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HomeMy WebLinkAboutMiscellaneous - 88 PHEASANT BROOK ROAD 4/30/2018 (2)0 e � 1 I' N. m Y O X. CA b NO N dD C o O i0 O CJ l� C7 i o k. a a 0 'ED , Applicant Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH �— 19 APPLICATION FOR SITE TESTING/INSPECTION Site Location Engineer Test/Inspection Date and Time t Fee 15D 0 C MAN, OA RD OF HEALTH Test No. (141(s S.S. Permit No. %7 D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 N0RT1j qA BOARD OF HEALTH OES `ED i616'Y Q ;1 .`�I.r.-_� ! ( I 19 � V APPLICATION FOR SITE TESTING/INSPECTION Applicanty-a-� i" ►�i�—sur r: L; Site Location Lt Engineer—•��/\J� > z.-_� - 1l�� `' :�i.� �Cvl r NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. 7'� D.W.C. No. C.C. Date Plbg. Permit No. 4r�f c � y . � x`, r Cyt y:k � 9��, t J,� • » � .i ,.c i civ"`. I � •i J s ,� �i,:E u a � M'—Yr r �'� �. � -"' 4^�r '' � i �`:Ks� �'� .4�;'S' {xy`=1t.� Y � ����5'�,✓tt' f r ty-.� �n�. ..r . • .. f td� ��� �..�..qty'` ��,;�la �}�'��S -� ' MAP. # _L T.# PARCEL # STREET '� _ ONSTRUC.TIO.N-APPROVAL, HAS PLAN REVIEW FEE .BEEN PAID? �� ; YES NO PLAN APPROVAL: DATE APP. BY_ DESIGNER: /�.�15%"//��E/ PLAN DA'fE. CONDITION WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS: '� CHEMICAL DA 1 E APPROVED._. RIA I DAIE flPPRUVED BACTERIA�I I DA 1'E APPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE <��N DATE ISSUED 7ZBY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:. _.._... ....DY: _. . .A Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 'GSM DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must -be -substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When JUN 15 201.5 filling out forms 1. System Location: on the computer, use only the tab � j� ayan\6 {— ""`�� Q �' 1__ °'"�` ' ANDOVER rim key to move your cursor - do not t Add r 0- s j use the return key. City/Town =*•----- State - - Zip Code 2. System Owner: VQ remm Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) ❑ Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: 2. Quantity Pumped Septic Tank ❑ Tight Tank %d Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No Name Vehicle License Number Stewa �eptic ervlce /7.ocaltion w re conte a disposed: es�r�=f ment. Plant, 20 So. Mill Bradford, Ma 01835 of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of 11E-# 6; 1 12 System Pumping Record TOWN CE NORTH ANDOVER Form 4 HEALTH DEPARTMENT M DEP has provided this form *for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left rgiiar of ho , Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck City/Town 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) ;S'ct__�M_ ;& State Zip Code State Zip Code Telephone Number — 2. Quantity Pumped eptic Tank 7�� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Entemrises Inc Company 7. Lo orp0 ere contents were disposed: G.L S Lowell Waste W, o;l t5form4.doc• 06/03 F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 of NOeT 1h 5427 I0. = 9 Town of North Andover HEALTH DEPARTMENT SACMUSE CHECK #: ���/�--' A. DATE: LOCATION: H/O NAME CONTRACT Type of Permit or License: (Check box)/f "' /�/ ❑ Animal (/ $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ®'Other. (Indicate) $� Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer k iG Commonwealth of Massachusetts 2013 Ci /Town of TOWN OF NORTH ANDOVER HEALTH DEPARTNE! T System Pumping Record`-�� Form 4 DEP has provided this form for us& by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using -this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Le fight rea hour 3Left /right side of house, Left / Right side of building, Left / Right front of building, a rear of building, Under deck Address City/Town 2. System Owner. Name Address (if different from location) City/Town State Zip Code State e 9 Telephone Number i. B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped; 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Other (describe): Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ❑-No If yes, was it cleaned? ❑ Yes ❑ No. 5. Conditiou of System: .0� 6. System Pumped By.- Nell y: Neil Bateson Name Bateson Enterprises Inc Company 7. Loi ere contents were disposed: Ca.L S. Lowell Waste Water t5form4.doc• 06103 F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 ARGEO PAUL CELLUCCI Governor COMMONWEALTH OF MASSACHUSE'T`TS EXECUTIVE* OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO•TEMON ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART A CERTIFICATION DAVID jB. E;Tw IB ;: isr. CommoiieT: ` Property Address: gg C•'H &ROOP, IZD, Name of Owner AA W 160= 09(-) .tJ A1 itJo27'N AAJD00E2 Address of Owrw:ee E>1 F 1ssPVL/L P_� iz00K Rt-, Date of Inspection: a1 z jcv Name of Inspector: (Please Print) Beni aurin C. Osgood, Jr. 1 am a DEP approved system inspector pursuant to Section 15.340 of ride 5 (310 -CMR 15.000) Company Narrie: New England -Engineering Services Inc. MaxngAddress:60 Beechwood Drive, North Andover, MA Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the Informationreported below is true, accurate and complete as of the"time of Inspection. The inspection was 'performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails- kupector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)w(thin thirty (301 -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 Department of*Environmental Protection. The original shouid'be sent 10,VW system owner• and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 --"'URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'A ' Property Address: 88 Pheasant Brook CER nnCAT10N (continued) Rd. North Andover, MA Owner: Monique Brown Date of inspection: 3/2/00 INSPECTION SUMMARY: Check A, -B, C, or D: Ap SY PASSES: j µ 1 have not found any Information which Indicates that any of the failure conditions described In 310 CMR 15:303 exist. Any fallura'r..''.:...: criteria not eval4ated are indicated below. COMMENTS: t 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. Indicate yes, no, or not determined (Y. N, or ND). Describe basis of determination In all Instances. If "not determined", explain why not: The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the Inspectioh; or the septic tank, whether or not metal; is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipes) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumphlMoro than -four -times a yeardue to broken or vbstmeted pipe(s). The system wNl pass"` inspection If (with approval of the Board of Health): • • •- •. broken pipes) are replaced obstruction is removed revised 9/2/98 ew:ortt e, v"USURFAta StYYAUr 010 . Fm I v..m ; a• �. -.. PART A ?w:. Property Address: 88 Pheasant Brook CERTIFICATION (continued) Rd. North Andover, MA Owner: Monique Brown Date of Inspection: 3/2/00 , C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Coriditiohs exist which require further evaluation by the Board of Health in order to determine If the system is falling to protect the: ; public health, safety and the environment. 1) SYSTEM WiLL PASS UNLESS BOARD OF HEALTH DETERMW'ES IN ACCORDANCE WiTH 310 CMR 15.303 (1)(b)-THATTHE SYSTI� IS NOT FUNCTIONING IN A MANNER WHIC1-LWILLPRQgCT. THE PUBLIC HEALTKAND SAFETY. AND THE EftHIBONMMT Cesspool or privy Is within 50 feet of surface water , Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES -THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a pubRe water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of •ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid)..- 3) alid). - 3) OTHER revised 9/2/98 Page 3 or 11 SUBSURFACESEWAGE DISPOSAL SYSTEM iNSPECTIONF-0RM i r PART A i CERTIFICATION (continued) Property Address: 8& Pheasant Brook Rd. North Andover, MA , Owner: Monique Brown Date of Inspection: 3/2/00 I i D. SYSTEM FAILS: ' You must indicate either "Yes" or "No" to each of the following. I , I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. The basis for this determination Is identified below. The Bpard of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of eeWage into-facility-or-artem "mponenrduago on! overkmded orcioggadSASor"sapooL ��---t— _ 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 isithin a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for –coliform bacteria, volatile organic compounds, ammonia nitrogen -and nitrate nitrogen. – E. LARGE SYSTEM FAILS: You must indicate either "Yes" or 'No' to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 1:0,000 gpd or greater (Large System) and the system is a significant thrept to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system4e-w1tidn200 4atof-a44butory4ea4ucteoe.dAnkiny.wator4upplr• the system is located In a nitrogen sensitive area (Interim Wellhead Protection Area =1WPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 16.304(2). Please consult the local regional office of the Department for further Information. revised 9/2/98 Pap 4of11 Property Address: 88 Pheasant Brook Rd. North Andover, MA Owner: Monique Brown Date of Inspection: 3/2/00 Check if the following have been dome: You must Indicate either "Yes" or "No" as to each of the following: Yegr No i Pumping information was provided by the owner, occupant, or Board of Heayth. _ None of the systemcoa�poaents.h&w&.baanpumpadLforstUasttwowaakcand-the•rystem hasAwoascelviwgwamitai flow rates during that -period. Large volumes of water have not been introduced into the system recently or as part of this . inspection. _ As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non -sanitary or industrial waste flow. _ The site was Inspected for signs of. breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on -the she has been determined based on: - _ Existing information. for example. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance Is unacceptable) 115.302(3)(b)) _ The facility owner (and.occupaats,H different from owner).ware.prouidad.with infaunati^avn tkw;roparmadrium ma f SubSurface Disposal Systems. revised 9/2/98 Page 5 of It SUBSURFACE SEWAGE DISPOSAq SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 88 Pheasant Brook Rd. North Andover, MA Owner: Monique Brown Date ofTnspection: 3/2/00 FLOW CONDITIONS RESIDENTIA / r '. Design flow: VA9 g.md.lbedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow_ Ntmber of current residents i ; Ghrbage grinder (yes or no): -&O Laundry (separate system) (yes or no);&D If yes, separataJnspaction-required Laundry system Inspected (es'or no) Seasonal use (yes or no):�%yd Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no) -_,4,,V Last date of occupancy: CA2A_aEA- COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: apd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, If available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of Information: /VE✓4F/2 l�u/11�c n System pumped as part of inspection: (yes or no)_LV J If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution boxisoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) Of yes, attach previous Inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed4if known) -and source ofinforn-wtion: -•--�� �-fZ- - �L-�- 25 Sewage odors detected when -arriving at the site: (yes or no) —AIC% revised 9/2/98 Pap 6of11 rf- el fact QFACE SEWAGEVSPOSAL SYSTEM INSPECTION FORM ) • PART C Property Address: 88 Pheasant Brook SYSTEM INFORMATION (continued)_ Rd. North Andover, MA Owner: Monique Brown Date of Inspection: 3/2/00 ' BUILDING SEWER: (locate on site pian) ' Depth below grade,";"' Material of construction: cast Iron V'40 PVC _ other (explain) Distance from private.water supply well or suction line Diameter y" Comments: (condition of joints, ver)ting, evidence ofisakage,-etc.) ""- .,.— .n - . .a n . ..1 n c r, - , c &-k)E� P� ASS'O/vc 6 1-) 1 - AAD SEPTIC TANK:_ (locate on site pian) Depth below grade:1-9 y f Material of construction: _concrete _metal _Rberglass _Polyethylene _other(explain) If tank Is (netal, list age _ 1s.age-confirmed by certlticate of Lompuance _ i i esnwr Dimensions• Sludge depth: 2" [c 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: 42 How dimensions were determined: /t2ER6u P C s71c-K Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid level in relation evidence of leakage, etc.) 7 -AA K. /S /ti .6.00 t7 CO n! bt721D`V _ if/y Evr i .x7—A- v VI / c i w / —.> n .T Dill ?]%yS //l/ e, 77J w l GREASE TRAP. N1 (locate on site plan) 'S Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness• Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: invert••structur". tegrity, c OX= KIN Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid.level in relation to outlet Invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7ofit Property Address: 88 Pheasant Brook Rd. North Andover, MA Owner: Monique Brown '. Date of Inspection: 3/2/00 TiGHT OR HOLDING TANK: JvmTank must be pumped prior to, or at time of, inspection) (locale on alto plan) Depth below grade:_ Material of construction: _cpncrete _metal_Fiberglass _Polyethylene —other(explain) i Dimensions: _ Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Data of previous pumping: Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site pian) Depth of liquid level above outlet Invert:_ Comments: (note If level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — �OX /N laevo cvN o /T/oN ssTTZI E3t.)z6 v-0op+c, ND. a: i...,10, , 1 .i- "-AD PUMP CHAMBERAh' (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page a of 11 1�• 1 i SUBSURFACE SEWAGE DISPOSAL SYSTEM IiNSKCTiON FORM PART C, Property Address: 88 Pheasant Brook SYSTEM INFORMATION (continued) Rd. North Andover, MA ; Owner: Monique Brown Date of Inspection: 3/2/00 ' SOiL ABSORPTION SYSTEM (SAS) (locate on site plan, if possible; excavation not required, location may be approximated by non-(ntrusive methods) If not located, explain; Ty e: leaching pits'. number:_ leeching chambers, number- leaching umberleaching galleries, number:_ leaching trenches, number, length: r leeching fields, number, dimensions: overflow cesspool, number:__ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) w — i — rc. - i U c 1sz7o r\ _ et,�, —e-✓1,0FNGE &F 1 CESSPOOLS (locate on site plan) Number and configuration: , Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimenslohs of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soli, signs of hydraulic failure,•.level of pending, condition of.vegetation, ete.l PRiVY:IVA (locate on site plan) Matedals of construction: Dimensions: Depth of sotlds: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.) revised 9/2/98 P&P 9of11 SUBSURFACE SWAGE DISPOSAL SYSTEM INSPECTION FORM i • PART C SYSTEM MJFORMATION (continued) Property Address: 88 Pheasant Brook Rd. North Andover, MA Owner: Monique Brown • Date of Inspection: 3/2/00 .SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least t*o permanent reference landmarks or benchmarks i locate all wells within 100' (Locate where public water supply comes Into house) revised 9/2/98 Property Addre Ri Owner: Monigc Date of Inspectic NRCS Report Sol[ Tyl I Typical USGS Date website visited Observation Well checked Groundwater depth: Shallow // Moderate _Deep SITE EXAM Slope 3 °Gc7 Surface water 11) ,2 AI G Check Cellar N, 11"'r Shallow wells N j N1G Estimated Depth to Groundwater 1 Feet Please Indicate all the methods used to determine High Groundwater Elevation: X-- Obtained from Design Plans on record Observed.Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers - Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) `t�3 c� Lc w v L—D T,, (l. Prl� r— +� r? ►2 ��, i� te, pvEtZ 1 ` G.T— sa T ►4ST eDeZ -Al CV— 3/ U 5-5c 5 60 t L, .v& A P & ftiDrcfi?e- 6"d v 2tv- 1nJk9( cl:—/ lqD G revised 9/2/98 page iuerit V Wlu Pw -4 c ow t 41'A IV 4x R"A a �'=r � ��.h�� y R „�,g r ��r � r c '_ VIA`, syr d, �t ., X 4 A 4r, V11 V Wlu Pw -4 c ow t 41'A IV 4x Town of North Andover E NORTH OFFICE OF 3� ° �t ° • �� COMMUNITY DEVELOPMENT AND SERVICES ° 146 Main Street + _ North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director April 7, 1997 RE: Lot 5 Evergreen Estates/Pheasant Brook Dear Mr. Hyde: I have attached a copy of the Planning Board decision concerning Evergreen Estates and a table with the status of all lots in the subdivision. As you can see from the table, Lot 5 must have the bottom of bed inspection before the "Form U" can be signed off by Health, or as an alternative, the septic system must be installed prior to any building construction being done on the lot. If the septic system cannot be installed at this location due to soil/rock conditions, it does not necessarily mean the lot is unbuildable, it simply means the septic system cannot be constructed in that exact location. No application has as yet been made by any licensed installer to excavate the leaching area (requirement for the bottom of bed inspection) on Lot 5. 1 hope this information will be of help to you. Please call if you have any further questions. Sincerely, Sandra Starr, R.S. Health Administrator Cc: Bill Scott, Director PCD BOH - Al Couillard BOARD OF APPEALS 688-9541 BURRING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 NEW ENGLAND ENGNIc EERING SERVICES March 3, 2000 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 88 Pheasant Brook Rd., North Andover Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system passes our inspection. If there are any questions please call me at my office, 686-1768. Sincerely 13 -� (f. BenJan in C. Osgood Jr., E.I.T. President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 v Town of North Andover/ t Health Department Date: Location: ` (Indicate Address, ,iiif�Residential, or Name` ofBusiness) Check #:/ _. Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type. $ .' ➢ Funeral Directors $ `' ➢ Massage Establishment $ ➢ Massage Practice $' ➢ Offal (Septic) Hauler $ =' ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ '. ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Trash/Solid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate)7� r _ Health Agent Initials i5`i6 White - Applicant Yellow - Health Pink - Treasurer 1Ew ENGLAND ENGINEEMG SERVICES, INC. 1600 Osgood Street Building 20 Suite 2-64 North Andover, MA 01845 Tagil: (978) 686-1768 • Fax: (978) 327-6138 Benjamin C. Osgood, Jr., P.E. President Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 APR 13 2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT April 11, 2006 RE: TITLE V REPORT: 88 Pheasant Brook Read, No. Andover, MA Dear Ms. Sawyer: Enclosed is the Title 5 Report for the above referenced property. The system PASSES the inspection. If there are any questions please call me at my office, 686-1768. Sincerely, G� BenjAin C. Osgo d, Jr. Certified Title 5 Inspector f of 11 COMMONWEALTH OF MASSACHUSETTS i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Owner's Address: 88 Pheasant Brook Road North Andover, MA 01845 Date of Inspection: April 10, 2006 Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (3 10 CMR 15.000). The system: _Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: The system inspection shall submit a copy of this inspection report to the Approving Authority ( Board of Health or DEP) within 30 days of completing this inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. 'System Passes: i:.5 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: A/0 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): Broken pipe(s) are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s) are replaced Obstruction is removed ND explain_ 3of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 C. Further Evaluation is Required by the Board of Health: AQ_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and (SAS) Soil Absorption System and the (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 D. System Criteria applicable to all systems: You must indicate "yes or No" to each of the following for all inspections: Yes No _y Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool / Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times .l pumped Any Portion of the SAS, cesspool or privy is below high ground water elevation Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply =/ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. / Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality. analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) � V O (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a. design flow of 10,000 gpd to 15,000 gpd. You cate either "yes" or "no" to each of the following: (The follo criteria apply to large systems in addition to the criteria above) Yes No _.,......._ .. The system is within 400 feet of a surface drinking water supply — " . The system is within 200 feet ,of a tnbutary-to a surface drinking water supply The system is located in a-niffogen sehsitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone H of a public water supply well If you answered "yeses"ata any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system -1 s 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. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 Check if the following have been done. You must indicate "Yes" or "no" as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant, or Board of Health v1 Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of an inspection 7 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 sign of break out? Were all system components, excluding the SAS, located on site? Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner ( and occupants if difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 FLOW CONDITIONS RESIDENTIAL (} j� Number of bedrooms (design) ! Number of bedrooms (actual): j DESIGN flow based in 310 CMR 1-5.203 ( for example: 110 gpd x # of bedrooms) Gl1 Number of current residents:_ Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no): Al v [if yes separate inspection required] Laundry system inspected ( yes or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd): Sump Pump (yes or no): /%/ V Last date of occupancy__C . -) P re, _ COMMERCIAIANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft, etc Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER (describe): Pumping Records Source of informal GENERAL INFORMATION 0c, Was system pumped as part of the ins*tion (yes or no): N' v If yes, volume pumped: gallons - How was quantity pumped determined? Reason for pumping:.. TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: t c 2 iea fLS r (-r Were sewage odors detected wen arriving at the site (yes or no): !of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other (explain) Distance from private water supply well or suction line: Ar l & Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: No Material of construction: Xconcrete metal fiberglass polyethylene Other (explain) Ktank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions:- -_ /,6bo 5 Sludge depth: /- Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: 41 Distance from top of scum to top of outlet tee or baffle: 3 r Distance from bottom of scum to bottom of outlet tee or baffle[ [Y`" How were dimensions determined: ?K ,6 -,4-5v a L s 7?c ie: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): --r,+AyK t✓ 4-00.p CeAyPt1Pva. -ra j -v c �c /:✓ l > -, Cc,v,Q,i?--)N. (�. GcJ 44 r'N , ) /,v 5`mj--if'?) 0 Al /Ls -77f C �r40` U ti 14 -t -L i ,v C- GREASE TRAP: N (locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sludge to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. 8Of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 TIGHT OR HOLDING TANK:- A/ (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: f) Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or out of box, etc.): 60 Y I A/ 0-04 0 ',X3 N, S,+ MG-4-0,iD5 edLd� 0</6e- 4 0 L- I A/ -!.v CA o'T: s7-Qe4c•174,," D 13 x 0� G -QR Oc w i71 AI w 1.5 C--9 70 PUMP CHAMBER. --i" (locate on sire plan) O i w c� &W AiD r Pumps in working order (yes or no) Alarms in working order (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 9of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required If SAS not located explain why 11f1 _/-_" leaching pits number leaching chambers, number leaching galleries number leaching trenches, number in length leaching fields, number, dimensions: lzCcy z s x s v overflow cesspool, number innovativetaltemative system Typethame of technology: Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc) 1/7%s ? CESSPOOLS: Al A (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 ayer Dimensions of cessDc Materials of Construction: Indication of groundwater inflow (yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: e--0ocate on site plan) Material of construction: Dimensions: Depth of solids: Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1. 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 88 Pheasant Brook Road North Andover, MA 01845 Owner's Name: Bruce Duncan Date of Inspection: April 10, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water / � feet J 43-6,: ,X Please indicate (check) all methods used to determine the high ground water elevation: _ Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavator, installers - (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: 5� S re / N�-LJi�Y/2 rZ, 1�1Z-�'i-1Q nn u� E NORTI� 5427 Town of Norah Andover �,'��,,,,,.,•�� HEALTH DEPARTMENT r CHECK LOC ION:1' H/O NAME. X10"/ CONTRACTOR NAME::;%,- Type of Permit or License: (Check box), ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ OffaI (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrasIVSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ;�O�t�herr- ndicate) $ -- Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer u 'A I. I Ty3 �MP �OWN EZ �Ril I r, I da-, ' RECE-�� IVED N L0 C T 0 7 2005 5ys-'—sm pomplNu OF 1'409TH ANDOVER 11LAITH DEPARTMENT L�- .1 8? Pkm ��� All) �nT� of �UMp1NQ;� , .ra'3 l�5[--�--�._....,....�.^,_..�.--_ .._--..-_.__ .�.� QUANTITY y�3 rvKb c)),, 3eRy,ca: S YS TE;TF 7�-:,- -,,',7- - - � -- - - - . - -.- Y.A noNa. 0 (3001) mblovrloN - CAVY OVLBA3 8 t KOM 8XCU$rVB SOLIDS C)NER EXPLAIN 14M 71 FORM U LOTS RELEASE FORM INSTRUCTIONS': This form is used to verify that all necessary approvals/permits from, Boards and Departments having jurisdiction have been, obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. **APPLICANT FILLS OUT THIS SECT 10N******************k**** APPLICANT `�o�y•� /YiDn��gu� �%�nr�wiU LOCATION: Assessor's Map Number SUBDIVISION (ft)e(ZcP rle 6A) ES4a4_cS STREET �/7 �dSa _3roo � 'A 6L 9'07 - 3 J Y y PHONEY'l 9m a59 - ydo l x as 1 PARC -E-1 as 3 LOT (S) 1: ST. NUMBER 0 t� L7—x ******OFFICIAL USE RECOMMENDATIONS OF TOWN AGENTS: /7f�4y "o/0 CON ERVATION ADMINISTRATOR /V COMMENTS TF N PLANNER CMENTS FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT 1 RECEIVED EY EUILDING ii ISPECTCR evized 9197 jm DATE Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH November 20, 19 97 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( X) or repaired ( ) by Arthur Hutton INSTALLER at Lot #5AEverQreen Estates SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 776 dated November 1 19 9,7 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH t • Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director NOTICE OF DECISION Any appeal shall be filled within (20) days after the ` date of filling this Notice in the Office of the Town .Clerk. Petition of DECM Essex, Inc. o o a -c =CVC1 Date March 4, 1997 orn�o Date of Hearing 2/4 & 2/18 & 3/4 7 c.� Premises affected Lots 5 & 6 Pheasant Brook Road in the zoning district R-2 Referring to the above petition for a special permit from the requirements of the North Andover Zoning Bylaw Section 7 Paragraph 2.1 SO as to allow access to Lot 5 through Lot 6 Pheasant Brook Rd. After a public hearing given on the above date, the Planning Board voted to APPROVE the Special Permit based upon the following conditions: CC: Director of Public Works Building Inspector Natural Resource/Land Use Planner flealfh_Sanitarian Assessors Police Chief Fire Chief Applicant Engineer File Interested Parties jic Signed _J��J��'.r) Joseph V. Mahoney, Chairman Richard Rowen, Vice Chairman Alison Lescarbeau, Clerk Richard Nardella John Simons Planning Board BOARD OF APPEALS 688-9541 BUU-DING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNLNG 683-9535 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 WILLIAM J. SCOTT Director t March 7, 1997 Ms. Jo--ce Bradshaw Town Clerk 120 Main Street No. Andover, MA 01845 Re: Special Permit/ Lots 5&6 Pheasant Brook Rd. Dear Ms. Bradshaw, 'ac , The North Andover Planning Board held a public hearing on Tuesday evening , February 4, 1997 at 7:30 p.m. in the Senior Center located behind the Town Hall Building, upon the application of DECM Essex Inc., 660 Rogers Street ,Lowell, MA 01852 requesting a special permit under Section 7 Paragraph 7.2 of the North Andover Zoning Bylaw. The legal notice was properly advertised in the North Andover Citizen on January 15 and January 22, 1997 and all parties of interest were duly notified. The following members were present: Joseph V. Nlahoney, Chairman, Richard Rowen, Vice Chairman, Alison Lescarbeau, Clerk, , John Simons. Kathleen Bradley Colwell, Town Planner was also present. The petitioner was requesting a special permit to allow access to Lot 5 through Lot 6 Pheasant Brook Road. The premises affected are land with frontage on the South side of Pheasant Brook Rd.. In the Residential - (R-2) Zoning District. Ms. Lescarbeau read the legal notice to open the public hearing. No one was present to represent Lot 5 Pheasant Brook. Ms. Colwell gave a brief presentation on the proposed access for the benefit of the Board and the abutters present. The applicant has requested access other than over the legal frontage on the direction of the Conservation Commission in order to avoid a driveway between two vernal pools. The Board continued the public hearing to the next meeting on February 18th. The North Andover Planning Board held a regular meeting on February 18, 1997: The following members were present: Joseph V. Mahoney, Chairman, Alison Lescarbeau, Clerk, Richard Nardella and John Simons. Richard Rowen, Vice Chairman and Alberto Angles, Associate Member was absent . Kathleen Bradley Colwell, Town Planner was also absent. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Lot 5 Pheasant Brook - access Al Coulliard was present representing DECM Essex Inc. Mr. Coulliard stated that they are requesting a special permit to allow access to lot 5 over lot 6 due to the presence of two vernal pools on the site. Mike Howard, Conservation Administrator, wrote a letter to the Planning Board explaining why the Board should allow access over lot 6 and eliminate the potential alteration of this sensitive wetland resource area. Mr. Nardella stated that he is absolutely not in fr.vor of granting this special permit. Mr. Simons asked what benefit the Town would gain by denying it. He said he thought the situation was a perfect example of the reason for the existence of the special permit provisions. Mr. Mahoney concurred with Mr. Simons. Mr. Nardella suggested that the Board continue this discussion at the next meeting because not all the members are present and he would like to stick to his guns about special permits. With 4 affirmative votes required and only 4 members present, the hearing was continued to March 4, 1997. The North Andover Planning Board held a regular meeting on March 4, 1997. The following members were present: Joseph V. Mahoney, Chairman, Richard Rowen, Vice Chairman and Alberto Angles, Associate Member. Alison Lescarbeau, Clerk and John Simons. Kathleen Bradley Colwell, Town Planner was also present. Lot 5 Pheasant Brook -access Ms. Colwell recommended granting the special permit. On a motion by Ms. Lescarbeau, seconded by Mr. Rowen the Board voted unanimously to close the Public Hearing. Attached are those conditions. Sincerely, Joseph Vla- honey, Chairman J North Andover Planning Board Lot 5 and 6 Pheasant Brook Road Special Permit Approval - Access other than over the legal frontage The Planning Board makes the following findings regarding the application of DECM Essex, Inc., 660 Rogers St., Lowell, MA 01852, dated January 6, 1997 requesting a Special Permit under Section 7.2.1of the North Andover Zoning Bylaw to allow access to Lot 5 over Lot 6 Pheasant Brook Road. FINDINGS OF FACT: The Planning Board makes the following fi-ldings ^.s required under Section 7.2.1 of the North Andover Zoning Bylaw: The specific site is an appropriate location for access to the lot given the special environmental conditions that exist on the site such as vernal pools. Accessing across the legal frontage would be detrimental to the vernal pools on Lot 5. Vernal pools provide essential breeding habitat for a variety of species. Bisecting the two pools with a driveway would restrict amphibian travel corridors, increase water temperatures in the pools and cause the pools to become contaminated with storm water runoff. 2. The access will not adversely affect the neighborhood as the driveway is simply relocated a few hundred feet away from the legal frontage. There will be no nuisance or serious hazard to vehicles or pedestrians as the new driveway is located a sufficient distance from adjacent driveways. 4. The access in this location is in harmony with the general purpose and intent of this bylaw as it encourages the most appropriate use of land and conserves the value of the land. Upon reaching the above findings, the Planning Board approves this Special Permit with the following conditions: Special Conditions: 1. This decision must be filed with the North Essex Registry of Deeds. Included as a part of this decision are the following plans: Plans titled: Site Plan for Special Permit for Evergreen Estates North Andover, Mass. Prepared for: D.E.C.M. Essex, Inc. Prepared by: Christainsen & Sergi 160 Summer Street Haverhill, MA 01830 a) Any changes made to these plans must be approved by the Town Planner. Any changes deemed substantial by the Town Planner will require a public hearing and a modification by the Planning Board. 2. Prior to any site disturbance: a) The location of the driveway must be marked in the field and reviewed by the Town Planner. b) All erosion cont-ol dev: ces must be in place as shown on the plan and review -.d by the Town Planner. c) The decision of the Planning Board must be recorded at the North Essex Registry of Deeds and a certified copy of the recorded decision must be submitted to the Planning Office. d) Tree clearing must be kept to a minimum. The area to be cleared must be reviewed by the Town Planner. e) A performance guarantee of five thousand ($5,000) dollars in the form of a check made out to the Town of North Andover must be in place in accordance with the plans and the conditions of this decision and to ensure that the as -built plans will be submitted. 3. Prior to Certificate of Occupancy issuance: a) Easements pertaining to the rights of access for the driveway must be recorded with the Registry of Deeds and a certified copy of the recorded document filed with the Planning Office. 4. The contractor shall contact Dig Safe at least 72 hours prior to commencing any excavation. 5. Gas, telephone, cable, and electric utilities shall be installed as specified by the respective utility companies. 6. No open burning shall be done except as is permitted during the burning season under the Fire Department regulations. 7. No underground fuel storage shall be installed except as may be allowed by Town Regulations. The provisions of this conditional approval shall apply to and be binding upon the applicant, its employees and all successors and assigns in interest or control. 9. This permit shall be deemed to have lapsed after a two (2) year period from the date on which the Special Permit was granted unless substantial use or construction has commenced. Therefore the permit will lapse on � - ' + /\ �CXP cc. Conservation Administrator Director of Public Works Health Administrator Building Inspector Police Chief Fire Chief Assessor Applicant Engineer File Lot 5 and 6 Pheasant Brook Road - Access f NORTI� o�••�.o ,.rho ,O, w ♦ i SSACNUSft Town of North Andover, Massachusetts ROARD OF HFAI_TH Form No. 2 00,1-0 19 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant ___ Test No. Site Location A1 ice_ 4- cJ Reference Plans and Spec ENGINEER DA Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. t�. � Fee � K/ //,J 2 CH RMA , BOA D OF HEALTH Site System Permit No. Lot# Date Plans Submitted Date Plans Approved Date Form "U" Sign Off Notes: IA 6/13/96 9/19/96 9/19/96 -SS 2A 6/13/96 1/9/96- 7/23/96 9/19/96 -SS 3A 2/20/96 4/2/96 8/5/96 -SS 4 3/25/96 5/28/96 see note 1 5 10/1/95 11/1/95 7A7-,4 see note 1 6 8/30/96 9/3/96 9/3/96 - SS 7 6/17/96 6/25/96 8/5/96 -SS 8 4/1/96 4/15/96 8/5/96 -SS 9 9/20/96 9/27/96 9/27/96 see not 3- 9/26/96 10 2/28/96 4/2/96 8/5/96 -SS 11 2/29/96 4/2/96 8/5/96 -SS 12 9/18/96 9/20/96 9/20/96 -SS 13 9/18/96 9/27/96 9/27/96 see note 3 - 9/26/96 14 12/4/95 8/1/96 8/29/96 -SS 15A 1/31/95 3/19/96 8/5/96 -SS 16A 6/14/96 7/29/96 8/26/96 -SS 17 8/2/96 5/24/96 8/19/96 -SS 18 10/1/95 11/26/95 see note 1 19 1 12/19/95 2/6/96 see note 1 20 2/20/96 4/2/96 see note 1 21 9/20/96 9/27/96 9/27/96 see note 3 - 9/26/96 22 8/8/96 9/3/96 9/3/96 1 - Excavation needed 2 - Additional tests needed. Previous tests either did not pass or are incomplete. 3 - Plans require variance (s) from Board of Health. TABLE #2 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WII IJAM J. SCOTT Director March 24, 1997 Mr. Roland A. Coulliard D.E.C.M. Essex Inc. 660 Rogers Street Lowell, MA 01852 146 Main Street North Andover, Massachusetts 01845 Re: Septic testing - Evergreen Estates Dear Mr. Coulliard, I am writing to remind you that some of the lots in the Evergreen Estates subdivision require additional septic testing prior to Building Permit issuance per the decision of the Planning Board. I have had several applicants come into my office seeking a building permit who were unaware of these conditions. The leaching bed must be excavated on lots 4, 5, 19, and 20 before a building permit can be issued. If the leaching bed has not been excavated, the applicant may choose to place a note on the deed for the lot stating that the septic system must be installed, inspected and approved by the Board of Health in accordance with all state and local regulations before construction of the primary building is begun. This includes the pouring of foundation walls. A certified copy of the recorded deed must be submitted to the Planning Department and Board of Health. If you have any questions please do not hesitate to call me at 688-98535. Very truly yours, Kathleen Bradley Colwell Town Planner cc. W. Scott, Dir. CD&S S. Starr, Health Adm. BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 c9N D *** TOCD CD wti CD Y �M w � 01 �o O ASA 3 Z7 aq G' r' o Q o n gsA a;�o a O- - cn Z C/1 CD D 3 �. m co 3 a O Di 3 Cn n o sLA D o cn y n D a�a • v v Z o v N 2 < m CD 0 G C: 3 D z _ Z w rn m f9 D r) v m. D N r a O V l \ Q• �� m �O O m o -� z C' � m w FORM U - LOT RELEASE FORM INSTRU'IO S: This form is used to verify that all necessary approva ermits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: C r =�° T i t� �v , f c Phone 66 LOCATION: Assessor's Map Number Parcel Subdivision r E N /�, ; ; ��: Lot (s) 5 Street St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: ✓ ' Date Approved ' Conservation Administrator Date Rejected Comments 4 Date Approved Town Planner Date Rejected Comments Date Approved Food Inspectoorr-Health Date Rejected Date Approved ✓a 71 t. Septic Inspector -Health Date Rejected Comments fi F., pr. Public Works - sewer/water connections driveway permits-cJ Fire Department � C ��:.' eJ ►1!x}4 %(1 ��J"'Gi '` k �1 nl L wr.� � �� IC2� IVt S161/�9TI��. �✓tJ �.�Dt&6, S -/ CJ._ 4� ,� a�J J✓/�lN�i��c y.Zc c,�r Received by Building Inspector Date ���� NORTh Ot t�ao ,e 1ti0 �o •'� y SACHUS�t Applicant Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH { 1997 DISPOSAL WORKS CONSTRUCTION PERMIT NAME ADDRESS TELEPHONE Site LocationT Permission is hereby granted to Construct (� or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 77C Fee CHAIRMAN, BOARD OF HEALTH D.W.C. No. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: / CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALLER SIGNATU TELEPH NE# CHECK ONE: REPAIR: NEW CONSTRUCTION: 61 � IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes No Approval - 2.2 Date: Y (a) i ne retaining wall shall be constructed of reiraorced concrete, s'all have noZ. ` ,.. , and shall be waterproof. (b) The retaining wall shall be designed by a Registered ?rofessional Engine certify that the above condition is met by the submitted design. (c) The upgradient side of the retaining wall shall be Ovate -proofed, (d) Construction of the retaining wail shall be supervised by the design engineer.{ - e An as -built plan shall be prepared and certined by the design engineer that the O been constructed in accordance with his approved design plan. (f) The elevation of the too of the retaining wall shall be no lower than the "breakam. 'Co 00 80 70 Q (n 60 C tL $0 z LU 40 LU 30 20 11 0 devation, which is the elevation of the top of the two inch layer of 'A inch to '/-, inch washed stone aggegate cover. : (� The distance from the wall to the edge of the leaching area should be at least ten fee- (3) ee(3) FM material for systems constructed in fill shall consist of select on-site or imported soil material. The fill shall be comprised of clean granular sand, free from organic matter and deleterious substances. Matures and layers of different classes of soil shall not be used. The fill shall not contain any material larger than two inches. A sieve analysis, using a 44 sieve, shall be performed on a representative sample of the fill. lip to 45% by weight of the 511 sample may be retained on the 94 sieve. Sieve analyses also shall be performed on the fraction of the fill sample passing the 94 sieve, such analyses must demonstrate that the material meets each of the following specifications: SIEVE SIZE E: F ECTIVE °% THAT IVU ST PARTICLE SIZE PASS SIEvz- " 4 4.75 nun 10001% 50 0.50 mm 10% - 10001% 4100 0.15 mm 0% - 204% -4200 0.075 nuc, 0% - 5% A piot of the sieve analyses of the portion of the sample passing the : sieve shall tali on or between the lines on the following graph: PARTICLE SIZE _DI S_T_RISU1 ION #200 COO fSo tb ';'10 M D iG PIP— C'7r V.;cror. 60 200 600 1 2 6 0 mm 12/1/95 (Effective 11/3/95) - corrected 3 i 0 CLLR - 531. D ��d � �crAihJEc.� !^ i I I I V.;cror. 60 200 600 1 2 6 0 mm 12/1/95 (Effective 11/3/95) - corrected 3 i 0 CLLR - 531. D ��d � �crAihJEc.� UNIFIED SOIL CLASSIFICATION COBBLES GRAVEL SAND SILT OR CLAY COARSE I FINE COARSE MEDIUM I FINE: U.S. SIEVE = IN IrlCHES U.S. STANDARD SIEVE No. EYDROIEL-M 3 3/4 3/8 4 10 20 40 80 140 200 100 0 80 20 F x F. x 60 w 40 c7 z A W z V a F W a a 4060 Z z z U W U Q, W a W a r� 20 80 0 100 103 102 10 1 1C)71 10-2 10 s N3A 1► ,�11 1�'-1 YWW SAMP SYMBOL NUMBER DATE DESCRIPTION O 1341 C ;gp) 'REVIEWED BY: B;QM K. WETHERBEE 111, P.E. Source C. HUBBARDSTON PIT ACTIVE FACE y r �n�� Project No.9370 PITCHERVII.T.E SAND AND GRAVEL y , , U T S k� of GRAIN SIZE DISTRIBUTION- gore -3 ` Massachusetts CDCD cu M N OQ r i 3=� + 1 CD �- O n n e.. 1.; O Q — cD CD tA O" > CD a C s Q O N Y Q C) "� Q - O Z �' Q D CD N n D O O o Z �, a D Q o cn = < V) m C) CD w Ai C:: r 3 Aj N _ 1 w A 3 cn O Z D Z Z w occ 0 7 3 z a Z o �a m D Cn r' O _ 2 Q T � = 3 O� O m w t MORTM 1 M O 9 1ySAGNUSES Applicant N Form No. 3 Town of North Andover, Massachusetts BOARD OF HEALTH a' Q 1 19 L DISPOSAL WORKS CONSTRUCTION PERMIT R ILL Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF'HEALTH Fee C-- D.W.C. No. r-� DATE: TO: FROM: RE: BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 M E M O R A N D U M July 16, 1995 Planning Board Sandra Starr, 1 dm' istrator Evergreen Estates Soil Tests TEL. 682-6483 Ext23 There has been a large amount of additional soils testing out at Evergreen Estates off Salem Street. Based on the criteria of passing percolation tests and four feet of parent material observed in the deep holes, the following lots appear to be acceptable for septic system installation: Lots 1, 2, 3, 4, 5, 7, 8, 10, 11, 14, 15, 16, 17, 18, 19, 20, 22. In addition, Lots 12 and 21 look okay so far; they need an additional passing percolation test. Lots 6 and 13 have no passing percolation tests at this point, and Lot 9 has no soil tests at all. There is still the concern with the large amount of rock on the site which may interfere with the amount of parent material available for leaching. Because of this concern, the Board of Health must stipulate that prior to our signoff on any Form U for any individual lot in this subdivision, the leaching area for that lot must be completely excavated to insure that there is the requisite four feet of parent material present throughout the entire location proposed for the leaching area. cc: Board of Health Phil Christiansen Kenneth Mahoney, Director, Planning & Comm. Dev. Michael Howard, Conser. Admin. MAP AND PARCEL ADDRESS OWNER n SIZE OF LOT IN SQUARE FEET /' 6w # BEDROOMS_ SEPTIC SYSTEM LOCATION v V 1 (For example, FRONT YARD SOUTHEAST CORNER) FINAL GRADING DATE J b — j7" 7 AS BUILT PLAN IN FILE? /16 INSTALLER DWC PERMIT DATE -5-- - — !-Z' % CERTIFICATE OF COMPLIANCE DATE It—,9-62 ^� ENGINEER r r, .r FORM C APPLICATION FOR APPROVAL, OF DEFINITIVE PLA94CE U -AD `N OWN C�.ER< NORTH ANDOVER January 17 l i; - �9 95 To the Planning Board of the Town of North Andover: The undersigned, being the applicant as defined under Chapter 41, Section 81—L, for approval of a proposed subdivision shown on a plan entitled Definitive Subdivision Plan "Evergreen Estates" located in North Andover by Christiansen & Sergi, Inc. dated December 28. 1994 being land bounded as follows: Northerly bt Com of MA land of Steer Fried; easterly by land of Fried,eadde.r, Rough, .Green, Galeassi, Yourre, Mateja, }3i ac r Ql nCk\T and Tian; s.., Salem St. , aft4 Farr, met2thet -- L-- ' Farr and Com of MA; westerly by Com of MA.. hereby submits said plan as a DEFINITIVE plan in accordance with the Rules and Regulations of the North Andover Planning Board and makes application to -the Board for approval of said plan. 1087 314 Title Reference: North Essex Deeds, Book 2901 Page 13 ; or Certificate of Title No. , Registration Book page ; or Other: Said plan has(y) has not( ) evolved from a preliminary plan submitted to the Board of A u n 2.L-19 , 94 and approved ( with modifications) ( ) disapproved (X on Oct 4 9 1994 The undersigned hereby applies for the approval of said DEFINITIVE plan by the Board, and in furtherance thereof hereby agrees to abide by the Board's Rules and Regulations. The undersigned hereby further covenants and agrees with the Town of North Andover, upon approval of said DEFINITIVE plan by the Board: 1. To install utilities in accordance with the rules and regulations of the Planning Board, the Public Works Department, the Highway Surveyor, the Board of Health, and all general as well as zoning by—laws of said Town, as are applicable to the instai?ation of utilities within the limits of ways and streets; 2.- To complete and construct the streets or ways and other improvements shown thereon in accordance with Sections Iv and V of the Rules and Regulations of the Planning Board and the approved DEFINITIVE plan, profiles and cross sections of the same. Said plan, profiles, cross sections and construction specifications are specifically, by.reference, incorporated herein and made a part of this application. This application and the covenants and agree— ments herein shall •be binding -upon all heirs, executors, administrators, successors, grantees of the whole or part of said land, and assigns of the undersigned; and 3. To complete the aforesaid installations and construction within two (2) years from the date hereof. f Received by Town Clerk: -- Date: Signature of Applicant Messina Development Corp., 805 Winter St. Time: North Andover, MA 01845 Signature: Address Notice to APPL1(AW/T V CLERK and Certification of A on or Planning Board on Definitive Subdivi.-Lon Plan entitled: Evergreen Estates By: ` Christiansen & Sergi dated Qg-pinhpr 7R 19 94 The North Andover Planning Board has voted to APPROVE said plan, subject to the following conditions: 1. That the record owners of the subject land forthwith execute and record a "covenant running with the land", or otherwise provide security for the con- struction of ways and the installation of municipal services within said sub- division, all as provided by G.L. c. 41, S. 81-U. 2.That all such construction and installations shall in all respects conform to the governing rules and regulations of this Board. 3. That, as required by the North Andover Board of Health in its report to this Board, no building or other structure shall be built or placed upon Lots No. as shown on said Plan without the prior consent of said Board of Health. 4. 'Other -conditions: sr z .o See attached _zr+ornm Cn Z7 „{ U_ In the event that no appeal shall have been taken from said approval within twenty days from this date, the North Andover Planning Board will forthwith thereafter endorse its formal approval upon said plan. The North Andover Planning Board has DISAPPROVED said plan, for the following reasons: NORTH ANDOVER PLANNING BOARD Kir Date: August 15, i995 By: 4Y Josepi, V. Mahoney, Chairman f ie `r 4. a. A complete set of signed plans, a copy of the Planning e7 Board decision, and a copy of the Conservation Commission order of Condition must be on f ile at the Division of Public Works prior to issuance of permits for connections to utilities. The subdivision construction and installation shall in all respects conform to the rules and regulations and specifications of the Division of Public Works. b. All site erosion control measures required to protect off site properties from the effects of work on the lot proposed to be released must be in place. The Town Planning Staff shall determine whether the applicant has satisfied the requirements of this provision prior to each lot release and shall report to the Planning Board prior to a vote to release said lot. C. The applicant must submit a lot release FORM J to the Planning Board for signature. d. A Performance Security (Roadway Bond) in an amount to be determined by the Planning Board, upon the recommendation of the Department of Public Works, shall be posted to ensure completion of the work in accordance with the Plans approved as part of this conditional approval. The bond must be in the form of a check made out to the Town of North Andover. This check will then be placed in an interest bearing escrow account held by the Town. Items covered by the Bond may include, but shall not be limited to: i. as -built drawings ii. sewers and utilities iii. roadway construction and maintenance iv. lot and site erosion control V. site screening and street trees vi. drainage facilities vii. site restoration viii.final site cleanup e. Three (3) complete copies of the endorsed and recorded plans and two (2) certified copies of the recorded subdivision approval, Covenant (FORM I), Right of Way easements, and FORM M must be submitted to the Town Planner as proof of filing. Prior to a FORM U verification for an individual lot, the following information is required by the Planning Department: a. All lots must be approved by the Board of Health. The Board of Health has determined that Lots 6, 9, 12, 13, and 21 cannot be used for building sites without injury 4 5. to the public health without further testing. No building or structure shall be placed upon these lots without consent by the Board of Health. b. Due to the large amount of rock on the site which may interfere with the amount of parent material available for leaching, the Board of Health will require that the leaching area for each lot be completely excavated to insure that there is the requisite four feet of parent material present throughout the entire location proposed for the leaching area. C. The applicant must submit to the Town Planner proof that the FORM J referred to in Condition 3 (c) above, was filed with the Registry of Deeds office. d. A plot plan for the lot in question must be submitted, which includes all of the following: i. location of the structure, ii. location of the driveways, location of the septic systems if applicable, iv. location of all water and sewer lines, V. location of wetlands and any site improvements required under a NACC order of condition, vi. any grading called for on the lot, vii. all required zoning setbacks, viii. location of any drainage, utility and other easements. e. All appropriate erosion control measures for the lot shall be in place. Final determination of appropriate measures shall be made by the Planning Board or Staff. f. All catch basins shall be protected and maintained with hay bales to prevent siltation into the -drain lines during construction. g. The lot in question shall be staked in the field. The location of any major departures from the plan must be shown. The Town Planner shall verify this information. h. Lot numbers, visible from the roadways must be posted on all lots. Prior to a Certificate of Occupancy being requested for an individual lot, the following shall be required: a. A stop sign must be placed at end of Pheasant Brook Road where it intersects with Salem Street. b. A driveway easement across Lot 22 must be granted to Ian 5 TFMT I I I e` i 6171, r. ta 'a> A I '1Z V �4 -AO gAn 11 ININII�NIIII� 1 � � � n NI Nnn '1Z V �4 -AO gAn PITS MIN 660 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x #) (G/ft2) FIELDS MIN 660 GPD VZ900 ft2 BED ✓ GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4" PEA STONE? DIST LINE SLOPE .005? >3' COVER -VENT "— SCH 40 L,---- MIN 12" COVER L- /� RATE n2l /WJ//LDG X 660 = I ZJ� V X =,53 = TOTAL co/ 40 G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE MANHOLES TO GRADE inlet) HWL LWL OP. SWITCH Copyright m 1995 by S.L. Staff DISCHARGE RATE DISCHARGE TIME gpm ALARM SEP. CIRC. GW (Min. 1' below CHECK VALVE BLEEDER HOLE MANUAL PLAN -PNE/i5/9iUT 64r- VIEW CHECKLIST ADDRESS /Cor j— ENGINEER GENERAL 3 COPIES Z,"/ STAMPy/ LOCUS NORTH ARROW SCALE CONTOURS( PROFILESECTION 6,--' BENCHMARK C� SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?ko DRIVEWAY C".,/(Elev) WATER LINE �� FDN DRAIN SCH40 L,, -'TESTS CURRENT? SOIL EVAL SEPTIC TANK / / f� MIN 1500Gy .17 INVERT DROPy GARB. GRINDER/V) (+200% EDF) 25' TO CELLAR/ MANHOLE,-- ELEV GW # COMPS. D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET �a �. - OUTLET (2 " OR . 17 FT) TEE REQ' D? LEACHING / / MIN 660 GPD? 1Z RESERVE AREA `` 4' FROM PRIMARY? v 2% SLOPE 100' TO WETLANDS 100' TO WELLS 4' TO S.H.GW L--*"(5'>2M/I ) rZe,; V6 35' TO FND & INTRCPTR DRAINSD� 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY L---- MIN 12" COVER t� FILL?A1 (25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd W OR D (MIN 6') BE 10' MIN. BOT (L x W x #) Copyright Cj 1995 by S.L. Swrr Td gA) O � SLOPE (min .005 or 6"/1001) SIDEWALL DIST. 3X EFF. RESERVE BETWEEN TRENCHES? IN FILL? MUST 4" PEA STONE? VENT? (>3' COVER; LINES >501) + SIDE X LDNG = TOT (DxLx2x#) (G/ft2) No................ _....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T u'nl .......... 7V ..... ../) All) ol1E :-..... Appliratinit for 11hynnal Hlnrim Timm BUAKU vv - FE E ............. 4GT 11995 N erlltit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: pp •. •...•••._ ..�........ ......•______-••• _ _s .•_-__. ___._..•...__..._.._...._._..._.....__.......................................................................... ocation - Address or Lot o. .t►t�'i.Q�l._.._tl''1�c'.. �1 C'�►x................... r�o ..QLd'id Owner Address .. ----....-•.................... ...•-----••... ----• -•............------........---------•--....... ...................................... Installer Type of Building ' L� Dwelling — No. of Bedrooms ........... -/----------------------------- -Expansion Attic 11 Address ��.�I+7 Size Lot .... �'S ........_--9t;-Et'et Garbage Grinder ( ) Other—Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures . Design Flow ......................................... gallons per person per day. Total dai `ily flow .......___-4t.0....._ _............gallons. Septic T&41 (quid capacity _3- —gallons Length. #.�------ ��'idth............... Diameter..........__._.. Depth./.. :• ...... Disposal-- No ..................... Width ...��.t�O....... Total Length ... �.._..... Total leaching area../��Q__--sq. ft. Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft. Other Distribution box ( oo) Dosing tank Percolation Test Resul s Performed 1)jC/.Sf..j.�A?,S!!1..�_S �................... Date.��,'�._.._.!-.�jC�S Test Pit No. 1... 4......minutes per incyDepth of Test Pit ..... ��.---- Depth to ground water ....... n0 ... O.•.W. Test Pit No. 2 ------ nL..... minutes per inch. Depth of 'Fest, Pit ..... . ........ Depth to ground water......�f •--------------------------.........-----------------------------.......•-----••-••---•••••-•-•---------....-•-••-----•----------•------•-----------... Description of Soil ......... --------1----------•------ .......... ---------------------•---.--..cear+ase-------- &2*Ww y----. -- ----------- -------------- ----------------- -------------•-----------------------------------------•-----------------------•------- -------------------------•---------------•----•-----•---••-•.....-•--------•---- Nature of Repairs or Alterations —Answer when applicable.............................._............._......._.......................................... ---• • •...•-----------------•-------•----........---------- _.._.....-----•--...------•-•------•-------------• ••--------------------------•-----•--• •----•-..... _.... _.... __............--------•--.-_.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T'ITLE, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation, until a Certificate of Compliance has been issued by the board of health. Signed ------- ---------------------------------------------- ----------------------------- -------------------------------- Date Application Approved By .................................................... ------------------------•-----•-----------------•---------------------•--.....-- Date Application Disapproved for the following reasons: ....................................................................................................... ---•••-- ----------------------------•----•----.....-----•----...---------------------------------•-----•-••-----•------------...------------------------•-----_.._...----------...----..............------•-•--- Date PermitNo ......................................................... Issued ......... .............................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF Tafi#irttte of Tompliattre TH1.S LS TO CERTIFY, Tifat the Individual Sewage Disposal System constructed by............................................................................................................................................................ Installer ) or Repaired ( ) at.................................... :....... Ills been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ---------- ---------- --------------------- dated ................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector------------------...----------------------- --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................I ................... OF .......................................................... .......................... NO......................... FEE ........................ juitivoli ll �lnrkn C9111t,otruffinit If erlttit Permissionis hereby granted ..................... ------------------------ --- --- r ------ -......... ........................................................................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No...._.... :.- street as shown on the application for Disposal Works Construction Permit No ..................... Dated ................................. ......... DATE............................................... -----------------------•-------- FORM 1259 HOBBS & WARREN. INC.. PUBLISHERS .............................................................................................. .......... Board of health Commonwealth of Massachusetts _ City/Town of NORTH ANDOVER, System Pumping Record Form 4 RECEIVE CHUSETTS RTMENT DEP has provided this form for use by local Boards of Health. The System PumpinRecord must be submitted to the local Board of Health or other approving authority. Signaturd of Hauler http://www.mass.gov/dep/waterlapprovals/t5forms.htm#inspect Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms on the computer, use * I aq pj .f/ F "Sp✓•q'4(:P-'j lJ)� e/:{ tr i 4 Y..;�. L y f` t � � 1 1� \ -J k�_. '.e✓/' 7 �t._ i,..�8 only the tab key to move our do Address g m ° ( , r R� ����� -. "t 7 r L— � �' �--_�� cursor - not use the return City/Town State Zip Code key. 2. System Owner: l Name lzam. Address (if different from location) City/Town State �j Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 44 —(b � � 2. Quantity Pumped: Date Gallons I Type of system: ❑ Cesspooi(s) Ezseptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Vehicle License Number Company 7. Location where contents were disposed: Signaturd of Hauler http://www.mass.gov/dep/waterlapprovals/t5forms.htm#inspect Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5Inspector $ ®- Title 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials. White - Applicant Yellow - Health Pink - Treasurer 5443 O Town of North Andover `+�'•,,,.o.: HEALTH DEPARTMENT ,SSACMUStt CHECK#:e +ATE: LOCATION: H/O NAME:C% CONTRACTOR NAM Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5Inspector $ ®- Title 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials. White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out fors on the computer, use only the tab key to move your cursor - do not use the rehim key. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Fo I m 'SIV 91) Subsurface Sewage Disposal System Form - Not for Voluntary sessm,'Ot- 4 2011 �Z 88 Pheasant Brook Road TOWN OF NORTH ANDOVER Property Address HFALTH DEPARTMENT Edward Hutner Owner's Name North Andover MA 01845 5/12/2011 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. A. General Information Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Ma 01810 State Zip Code .r S11 License Number 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 5/12/2011 Inspectori Signat4ej 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. L/ Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 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 88 Pheasant Brook Road Property Address Edward Hutner Owner's Name North Andover MA 01845 5/12/2011 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 09/08 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts AMNS Title 5 Official Inspection Form WUWSubsurface Sewage Disposal System Form - Not for Voluntary Assessments B) System Conditionally Passes (cont.): RAA n-InAX 5/12/2011 Date of Inspection ❑ 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover page. Cityrrown B. Certification (cont.). B) System Conditionally Passes (cont.): RAA n-InAX 5/12/2011 Date of Inspection ❑ 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -- o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 88 Pheasant Brook Road. Property Address Edward Hutner Owner Owner's Name information is required for every North Andover MA 01845 5/12/2011 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) 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 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 0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins • 09/08 I Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �< 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover MA 01845 5/12/2011 page. City(rown 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 • 09108 TWe 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover page. Citylrown C. Checklist MA 01845 State Zip Code 5/12/2011 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x # of bedrooms): 660 t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road D. System Information Description: State Zip Code 5/12/2011 Date of Inspection Property Address ❑ Edward Hutner Owner Owners Name information is required for every North Andover page. CityrFown D. System Information Description: State Zip Code 5/12/2011 Date of Inspection 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: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No Number of current residents: 5 ❑ No Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( Y 9 (gPd))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date 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: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 09/08 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date 5/12/2011 Three years ago, owner 1500 gallons Measured tank tank & tees Date of Inspection ® 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover MA 01845 5/12/2011 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: 14 years old, 10/15/1997, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: Material of construction: 2 feet ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC thur wall to septic tank. 3" PVC in house no leaks visible. Septic Tank (locate on site plan): Depth below grade: Leet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age:- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 5" l5ins • 09108 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover MA 01845 page. Cityfrown State Zip Code 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 How were dimensions determined? 22" 5,1 8" 16" 5/12/2011 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.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: I 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 • 09/08 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 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is North Andover required for every page. Cityfrown N State 01845 5/12/2011 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 Desi n Flow U gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No f 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover MA 01845 5/12/2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site- plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level 8r distribution equal. No evidence of leakage. Evidence of carryover, pumped d - box to clean. D -box cover broken, replaced same. 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.): 1 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover page. Cityfrown D. System Information (cont.) MA State 01845 5/12/2011 Zip Code Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 25'x 50' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and confi9 "ration 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 • 09/08 ❑ 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 M °'( 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is required for every North Andover MA 01845 5/12/2011 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): F l 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owners Name information is required for every North Andover MA 01845 5/12/2011 page. Cityrrown State Zip Code Date of Inspection t5ins • 09108 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 13 R 3 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 v Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) Site Exam: MA 01845 5/12/2011 Date of Inspection ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: '4 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: 4/6/1995 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -.explain: You must describe how you established the high ground water elevation: As per test pit data on design plan show no water 4' deep. Before filing 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 Commonwealth of Massachusetts Title 5.Official Inspection Form Subsurface.Sewage Disposal System Form Not for Voluntary Assessments 88 Pheasant Brook Road Property Address Edward Hutner Owner Owner's Name information is North Andover required for every page. Cityrrown MA 01845 State Zip Code E. Report Completeness Checklist 5/12/2011 Date of Inspection ® inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 5/6/2011 2:21:55 PM by Karen Hanlon Town of North Andover Tax Map # 210-106.B-0223-0000.0 Parcel Id 17618 88 PHEASANT BROOK ROAD EDWARD HUTNER 88 PHEASANT BROOK ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type Size Total 1.53 Acres FY 2011 UB Mailina Index Name/Address EDWARD HUTNER 88 PHEASANT BROOK ROAD NORTH ANDOVER, MA 01845 DUNCAN, BRUCE & WENDY 88 PHEASANT BROOK ROAD NORTH ANDOVER, MA 01845 . UB Account Maint. Type Loan Number Owner Previous Customer Active/Inact. From Inactive 8/8/2006 Account No Cycle Occupant Name Active/Inactive Bldg Id. 20736.0 - 88 PHEASANT BROOK ROAD Last Billing Date 4/6/2011 3170123 03 Cycle 03 Active UB Services Maint. Account No. 3170123 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 214.75 /1 UB Meter Maintenance Account No. 3170123 Serial No Status Location Brand Type 32772940 a Active ERT HH b Badger w Water Date Reading Code Consumption Posted Date 3/9/2011 411 a Actual 45 4/13/2011 12/10/2010 366 a Actual 20 1/12/2011 9/10/2010 346 a Actual 31 10/15/2010 6/7/2010 315 a Actual 16 7/15/2010 3/8/2010 299 a Actual 14 4/14/2010 12/10/2009 285 a Actual 18 1/12/2010 9/10/2009 267 a Actual 23 10/15/2009 6/5/2009 244 a Actual 16 7/20/2009 3/12/2009 ( 228 a Actual 16 4/29/2009 12/5/2008 212 a Actual 18 1/20/2009 9/9/2008 194 a Actual 24 10/10/2008 6/5/2008 170 a Actual 18 7/16/2008 3/10/2008 152 a Actual 13 4/11/2008 12/7/2007 139 a Actual 18 1/22/2008 9/4/2007 121 a Actual 62 10/12/2007 6/14/2007 59 a Actual 18 7/20/2007 3/13/2007 41 a Actual 17 4/16/2007 12/8/2006 24 a Actual 16 1/19/2007 9/13/2006 8 a Actual 8 10/20/2006 Trouble Code:03 8/2/2006 0 n New Meter 0 10/20/2006 8/2/2006 1042 r Replacement 0 10/20/2006 8/2/2006 1042 f Final Bill 15 8/2/2006 Size 0.63 0.63 Page 1 1 Residential • S Commonwealth of Massachusetts City/Town of ° System Pumping Record Form 4 t5form4.doc• 06/03 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front lf-h use, right front of house, left side of house, right side of house, Left rear of house, -666 �i' ar of ho_u.se,, left side of building, right rear of building, under deck. ?5� Cityrrown 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ C" State Zip Code Std 1 � ^ Zi Pode Telephone Number Date 2. Quantity Pumped.• Cesspool(s) [Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. ConditiWi ofr�System: T �IJCx It, 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company ts-c4L' Gallons ❑ Tight Tank If yes, was it cleaned? , ❑ Yes ❑ No 7. Ocat+aq-where contents were disposed: G.L.S F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 GO T' !v �phlemsISvrze,. r,4G(uc &1A4,1q-9'