2015 18 4/28/2015 19 1/15/2015 18 10/15/2014 24 7/16/2014 14 4/1112014 15 1/17/2014 14 10/15/2013 11 7/24/2013 12 4/22/2013 12 1/9/2013 15 10/15/2012 11 7/16/2012 10 4/1412012 13 1/17/2012 Size 0.63 0.63 Until YTD Cons 498 Variance -8% 21% -9% -2% 5%. -9% -6% 13% -29% 70% -13% 7% 20% 3% .12% -12% 32% 12% -21 1% m IRIUMBIUMMIM-1 } NOV 20 y gib. TOWN OFF NORTH ANDOVER HEALTH DEPARTMENT PUBLIC HEALTH DEPARTMENT (ommunity Development Division TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned( hereby certify that the Sewage Disposal System ( constructed; ( ) repaired; By: ar3 Y 1 ✓� �0 4 C_ c r (Print Name) _ Located at: a J CA-' I &5T (Installation Address) Was installed in conformance with the North Andover Board of Health approved plan, originally dated 1 -1 1 1 & and last revised on Z' I a I 16 , with a design flow of T 736a gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. •T Bottom of Bed Inspection Date: © fx? VA Engineer Representative (Signature) And — Print Name Final Construction Inspection Date: 0 7 iU Engineer R resentative (Signature) (S � � �► � �i,r'c' fj And — Print (Signature) And — Print Name Z� Date: _Z(' `140/a �i*y 7VW A jt4��i& And — Print Name 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com, , AS -BUILT CHECI dST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS ✓ LOCATIONS & DINTNSIONS OF SYSTEM, SERVE TIES TO LOT LINES & DWELLING, WELLS '~ b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM 1� TOP OF FDN ELEVATION Y LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE [� DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX _ ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS ETC. / NORTH ARROW . V LOCATION & ELEVATIONS OF BENCHMARK USED DelleChiaie, Pamela From: Sawyer, Susan Sent: Tuesday, October 05, 2010 8:40 AM To: DelleChiaie, Pamela; Grant, Michele Subject: 855 Winter Needs tank inspection 855 Winter Told John one or both of us could go out before the 11 AM insp. Susan SlrlUyn Juric ReaM JDlwd" 16CO Uegaad stud JV4 2U, unit 2-36 .Na4& Qndam,✓ta 01845 a ffice 978 688-9540 fwx 978 6884476 All email messages and attached content sent from and to this email account are public records unless qualified as an exemption under the [ http://www.sec.state.ma.us/pre/preidx.htm ]Massachusetts Public Records Law. Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: htt�:/twww.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. DelleChiaie, Pamela From: Randy Burley [rburley@millriverconsulting.com] Sent: Monday, October 18, 2010 8:53 AM To: 'Daniel Ottenheimer'; Grant, Michele; 'Isaac Rowe'; 'Marianne Peters'; DelleChiaie, Pamela; Sawyer, Susan Subject: Construction Inspection 855 Winter St Attachments: Construction Inspection Form 855 Winter St.doc Attached is the report from the final inspection I performed with John Soucy last Friday. The system was installed per plan with the floats modified as you indicated. My only comment to John was a suggestion to caulk the electrical conduit leaving the pump chamber. The vent back to the pc from the d box may allow sewer gas to pass back through the electrical conduit and cause odor issues. Randy Burley Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930 Ph 978-282-0014 Fx 978-282-1318 www.millriverconsulting.co rburleygmillriverconsulting.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: htto://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. V ,fit Liv 16'-ryO\ o t� F- A PUBLIC HEALTH DEPARTMENT Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 855 Winter St MAP: 104 B LOT: 41 INSTALLER: John Soucy DESIGNER: Clayton Morin, Engineering and Survey Services Inc. PLAN DATE: July 7, 2010, rev. August 12, 2010 BOH APPROVAL DATE ON PLAN: August 13, 2010 INSPECTIONS TANK INSPECTION: 10_bl to 110 DATE OF BED BOTTOM INSPECTION: 6 DATE OF FINAL CONSTRUCTION INSPECTION: October 15, 2010 DATE OF FINAL GRADE INSPECTION: I j lall 0 SITE CONDITIONS ® Contractor reports any changes to design plan ® Existing septic tank properly abandoned ® Internal plumbing all to one building sewer ® Topography not appreciably altered Comments: SEPTIC TANK ® Building sewer in continuous grade, on compacted firm base ® Cleanouts per plan Bottom of tank hole has 6" stone base Weep hole plugged ® 1500 gallon tank has been installed H-10 loading ® Monolithic tank construction ❑ Water tightness of tank has been achieved by 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 A Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: TF+ PUBLIC HEALTH DEPARTMENT (ommunity Development Division testing ® Inlet tee installed, centered under access port ® Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of final grade installed over one access port ® Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ® Weep hole plugged ® 1000 gallon Pump Chamber installed ® H-10 loading ® Monolithic tank construction ® Inlet tee installed, centered under access port ® Pump(s) installed on stable base ® Alarm float working ® Pump On/Off floats working ® Separate on/off floats ® Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ® Hydraulic cement around inlet & outlet ® Alarm & Pump are on separate circuits ® Alarm sounds when float is tripped ® Location of control panel: garage, house on slab ® Alarm signal located inside: garage 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 V►ORTH q O �t%_e o 16716 X00 O i PUBLIC HEALTH DEPARTMENT (ommunity Development Division DISTRIBUTION -BOX ® Installed on stable stone base ® H-20 D -Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM (General) ® Bottom of SAS excavated down to C soil layer, as provided on plan ® Size of SAS excavated as per plan ® Title 5 sand installed, if specified on plan ® 40 Mil HDPE barrier installed ® Laterals installed and ends connected to header (and vented if impervious material above) ® Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ® Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ® Number of chambers per row: 8 ® Number of rows (trenches): 4 Comments: Total Chambers = 32 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townafnorthandover.com Inspection Form June 2008 0. pORTH r6q�� OL O A� � t A is PUBLIC HEALTH DEPARTMENT Community Development Division SYSTEM ELEVATIONS 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 AS -BLT INVERT ELEV DESIGN INVERT ELEV Building Sewer OUT 79.36 13' from ST Septic Tank IN 79.09 78.50 Septic Tank OUT 78.82 78.25 Pump Chamber IN 78.80 78.20 Pump Chamber OUT 78.61 77.95 Distribution Box IN 79.95 79.94 Distribution Box OUT 79.78 79.77 Chamber 1 TOP 80.02 80.00 Lateral 1 INVERT 79.69 79.67 Chamber 2 TOP 80.02 80.00 Lateral 2 INVERT 79.69 79.67 Chamber 3 TOP 80.02 80.00 Lateral 3 INVERT 79.69 79.67 Chamber 4 TOP 80.02 80.00 Lateral 4 INVERT 79.69 79.67 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 • r►ORTH O��ttiec ,6" LO r y� COCMiCM -K PUBLIC HEALTH DEPARTMENT Community Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form lune 2008 Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , ,Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form lune 2008 NORT►� rr-NO L O COCMICM WKK y1' �.A ADRATED �,Pa �'�5 PUBLIC HEALTH DEPARTMENT Community Development Division SYSTEM ELEVATIONS BM = HR= HI = ROD ELEVATION AS -BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT . Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthondover.com Inspection Form June 2008 SKETCH PLAN Th /vje� - p LED. ib 'N �t1- ,. •6 OOL O PUBLIC HEALTH DEPARTMENT [ommunity Development Division 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection form June 2008 pORTFI /6 q�rO 3r 0t : �� 6 O O to y� Ty S PUBLIC HEALTH DEPARTMENT Community Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Inspection Form June 2008 Commonwealth of Massachusetts Map-Block-Lot 104.B0041 .ts-04, o----------------------- ,� Board of Health Permit No m BHP -2010-0733 North Andover ----------------------- "' ' FEE P.I. 250.00 F.I. _______________________ s�,�,�Nusks DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted JOhn_SOucy ----- --------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. atNo -855-WINTERSTREET------------- ----------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construct' n Permit No. BHP-20__0=„O�r3 LE copy Dated September 29,_2010 IF1 Issued On: Sep -29-2010 'i Bo d of Health Ll s Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. reb Application for Septic Disposal System Construction Permit -TOWN OF Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* Repair or replace an existing on-site sewage disposal system* ❑ Repair or replace an existing system component — What? A. Facilitv Information or Lot # city/Town 2./* -TYPE OF SEPTIC SYSTEM*: Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) C, /'� f6 TOD 'S DAfE $ 250.00 — Full Repair $125.00 - Component ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. t."A+W Ad ess (if different from above) City/Town St eZip Code 7 6�- �L(00 Tele he t umber 3. Installer Information 0 V A (.AG A'C LA Name _ . ` Name of Companj 06 City/Town State Zip Code 603 9 -7C-7S Telephone Number (Cell Phone # if possible please) 4. Designer Information tWAill~✓ Name _ Name of Company Address 44410t H44, City/To n State Zip Code _7 `i' i Telephone Number (Best # to Reach)t✓ Application for Disposal System Construction Permit • Page 1 of 2 * ort•,,.. ,ei,� Application for Septic Disposal System 0 Oil Construction Permit -TOWN OF TODA DAT ,. $ 250.00 — Full Repair ORTH ANDOVER, MA 01845 �',SSACHII+tt $125.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation u til a C ificate of Compliance has been issued by this Board of Health. Name Date ApplicatioK(� proved Disapp For Office Use Only: 1. Fee Attached. (Board of Health Representative) Date for the following reasons: 2. Project Manager Obligation Form Attached? 3. Pump Svstem? Ifso, Attach copy of Electrical Permit 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes V Yes, Yesz eses-, Yes No No No No No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: BSc (,VT4 -x.01 S4 - (Address of septic system) For plans by Relative to the app 'cation o 0 Y (/\ So Lk ql (Installer's name) Dated /0 o ay s daFeT And dated With revisioi (Engineer) , I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or MY company a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept&townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a 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. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans No instructions by the homeowner, general contractor. or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: Q oday's Date) TV Lk6 7 Z_ ame —Print) e — e Ow TOWN OF NORTH ANDOVER NORTH ANDOVER, MASSACHUSETTS 01845 Permit Number Date Issued Expiration Date Jackie's Law — Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicants 1A Street Address P e Cell F o W 44-1 Qq/To" L&M MA /ro,?o7Y� ZIP t Name of Excavator (if different from applicant) Phone Cell Street Address �016 City/Town MA I ZIP Name of OwnerPrope��y /� �^ (�A J i -(-` y✓ Street Address Phone Cell x007 1quo City/Town MA ZIP Other Contact Permit Fee Received No Yes Description, location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose (include a description of what is (or is intended) to be laid in proposed trench (eg; pipes/cable lines etc..) Please use reverse side if additional space is needed. Insurance Certificate #: Name and Contact Informatio of Insurer: GV7 Policy Expiration Date: Dig Safe #: Name of Compe ent Person (as defined by 520 CMR 7.02): Mass �setj 3 ting L0nse # / W1 -7 License Grande: Expiration Date: BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED, INCLUDING OSHA REGULATIONS, G.L. c. 82A, 520 CMR 7.00 et seq., AND ANY APPLICABLE MUNICIPAL ORDINANCES, BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW, THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO, FOR THE DURATION OF CONSTRUCTION, AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT, INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH, AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND, INDEMNIFY, AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY, CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON,QR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. ARPLI ANT SIGNAT � c DATE C� AVATOR SIGNATURE DIFFERENT) DATE b 'S SIGN TURE {IF DIFFE NT) DATE: 2JPage 9671 J r The Commonwealth of chusetts .department of Public Safety Of"1 1. TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Date ...9.... . k.. l...... NORTH ANDOVER PERMIT FOR WIRING This certifies that = �e U O� , //S ...................... ......... e ................................................ has permission to perform �. .; ................................ wiring in the building of ....�!`�'"... at ..,��`.3..... r :. ,i�� . ........... ............. . North Ando r, Mas as/ Fee.. f .,��..�........ Lic...:::.............` :....... ......... ELECTRICALSPE OR Check # No. of Switch outlets No. of Ranges No. of Disposals No. of Dishwashers No. of Dryers No. of Water aters KW No. of Gas burners No. of Air Cond. tons otal Na of Heat Tota Pumps T Tc s K Space/Area Heat' KW Heating D evi KW No. of No. of No. Hydro Massage Tubs ( No. of Motors Total HP �LY OTHER: office u" 3* Punic NO. —k71k oaa,pw+cv a Fee caeaEed peave Blank) ELECTRICAL WORK Code. 527 CMR 12:00 :)ate—&015 2 7 ---l©lo To the Inspector of Wires: �II ;9 c#k Appropriate Box) uthorizaum No. ndgrd ❑ No. of Meters -_- _U ndgrd ❑ No. of Meters o. of Transformers Total #CVA a. of Emergency Lighti tery Units /Sing MS of Zones a d vi Ing Devices ontainedounding Devices nicipalan.. im❑Other INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General taws I have a.current Liability Insuranoa Policy Including Completed9perations Coverage or its substantial equivalent I have submitted valid proof of same to this otfice. YES -B' NO ❑. N you have cheec� keedd YES, please indicate the type of coverage by checking the appropriate box. INSURANCE LJ BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electrical Work $ Gti Work to Start Signed under the penalties of perjury: FIRM NAME Licensee Signature i_ YES NO D (Expiration Hate) UC. NO. % �/ Bus. Tel. No. Address --,X4. y�� J s �.�CJ� ��9 /c5' Att. Tel. No. 'Z/ ec}�� OWNER'S INSURANCE WAIVER: I am aware that the licensee dorms riot have the insurance coverage. or its substantial equivalent as required by Massachusetts General taws, and that my signature on this permit application waives this requirement Owner 11 Agent d (Please d*cic one) Telephone No. PERMIT FEE $ (Signature of t:?wner or Agent) 1 °F NOED Rry q�mcopy {r SSA CH�1s� North Andover Health Department Community Development Division September 13, 2010 Brian Keenan c/o: On Deck Properties 49 Derby Lane Tyngsboro, MA 01873 RE: Septic System Design approval for 855 Winter Street Map 104B Lot 41 Dear Property Owner, The North Andover Board of Health has completed the review of the septic system design plans for the above referenced property, submitted on your behalf by Engineering & Surveying Services dated July 7, 2010, last revised August 12, 2010 and received August 13, 2010 and the Form 9A Local Upgrade Approval Application was received on August 30, 2010. This plan has been approved. This approval includes the Health Department approval of a local upgrade for allowing the use of a single test pit in the leaching area rather than the required two. Please keep a copy of the attached document for your records. The design has been approved for use in the fully compliant construction of an onsite septic system for a 3 -bedroom house (maximum 7 -room). In accordance with state subsurface disposal regulations plans shall expire three years from the date approved unless construction on the lot has begun, however it is reduced to two years since this installation is the result of a failed Title V inspection. During this time, a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance be endorsed by the installer, designer and the Town of North Andover. The previously issued disposal works construction permit has been rendered void. The contractor must apply and receive the current approved plan. There will be no charge for this since no inspections had occurred. Please notify your contractor. This approval is subject to the following conditions: 1. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation, the originally issued Disposal System Construction Permit is void, 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Winter Street Septic Plan Approval September 13, 2010 the installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit. 2. It is the responsibility of the applicant and/or the applicant's septic system designer, septic system installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe or imply compliance with any of the aforementioned requirement. Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you may have. Sincerely, Director Cc: Greg Saab, Engineering & Surveying Services (ESS) Atach — Form 9B — Local Upgrade Approval Form 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com r� Commonwealth of Massachusetts City/Town of North Andover o Local Upgrade Approval Form 913 '7M DEP has provided this form for use by local Boards of Health if they choose to do so. The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. A. Facility Information Important: When filling out forms 1 on the computer, use only the tab key to move your cursor - do not use the return key. reb L 3. Facility Name and Address On Deck Properties Name 855 Winter Street Street Address North Andover MA 01845 City/Town State Zip Code Owner Name and Address (if different from above): On Deck Properties — c/o: Brian Keenan 49 Derby Lane Name Street Address Tyngsboro City/Town 01873 Zip Code Type of Facility (check all that apply): ® Residential ❑ Institutional 4. Design flow per 310 CMR 15.203: 5. System Designer: 70 Bailey Court Address B. Approval MA State 617.888.2223 Telephone Number ❑ Commercial ❑ School 330 gpd Greg Saab Name Haverhill City/Town 1. Local Upgrade Approval is granted for: ❑ Reduction in setback(s) — specify: ❑ Reduction in SAS area of up to 25%: MA 01832 State, ZIP SAS size, sq. ft. % reduction 855 Winter Street 9B 8 27 10 (2) • rev. 7/06 Local Upgrade Approval* Page 1 of 2 -� Commonwealth of Massachusetts City/Town of North Andover e Local Upgrade Approval Form 9B < �G M B. Approval (continued) ❑ Reduction in separation between the SAS and high groundwater: Separation reduction ft Percolation rate min./inch Depth to groundwater ft ❑ Relocation of water supply well (explain): ❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater ® Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: North Andover Health De artment Approving Authority Susan Sawyer, Health Director _ September 13, 2010 Print or Type Name and Title Signature X Date 855 Winter Street 9B 8 27 10 (2) • rev. 7/06 Local Upgrade Approval* Page 2 of 2 August 2, 2010 North Andover Health Department Community Development Division Clayton Morin, P.E. Engineering & Surveying Services 70 Bailey Court Haverhill, MA 01832 Re: Subsurface Sewage Disposal System Plan for 855 Winter Street (Map 104B, Lot 41) Dear Mr. Morin: The proposed wastewater system design plan for the above site dated July 7, 2010 and received on July 15, 2010 has been reviewed. Unfortunately, the plan cannot be approved until the following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North Andover regulation that is not met by this design follows each item. Before going forward with the revisions, please download the revised North Andover Regulations from this link dated February 25, 2010. We expect you will find this rewrite an improvement. There are no duplicate items already noted in Title V already and items in conflict with Title V have been removed. These are just a couple of the things focused upon by the board.: httn://wwiv.townofnorthandover.com/Pages/NAndoverMA Health/permitsan dregs Please review the most recent North Andover Board of Health regulations. Many of the following items pertain to the revised regulations, specifically section "3 Design Requirements". 1. A Local Upgrade Approval request form is needed for only one deep observation test pit is the proposed disposal area (3 10 CMR 15.102(2)). 2. Please provide a note or chart on the design plan for the Local Upgrade Approval request (NA 3.2). 3. The design flow should reflect the number of bedrooms in the existing dwelling. The existing dwelling has three bedrooms. The current design assumes a four bedroom design based on the previous set of local regulations. 4. Please provide a note that the proposed system is not designed for a garbage grinder unless the system will be designed with a 50% increase in the size of the leaching facility (3 10 CMR 15.240(4)). 5. The full legal dimensions of the lot must be shown (3 10 CMR 15.220(4)�NA 3.2)). 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Z 855 Winter Street — Septic Plan Review August 2, 2010 6. Please provide a statement identifying whether the property is within or not within the Lake Cochichwick watershed (NA 3.2). 7. Please show all watercourses or wetlands within 150' of the system (NA 3.2). 8. Please provide the elevation/location statement as described in section 3.2 of the North Andover Board of Health regulations. 9. In the profile view on sheet 2 of 2, the invert elevation at the house is depicted as 78.12' and the invert at the proposed septic tank is depicted as 78.50'. Please modify this discrepancy. 10. In the profile view on sheet 2 of 2 under "Special Construction Note", the unsuitable removal of soil does not have to extend 6" into the C horizon. Also it appears that the B horizon should remain in place due to the limited amount of C horizon soil (37"). Please modify this note accordingly. 11. Please indicate the brand and model number of the effluent filter proposed. Please feel free to contact the office with any questions you may have. We look forward to working with you to obtain a wastewater treatment and dispersal system which will be in compliance with all regulations and assure protection of public health and the environment of North Andover. Sincere , 1� i' Susan Y. Sawyer, REHS/R Public Health Director cc: On Deck Properties File 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com W DelleChiaie, Pamela From: Sawyer, Susan Sent: Thursday, August 26, 2010 5:21 PM To:—Dela hiai, Pamela Subject: 855 Winter S Attachments: 855Wint et 9B 8.27.10.doc; 855 Winter Street ap 8.27.10.doc Here is the 9B and app Itr DRAFTs Waiting for the 9A from Greg Saab. I left him a message yesterday. Thx Have a good weekend. s Swan Sauk Yub& ReaQtFc lDiud" 1600 Uogaad Stud ,W420, and 2-36 ✓Vadh andauex, .Ma 01845 eake 978 688-9540 fax 978 688-8476 All email messages and attached content sent from and to this email account are public records unless qualified as an exemption under the [ http://www.sec.state.ma.us/pre/preidx.htm ]Massachusetts Public Records Law. 41 Commonwealth of Massachusetts City/Town of North Andover e Local Upgrade Approval r` Form 913 M DEP has provided this form for use by local Boards of Health if they choose to do so. The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. 855 Winter Street 913 8 27 10 • rev. 7/06 Local Upgrade Approval* Page 1 of 2 A. Facility Information Important: When filling out forms 1. Facility Name and Address on the computer, use only the tab On Deck Properties key to move your Name cursor - do not the 855 Winter Street use return key. Street Address North Andover MA 01845 �y Cityrrown State Zip Code 2. Owner Name and Address (if different from above): Name Street Address City/Town State Zip Code Telephone Number 3. Type of Facility (check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Design flow per 310 CMR 15.203: 330 gpd 5. System Designer: Clayton Morin 70 Bailey Court Name PE ❑ RS 66 Park Street Haverhill MA 01832 Address Citylrown State, ZIP B. Approval 1. Local Upgrade Approval is granted for: ❑ Reduction in setback(s) — specify: ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. % reduction 855 Winter Street 913 8 27 10 • rev. 7/06 Local Upgrade Approval* Page 1 of 2 Commonwealth of Massachusetts City/Town of North Andover Local Upgrade Approval Form 9B B. Approval (continued) ❑ Reduction in separation between the SAS and high groundwater: Separation reduction Percolation rate Depth to groundwater ❑ Relocation of water supply well (explain): ft. min./inch ft. ❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater ® Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: North Andover Health Departmi Approving Authority Susan Sawyer, Health Director Print or Type Name and Title Signature August 27, 2010 Date 855 Winter Street 9B 8 27 10 • rev. 7/06 Local Upgrade Approval, Page 2 of 2 Commonwealth of Massachusetts City/Town of Form 9A -Application for Local Upgrade Approval M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Kip Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.415. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CMR 15.000. A. Facility Information Facility Name and Address: ON Imo.'eCK 1- pE2TAI--- S G-SrQAiJ Name e '55 \l 1 1,-)"jf'= P__ Street Address City/Town State Zip Code 2. Owner Name and Address (if different from above): Name City/Town Zip Code 3. Type of Facility (check all that apply): M_ Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: 33 D�t3ca�'1 1�F>SIDC��-Iw� 51n1Gt_� F—Avhkc../ I7w�ik%m6- 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) C, Conventional ❑ Other (describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of W Form 9A — Application for Local Upgrade Approval a o w DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: Design flow of proposed upgraded system Design flow of facility: B. Proposed Upgrade of System ti) A- gpd 3( -Q -a gpd 350 gpd 1. Proposed upgrade is (check one): Voluntary ❑ Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: 2. Describe the proposed upgrade to the system: 3. Local Upgrade Approval is requested for (check all that apply): ❑ Reduction in setback(s) — describe reductions: ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. ❑ Reduction in separation between the SAS and high groundwater: Separation reduction Percolation rate Depth to groundwater t5form9a.doc • rev. 7/06 ft. min./inch ft. date of inspection % reduction Application for Local Upgrade Approval* Page 2 of 4 t Commonwealth of Massachusetts City/Town of W Form 9A — Application for Local Upgrade Approval a o w DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information (continued) 7. Design Flow per 310 CMR 15.203: Design flow of existing system: Design flow of proposed upgraded system Design flow of facility: B. Proposed Upgrade of System ti) A- gpd 3( -Q -a gpd 350 gpd 1. Proposed upgrade is (check one): Voluntary ❑ Required by order, letter, etc. (attach copy) ❑ Required following inspection pursuant to 310 CMR 15.301: 2. Describe the proposed upgrade to the system: 3. Local Upgrade Approval is requested for (check all that apply): ❑ Reduction in setback(s) — describe reductions: ❑ Reduction in SAS area of up to 25%: SAS size, sq. ft. ❑ Reduction in separation between the SAS and high groundwater: Separation reduction Percolation rate Depth to groundwater t5form9a.doc • rev. 7/06 ft. min./inch ft. date of inspection % reduction Application for Local Upgrade Approval* Page 2 of 4 f.. • Commonwealth of Massachusetts City/Town of m Form 9A - Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. B. Proposed Upgrade of System (continued) ❑ Relocation of water supply well (explain): ❑ Reduction of 12 -inch separation between inlet and outlet tees and high groundwater Use of only one deep hole in proposed disposal area ❑ Use of a sieve analysis as a substitute for a perc test ❑ Other requirements of 310 CMR 15.000 that cannot be met— describe and specify sections of the Code: If the proposed upgrade involves a reduction in the required separation between the bottom of the soil absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the high groundwater elevation pursuant to 310 CMR 15.405(1)(h)(1). The soil evaluator must be a member or agent of the local approving authority. High groundwater evaluation determined by: Evaluator's Name (type or print) Signature Date of evaluation C. Explanation Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be completed) 1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible: _)D u G `Tb I .,b GA T(r3!,J OT- C X S� ► ►� fs � L 5. . S . dKILy () N E :1 C-�5--T -p �-r wA Sr S b� 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible: N IPr t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval, Page 3 of 4 Commonwealth of Massachusetts City/Town of s Form 9A — Application for Local Upgrade Approval DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: 4. Connection to a public sewer is not feasible: N I N 5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the appropriate boxes): ❑ Application for Disposal System Construction Permit ❑ Complete plans and specifications ❑ Site evaluation forms ❑ A list of abutters affected by reduced setbacks to private water supply wells or property lines. Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2). ❑ Other (List): D. Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for deliberate violations." Facility Owner's Signature Date Print Name E.S.S• Name of Preparer 7o 13Ai I- 6 V Ci Preparer's address M j4 O/6 3d1— State/ZIP Code eIIz//0 Date 14AV&-X di LC, City/Town 17B . S -S-6 . 6d -&'l Telephone t5form9a.doc • rev. 7/06 Application for Local Upgrade Approval* Page 4 of 4 TOWN OF NORTH ANDOVER Th Office of COMMUNITY DEVELOPMENT AND SERVICES`' t.'k'"Q4 HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 978.688.9540 - Phone Susan Y. Sawyer, REHS/RS 978.688.8476- FAX Public Health Director E-MAIL: healthdeptnn,townoftiorthandover.com WEBSITE: hgp://www.townofnortliandover.com 7'OWt �r N allf Date of Submission: �� ty�� . _ Site Location: 9.5� I JIAJV!2�. .S`p"2e-i�"' Engineer: (, Y -1-6/J O/Z New Plans? Yes_X_$225/Plan Check # (includes 1St submission and one re- review only) Revised Plans?Yes $75/Plan Check # Site Evaluation Forms Included? Yes No Local Upgrade Form Included? Yes No K Telephone #: q78. Yg-&. 6D y Fax #: q79. &S -(o_ Daft E-mail: C53 — C/ Afel— 10d Homeowner Name: DCC k. 4: vOALM 4V7 Pd -9 Sail 12Z1 An1 X6-8-AJAAJ OFFICE USE ONLY When thesubmi cion is complete (including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt ➢ V1 Copy File; Forward to Consultant ➢ Enter on Log Sheet and Database No. COMMONWEALTH OF MASSACHUSETTS Board of Health, NOR14 An• LSV& km, APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ()(Repair () Upgrade () Abandon () - IA -Complete System ❑Indvidual Components Location a �-s W I M -S -' Owner's Name C)M -0LCA t "Pro r-il Map/Parcel# ) C q e) Address l tV ' S T Lot# Telephone# 1� , V66 8 aX3 Installer's Name Designer's Name 'S S Address Address -70 P i I_,Z-. Telephone# Telephone# -7 8. s� - 0 a 19 Type of Building: C I -T7-k Dwelling - No. of Bedrooms 3 Other - Type of Building Other Fixtures Lot Size 96712%J96. Gatbage grinder ( ) No.of persons Showers( ), Cafeteria( ) Design Flow(min. required) *Y0 V gpd, Calculated design flow_J�1/40 Design flow providedq; ' gpd Plan: Date107 1/ 6 Numbe( of sheets_ Revision Date Title 6 fc;t,tbSU Ger- !S 6-wACS6 P)sp06AC !S to ) Description of Soil(s) 5, G?AA,%— Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS J,5-60 G411 1:, A it e%a.J rt 9 errs o i r `F11t . e A'U e",O -6 n f% 147-i Date of Evaluation L+- 16 2gehG J!tn{' 1, 60o t fit. 00* a n n i q.1 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Inspections DEP APPROVED FORM 5/96 No. _ r COMMONWEALTH OF MASSACHUSETTS Board of Health, , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ). Repaired ( ), Upgraded ( ), Abandoned ( ) by: Fee at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated . Approved Design Flow _ (gpd) Installer Designer: Inspector Date The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Observation Hole # Commonwealth of Massachusetts q(011 sYaF Zbl Depth of Perc Start Pre -Soak City/Town of W Percolation Test LEA10T Form 12 N F NORTH ANDOVER M H DEPARTMENT Time at 9" Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Time at 6" Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with Time Time (9"-6") the local Board of Health to determine the form they use. Important: A. Site Information When filling out Test Passed: ® Test Passed: ❑ forms the computer, use o m -D E C < ? R dPEP',. � ES only the tab key to move your do Owner Name 955 w i ti- e p— S%KEG 6 -1 -- Witnessed By: cursor - not use the return key. Street Address or Lot # ►�© P_ _r �.1J�D0'Jt 2 C Lass' Cit /Town ?_1A&tiJ State Zip Code isl1 - 080 -- Z.Z.Z Contact Person (if different from Owner) Telephone Number B. Test Results 6l2q Id Date Time Date Time Observation Hole # ' q(011 sYaF Zbl Depth of Perc Start Pre -Soak l Iq I ' Zq End Pre -Soak ` ! Z q Time at 12" ` q t0 Time at 9" Time at 6" + 2 - ;2O2 m inl Time Time (9"-6") a Rate (Min./Inch) Test Passed: ® Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ Test Perform By: -'.S '4%4 C. Witnessed By: Comments: C Lass' S� t PAW /0 t5form12.doc• 06/03 Perc Test • Page 1 of 1 �IIIII u4IIIII y Il�lil J�II!L':Y!I!:YI�III! ' Ililll��1��lllllllllll �S a O NjO E (�z •� 40 LL Q N U) 'c Z) CL m 2 m <0 U C O U a d N N w D Z ❑ ❑ I cx 0z0cu E] 19 m cu c Z o o a c >, a) U > C O IA ❑ O j a) N C o c c g c coo .00 c Z U ) o o 0 L L) - z N aa)) cc cc ca >+ T a) O O cu a) C a) LO LO a) aJ a) a) Q w :5i 'a a) L .o a > LC (C6 N L _ 0 O 0 LL ¢ � � 0 o v ui co r-� T 0 m rn ca n. 0 m �Zj ,Z/{ 0 O C } } 3 O 0 7 00 Cl. N c 0 CI. N 0 m m Z (6 < ❑ Z >� C O 0 O ❑ E O 0 o" 0 0 0 Z (6 C N ) O U L Q _ 0 0O U > C oca ( 0 Y L 0> 1'.2 Co J > > > �+ L Z 3 in m r N m cx 0z0cu E] 19 m cu c Z o o a c >, a) U > C O IA ❑ O j a) N C o c c g c coo .00 c Z U ) o o 0 L L) - z N aa)) cc cc ca >+ T a) O O cu a) C a) LO LO a) aJ a) a) Q w :5i 'a a) L .o a > LC (C6 N L _ 0 O 0 LL ¢ � � 0 o v ui co r-� T 0 m rn ca n. 0 m �Zj ,Z/{ 0 O Z 3 0 00 w ❑ ❑ ❑ N ZZCl. 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The following changes have been made. Each item below is numbered to correspond to the item number in the letter from John Noonan dated May 9, 2002. 1. The test pit labels have been revised on the plan view. 2. Test pit 2 is labeled to indicate that a water table was not determined. 3. The soil class is class I, the loading rate has not been revised. This has been confirmed with Mr. Noonan. 4. Buoyancy calculations have been provided. 5. Since the soil class is actually class I the pump calculations have not been revised. 6. A deed restriction is needed. This should be a condition of approval. 7. The variance for the use of a poly barrier is being requested. The design is consistent with DEP policy. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, 31—) C �� Benjamin C. Osgood, Jr., IT President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 NEW ENGLAND ENGINEERING SERVICES INC April 1, 2002 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 855 Winter Street, North Andover, Septic system design Dear Sandra: Enclosed are the following documents in reference to the above referenced property. 1. 5 sets of septic system design plans 2. Copy of soil evaluator sheets. 3. Application for plan approval. 4. Check to cover the fee. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, )�- C. /d, Benjamin C. Osgr., EIT President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 TOWN OF NORTH ANDOVER g� Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 . a. ��• NO USETTS 01845 Susan Y. Sawyer, REBS, RS 978.688.9540 - Phone Public Health Director978.688.8476 -- FAX J19 � healthdept Z townofnorthandover.tom ' �S� www.townofnorthandover.com TOWN Olr NtiRTH AN HEALTH DEPARTMENT APPLICATION FOR r DATE: !S- 17 1 IP MAP & PARCEL: _ t ��- 4 VOCATION OF SOIL TESTS: Lt-) 1' AJ17-IF 112 - OWNER: iJ i ! a. o h f'_ elf 4 Contact #: APPLICANT: i j r 1 ayN re e,14,n contact #: ADDRESS: _ LA Ct 4J �' T � c O L �t ✓l ejEt'. n3 S b6,-6 .' 6 1 X-7 3 ENGINEER: r t.. ✓\ f icy r'4 s` Contact #: A` CERTIFIED SOIL EVALUATOR r S ':T to I v Intended Use of Land: Residential Subdivision Single Family Home Commercial Is This: Repair Testing:--,/— Undeveloped Lot Testing: Upgrade for Addition: In the Lake Cochichewick Watershed? Yes THE FOLLOWING MUST BE INCLUDED WITH THIS FORM No I! ➢ Proof of land ownership (Tax bill, or letter from owner permitting test) ➢ &5"x Yr"Plot Plan & Location of TnOw (please inr 'tate tett pit sites on the Plan ➢ Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or uagrades. GENERAL INFORMATION ➢ Only Certified Soil Evaluators may perform deep hole inspections. 9 Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. ➢ At least two deep holes and two percolation tests are required for each septic system disposal area. ➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. ➢ Full payment will be required for all additional tests within two weeks of testing. Within 45 days oftesting, 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). ➢ Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval Date: Signature of Conservation Agent: Date back to Health Department: (stamp in): D2 FMiLA RR2T ,01 w a. o Dom APPNOYK NRm 5u wT RrRREOusm uw F^ g Y y; fAr.P6 �� rl cA"Asw � LIM v An n A 614NAIM Dt PARCLIS 41.201.8 106 wti, AS SAORA M "M nAW.0 A!MESYA" YAP R IDeB a - 1. M7AI PARCEL AREA 1(4066 S ... 16.5x! ACALx Q x 1Gtlf n R7i➢E'afi' 1 9 4. ORRR RECORD fSLATC OE CE IS RE NFANY a 99Y1 ORE, 9 BAR . a 4PIAfA ARIA LOTS LWD " z Y AC A6K 102 Sit REpNKD Or fi1RRG. 0. Mf N6f Q RCM -105 "021" CARR AESLA M9 82 AAD 21D L0 = OY WARDO"A 8 ASIC — ' 1 �OCEO WERE -M. f.KD.R.D. OR. R61 RG 16 R W ACAAK I SRWI PIR CFWA PER XR NiiiO 2AAER rRWA ENSW RAA Of REVOW CNAREO; 'PIAN OE lANO VAl ERE N ALRM AIMER'. AWPARCO rM R41RY K CREEK WTECL MAR 2. 1061. Gn .CRN A COtt.. RI.S. AND RECORDED Ar .c C..DAa A6 F%M 0 wo a. I , AKRS6 z �i z E� r wenam wr + �'��A.nvcw�. nu.e•Axv • .u.wr.. �� N�T WIN TER AAR .Aw AA.1 w a o KA b 491 – M 1 1 } [, (e,+jo h o Dom APPNOYK NRm 5u wT RrRREOusm uw F^ g Y y; ESSfk M Ty CREE1f 9E{r ASSOOAAGA I , AKRS6 z �i z E� r wenam wr + �'��A.nvcw�. nu.e•Axv • .u.wr.. �� N�T WIN TER AAR .Aw AA.1 w a o KA b 491 – M 1 1 } [, (e,+jo h ' ' : L ITF -;q ITT I J5 Li;► I i+ 61 r! r il; a�i�.T �� ' i I Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. e f---. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessme 15,- W I V� -�t u' -U C -- MAY 28 2010 P rty Address I4 e?ro--0'e c- I ��) 1, MM-WOERARM11W 1A 0)345' 5-- / - —10 State Zip Code Date of Inspection 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. _ oh -0 A. General Information 1. Inspector: C ll J�iouX G.� Name of Inspector Company Name i Company Address L'-) 1k, 7� oz A�7� City/Town State Zip Code Telephone Number License Number B. Certification 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 i Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature �— Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. 15ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 -. r_n -.-- - -1.1- - - � ..- � .1 - f Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 5�, (-) 1,4+,e r 5 Property Address Owner's Name City/Town B. Certification (cont.) State Zip Code Date of Inspection 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 o e failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any f ' re 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 followiryg statyements. If "not determined, " please explain. � _ The septic tank is metal and over 20 years old* or the septic tan hether metal or not) is structurally unsound, exhibits substantial infiltration or I iltrat' or tank failure is imminent. System will pass inspection if the existing tank is replaced with a c plying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is st cturally sound, not leaking and if a Certificate of Compliance indicating that the tank isZplain 20 years old is available. ❑ Y ❑ N ❑ ND (ow): t5ins- 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 35S Lbn"I Ac st ;M Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ Y ❑ N ❑ N(Explain below): El obstruction is removed F -1Y El ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ Y ❑ ND (Explain below): ❑ The System required pumping more than times a year due to broken or obstructed pipe(s). The system will pass inspection if (with appr-val 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 cl alth in order to determine if the system is failing to protect public health, safety or the en . nment. 1. System will pass unless Board of Health deter nes in accordance with 310 CMR 15.303(1)(b) that the system is not functionin ' a manner which will protect public health, safety and the environment: ❑ Cesspool or privyis with' 0 feet of a surface water ElCesspool or privy ' within 50 feet of a bordering vegetated wetland or a salt march t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for every page. 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) deterimes that the system is functioning in a manner that protectsthe p lic health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)a the SAS is within 100 feet of a surface water supply or tributary to a surface wa supply. ❑ The system has a septic tank and SAS and the SAS is ' in a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. n The system has a septic tank and SAS more from a private water supplywel Method used to determine distan the SAS is less than 100 feet but 50 feet or "" This system passes if the wet ater analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent an,04he presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provide at 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: Yep No ❑ Backup of sewage into faeility-er-system component due to overloaded or ele� SAS sr-eesspeel- ❑ 2/ Discharge or ponding of effluent to the surface of the ground or surface waters �/ due to an overloaded or clogged SAS or cesspool L� ❑ Static liquid level in the distribution box above outlet invert due to an overloaded o i; o SAS a"esspoel ❑A%A❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow l5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 4 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 Property Address Owner's Name City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El El i 0 M Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, Cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.] This 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 t ollowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 fe f a surface drinkiing water supply ❑ ❑ the system is within feet of a tributary to a surface drinking water supply El El the system is ated in a nitrogen sensitive area (Interim Wellhead Protection Area - IWP or a mapped Zone II of a public water supply well If you have answered "Ps`"to any question in Section E the system is condidered a significant threat, or answered "yes" inection 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 • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 5 of 17 a Owner Information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town State Zip Code Date of Inspection C Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No i❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ WJ 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? ❑ E� 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? El Was the site inspected for signs of break out? ��{ IJ ❑ 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? This size and location of the Soil Absorption System (SAS) on the site has been determined based on: d❑ Existing information. For example, a plan at the Board of Health. Rr ❑ 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): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): (s Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 6 of 17 Owner Information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name Cityfrown D. System Information Description: Number of current residents: Does residence have a garbage grinder? State Zip Code Date of Inspection ❑ Yes L/ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? �I-A ❑ Yes ❑ No Seasonal use? ❑ Yes 2/No Water meter readings, if available (last 2 years usage (gpd)): Detail: V Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15 3): Basis of design flow (seats/per ns/sq.ft.,etc.): Grease trap present? Industrial waste ho ng tank present? Non-sanita aste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes R No ,. Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 7 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 Property Address Owner's Name City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): State Zip Code Date of Inspection General Information Date Pumping Records: Source of information: ��fY Was system pumped as part of the inspection? ❑ Yes R(No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: gallons Type of System: I� 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) 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 • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ` M Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1� -(, -- 9P�J" Were sewage odors detected when arriving at the site? El Yes -[S/No Building Sewer (locate on site plan): Depth below grade: feet Material of construction: cast iron ❑ 40 PVC ❑ other (explain) 0 Ail Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): )JO ��P_qvckcsif— Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal If tank is metal, list age: r feet ❑ fiberglass ❑ polyethylene ❑ other (explain) Ni years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) r— ❑ Yes ❑ No Dimensions: Sludge depth t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 9 of 17 �M Owner Information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - N for Voluntary Assessments f it 10 V1 � 4� Property Address Owner's Name City/Town D. System Information (cont.) Septic Tank (cont.) State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle —3-0 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 2 How were dimensions determined? u e- J� u-I6,e— Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): C7 � �-e�u � ,-1 � �,�� nib !.G C� L t ti� �� ✓t' � � � .� -i-. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fibergl%ass ❑ polyethylene ❑ other (explain) Dimensions: Scum thickness Distance from top of scum to Distance from bottom of sc Date of last pumping: of outlet tee or baffle to bottom of outlet tee or baffle Date Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 10 of 17 a Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name CityfFown D. System Information (cont.) State Date of Inspection 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of al ❑ fiberglass ❑ gallons per day ❑ Yes ❑ No ❑ other (explain) Alarm in working order: ❑ Yes ❑ No 01 Date d float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 11 of 17 w Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments PrODerty Address Owner's Name CitylTown D. System Information (cont.) State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert –4— ) 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.): Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, conditioZpumps appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: (t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 12 of 17 Owner Information is required for every page. (t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 S�- (,) Vvt Property Address Owner's Name City/Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries E] leaching trenches 13/ fields leaching ❑ overflow cesspool ❑ innovative/alternative system State Zip Code Date of Inspection number: number: number: number, length: number, dimensions: number: 4- acv Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ur- L A, / �!)7_ —C L a Io 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 ❑ Yes Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 13 of 17 a �N Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town D. System Information (cont.) State Zip Code Date of Inspection 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 f:��4 level of ponding, condition of vegetation, etc.): (t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 14 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 Property Address Owner's Name City/'Town D. System Information (cont.) State Zip Code Date of Inspection 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: IJ/hand-sketch in the area below ❑ drawing attached separately d( -j NT � s5 CJI (t5ins - 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 15 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 r-% --�-4, L ,\ Property Address Owner's Name City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar ✓ ❑ Shallow wells Estimated depth to high ground water: State Zip Code Date of Inspection 6�D feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Before filling this Inspection Report, please see Report Completeness Checklist on next page. (t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 16 of 17 .a �M Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -S54 l-)tiY,+wst Property Address Owner's Name City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ 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 • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 17 of 17 ti MAP 1048 LOT 41 0 AREA=87,200 S.F. OR 2.0 ACRES o } GgRAGE =80.0' �3 B. M. N0, 855 ' co EX/S77NG h SLAB FOUND NG FOUND q TinN DRA/NSA nDN 2 o A ° o ° 0 8 oo° 0 CJ p°0 00 E C 0 O °o dt� WALK ° ° ° ° 00 A\ 0 0 TP#3/�� D GRAPHIC 8Cm5 o 10 a t IN Fm 1 kWh - 20 R i CLEAl WINTER STREE MCARDLE NOUT @ TIE IN V #�� 19" T A� SEPTIC SYSTEM AS -BUILT LOCATION: 855 WINTER STREET NORTH ANDOVER, MA DATE: 10-21-10 SCALE: 1 " = 20' A TO D = 51.1' (D= DBOX) A TO C = 44.9' (C = SEPTIC TANK) A TO E = 33.2' (E = PUMP TANK) 8TOC=21.8' BTOD=27.1' BTOE=19.4' INVERT TIE IN POINT = 79.34' INVERT TANK IN = 79.10' INVERT TANK OUT = 78.85' INVERT PUMP TANK IN = 78.83' INVERT PUMP TANK OUT = 78.58' INVERT D—BOX IN = 79.96' INVERT D—BOX OUT = 79.79' INVERT LINE BEGIN = 79.67' INVERT LINE END = 79.67' I CERTIFY THAT THE WORK ON AN ON—SITE SEWAGE DISPOSAL SYSTEM HAS BEEN DONE IN ACCORDANCE WITH TITLE 5. KiormvK A. 4 Mork E3 30969 k _1195k CIV. a TOWN OF NORTH AN PROFESSIONAL^ ENGINEER HEALTH DEPART& DATE: �I—J -2-010 ENGINEERING & SURVEYING SERVICES 70 BAILEY COURT HAVERHILL, MA. 01832 978-556-0284 4r