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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 9/21/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair and Construction of an
On -Site Sewage Disposal System
By: Bateson Enterprises
At:
90 Wintergreen Drive
Map104.B Lot 196
North Andover, MA 01845
of this certifsh -pot be Z7
d as a guarantee that the system will function satisfactorily.
�7
1 n A (Y' -
T ichele Grant
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
0 r y
{t'Cewet)
PNQpV�N
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( 'constructed; ( ) repaired;
By: —re VP 1 M32�)
(Print Name) ,may,
Located at: q0 lej krreV6 "mo i V e
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan, originally dated
15�-14-1S
.and last revised on , with a design flow of
`� (_1?12 gallons per day. The materials used were in conformance with those specified on the
approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local
regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on
the As -built which has been submitted to the Board of Health.
Bottom of Bed Inspection Date:s_I'
Pzit,L- 121AMO'?
And — Print Name
Final Construction Inspection Date: --o—
r ..
And — Print Name
Engineer Representative (Signature)
r -y�
Engineer Representative (Signature)
Installer: (Signature) Date: P
Tom
/J And — Print Name
I
Engineer: *144l�/�(Signature) Date: 4 /fl4/9--
VLAQi6d
And — Print Name
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
Town of North Andover —
Se-
(d0,Dr(,Vt,1_-
- AS -BUILT CHECKLIST
1) J All changes to the design plan have been reflected and noted on the as -built plan
2) "� As -built plan has a suitable scale; (1 inch = 40 feet or fewer for plot plans)
3) Street Address, Assessor's Map and Lot Number
4) J Lot Lines and Location of Dwellings served by the system
5) V1 Locations, Elevations and Dimensions of As -built system components, including reserve (if applicable)
6) t✓ Ties to all tank openings, d -box, and leach area from dwelling or Permanent Structure
.,/Setback distances are shown on the as -built plan from system components to:
Subsurface, interceptor & foundation drains
Catch basins
Property lines
✓ Dwellings or other structures
►,Private water supply or irrigation wells
✓ Watercourses or wetlands
8) Locations of Wells, Drains, Wetland Resource Areas within 150 feet of system
V/9) Location of water, gas, electric lines, cable, control panel (if applicable)
10) ✓ Location of Structures within 6 Inches of Finished Grade
11) Original Stamp & Signature
12) `� Location and holder of any easements which could impact the system
13) �/Impervious Areas; Driveways, etc
14) V✓ North Arrow
15) V Location & Elevation of Benchmark used
16) ./ STATEMENT ON PLAN (NA 5.3)
a. "I certify the locations, elevations, ties, cover material; exposed component covers etc.,
shown on this as -built substantially agree with the approved plan and have determined that the
break out elevations, if applicable, have been met."
Signature of Designer
Date
b. "If a STUCTURAL WALL IS PRESENT (NA 4.9) a Letter or statement on the as -built indicating
the wall - was, or was not, constructed in accordance with the intended design and any
manufacturer's specifications."
Signature of Designer
Revised 3/17/15
Date
SUMMARY OF INVERTS BUILDING TIES
SEWER ® FDTN. PRE-EXIST. BLDG. CORNER A B C
SEPTIC TANK IN 129.08 SEPTIC TANK OUT i4_.6.32_6 -
SEP11C TANK OUT 128.80 DIST. BOX 47.5 31.5 -
DIST. BOX IN 128.20
DIST. BOX_ OUT 128.04
BEG INV. LINES 127,97
END INV. LINES 127,82
AS E
OF
�
D -L�Y.L ^Tr E: THIS PLAN & CERTIFICATION IS NOT
A WARRANTY OF THE SUBSURFACE DISPOSAL
-- SYSTEM. IT IS A RECORD OF THE LOCATION
AND ELEVATION OF THE EXISTING SYSTEM
COMPONENTS.
"I HEREBY CERTIFY THE LOCATIONS, ELEVATIONS, TIES, COVER MATERIAL;
EXPOSED COMPONENT COVERS ETC., SHOWN ON THIS AS -BUILT SUBSTANTIALLY
AGREE WITH THE APPROVED PLAN AND HAVE DETERMINED THAT THE BREAK
OUT ELEVATIONS, IF APPLICABLE, HAVE BEEN MET."
APPROVED DESIGNS PLANS.
X-1A11U11 /U�cCcC�Etib�c O�/o Z�s
SIGNATURE OF DESIGNER DATE
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH ANDOVER, MASS. /90 WINTERGREEN DRIVE
AS PREPARED FOR
JOANNE SHAUGHNESSY
.DATE: 8-6-15 TM: 104B
SCALE: 1"=40' TL: 196
0 20 40 gp
II MERRIMACK ENGINEERING SERVICES
88 PARK STREET
ANDOVER, MASSACHUSETTS 01810
North Andover Health Department
Community and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 90 Wintergreen MAP: 104B LOT: 196
INSTALLER: Todd Bateson
DESIGNER: Merrimack Engineering
PLAN DATE: 5/14/15, revised 5/18/15
BOH APPROVAL DATE ON PLAN: 6/10/15
INSPECTIONS
TANK INSPECTION: 8/4/15
DATE OF BED BOTTOM INSPECTION: 8/4/15
DATE OF FINAL CONSTRUCTION INSPECTION: 8/6/15
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
N/A Contractor reports any changes to design plan
® Existing septic tank properly abandoned
® Internal plumbing all to one building sewer
® Topography not appreciably altered
® Building sewer in continuous grade, on
compacted firm base
N/A Cleanouts per plan
X Bottom of tank hole has 6" stone base
X Weep hole plugged
X 1500 gallon tank has been installed
H-10 loading
X Monolithic tank construction
® Water tightness of tank has been achieved by
visual testing
® Inlet tee installed, centered under access port
® Outlet tee installed, centered under access port
(effluent filter)
® 24" inch cover to within 6" of finish grade
installed over one access port
X Neoprene boots around inlet & outlet
Comments:
DISTRIBUTION -BOX
® Installed on stable stone base
® H-20 D -Box
N/A Inlet tee (if pumped or >0.08'/foot)
® Hydraulic cement around inlet & outlets
® Observed even distribution
® Speed levelers provided (not required)
® Schedule 40 PVC Pipe
Comments:
SOIL ABSORPTION SYSTEM (General)
X Bottom of SAS excavated down to C soil layer,
as provided on plan
X Size of SAS excavated as per plan — 30x40
w/overdig
X Title 5 sand installed, if specified on plan
N/A 40 Mil HDPE barrier installed
® Laterals installed and ends connected to
header (and vented if impervious material
above)
® Elevations of laterals and chambers installed as on
approved plan
N/A Retaining wall (boulder / concrete / timber/ block)
❑ Final cover as per plan
Comments: 2000
A
FINAL GRADE
[� Loamed
[� Seeded
Cover per plan
Comments:
DOCUMENTS NEEDED
Certification of Installation Form submitted
By engineer and signed and dated by
Engineer and installer
As -Built Plan
BM = 134.50
HR = 3.44
HI = 137.94
SYSTEM ELEVATIONS
ROD
ELEVATION
AS -BLT INVERT
ELEV
DESIGN INVERT
ELEV
Benchmark
Building Sewer OUT
129.5
Septic Tank IN
8.49
129.10
129.20
Septic Tank OUT
8.83
128.76
128.95
Distribution Box IN
9.48
128.11
128.17
Distribution Box OUT
9.56
128.03
128.00
Lateral 1 TOP
9.63/9.80
Lateral 1 INVERT
127.96 / 127.79
127.95 / 127.80
Lateral 2 TOP
9.63/9.80
Lateral 2 INVERT
127.96 / 127.79
127.95 / 127.80
Lateral 3 TOP
9.63/9.80
Lateral 3 INVERT
127.96 / 127.79
127.95 / 127.80
Lateral 4 TOP
9.63/9.80
Lateral 4 INVERT
127.96 / 127.79
127.95 / 127.80
Top of Chamber
Bottom of Bed/Chamber
127.29
127.3
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
® Wetlands bordering surface
water supply or trib. (in Watershed)
Tank
SAS Sewer
®
Property line
10
10 --
®
Cellar wall
10
20 --
®
Inground pool
10
20 --
®
Slab foundation
10
10 --
®
Deck, on footings, etc
5
10 --
®
Waterline
10
10 101
®
Private drinking well
75
1002 50
®
Irrigation well
75
100
®
Surface Water
25
50
®
Bordering Vegetated Wetland ,
Salt Marsh, Inland / Coastal Banka
75
100
® Wetlands bordering surface
' Suction line 222(2)
z 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA
wetland bylaws
water supply or trib. (in Watershed)
150
150
®
Trib. to surface water supply
325
325
®
Public well
400
400
®
Interim Wellhead Prot. Area
®
Reservoirs
400
400
®
Drains (wat. supply/trib.)
50
100
®
Drains (intercept g.w.)
25
50
®
Drains (Other) Foundation
10 (5)
20 (10)
®
Drywells
20
25
' Suction line 222(2)
z 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA
wetland bylaws
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Commonwealth of Massachusetts
BOARD OF HEALTH
North Andover
Map -Block -Lot
104. B0196
-----------------------
Permit No
BHP -2015-0320
-----------------------
FEE
$250.00
--------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd B-ateson
- - - - --------------------------------------------------------------------------------
to (Upgrade) an Individual Sewage Disposal System.
at No
--90----WINTERGREENDRIVE ---------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2015-032 Dated July -2-7,-2-0-1-5
---- --------- - Y
ILE------
Issued On: Jul -27-2015 Bppt O AL H
----------------------------------------------------------------------------------
#t<z� Application for peptic Disposal System
TODAY'S DATE
Construction Permit —TOWN OF
NORTH ANDOVER. MA 01845 fihiS- .omponent
Important: Application is hereby made for a permit to:
Whenfilling out [IConstruct a new on-site sewage disposal system*
forms on the .s ��,,�
computer, use I.rcepair or replace an existing on-site sewage disposal' system*
only the tab key Repair or replace an existing system component – What? RECEIVED
to move your
cursor -'do not
use the return A. Facility information JUL 2 7 2015
key. G/
o Tgm, op NORTH ANXINER
Address or lot # H; Al TH DEPARTMENT
raa
City/Town�--
`� 2.- *TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump cavity (choose one)
**'if pump system, attach copy of electrical permit to application—
➢ &tonventional System (pipe and stone system)
➢ ❑ Infiltrator or Blodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
➢ ❑ Pressure Distribution S.A.S. (No D -Box)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ 5j4Boes the system require an effluent filter? Yes 1% No
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the Make? What is the Modes{S
2. Owner Information
o A�N�� S �V k ua ii Are C'T_
Name
Car4LQ„j 012—
Address (if different from above)
ivy AL
Cityrrown State Zip Code
7930 '13 - hrL '7
Telephone Number
3. Installer Information
Name Name ofGo any
/)) Aq ; ` � I �4 BATEpON ENTERP
AddressLA
ANDOVERLA AD
0018 0
City/Town State Zip Code
9%r 09L703
Telephone Number (Cell Phone # If possible please)
4.�,,Desi_gner Information
� � 1( � Fr.� s,�:2 i't%Qr r � .� � c �� -oval ?r►� zee.`-*-�,
Name Name of Company
Arrrlrpge
City/Town
�, !V 1 S_/
State Zip Code
Telephone Number (Best # to Reach)
Application .for Disposal System Construction Permit • Page 1 of 2
jar � 1
W.,
nit' TOWN OF
PAGE 2OF2
A. Faeility.Information continued....
7 d 41- /5
TODAY'S DATE
$.250.00 - Full Repair
$125.00.- Component
5. T1rpe'of Building; ®Residential Dwelling or ❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system In accordance with the provisions of Title.5 of the
y Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
' North Andover, and not to place the system hi operation until a Certificate of Compliance has
been Issue y this Board of Health.
Name
Date
oa d of Health Representative)
Date
Application Dlsapproi�d. for the following reasons:
For Coffee Use Only
1 Fee Attached. Yes No
2.. ProjectMariaget Obligation Form Attached. Yes No '
,_ •
A: Puma System? Ifsot fEl P No
4. FoundationAs Built.? (hew construction •ronl}r) • Yes_ No
(Same scale as approved plan)
A FloorPlans? (hew construction only): xes_
No
Application for pispgsal 5ystem-:0onstraction Permit' Page 2 of 2
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6.
(Bodjo ixtt; :
North Andover Health Department
(ommunity and Economic Development Division
June 10, 2015
Joanne Shaughnessy
90 Wintergreen Drive
North Andover, MA 01845
Re: Subsurface Sewage Disposal System Plan for
90 Wintergreen Drive (Map 104B, Lot 196)
Dear Ms. Shaughnessy:
The proposed wastewater system design plan for the above site dated May 14, 2015 and received
on May 18, 2015 has been approved.
The design plan has been approved for use in the construction of a new on-site septic system for
a 4 -bedroom (max 9 -room) home. This design plan approval is valid until June 10, 2017.
During this time, a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer, designer and the Town of North
Andover. In the event of an imminent health problem, such as sewage backup into the dwelling
is occurring, the North Andover Board of Health may reduce the time period for which this plan
is valid.
This approval is also subject to the following conditions:
If site conditions are found in the field to be different from those indicated on the
design plan and/or soil evaluation, the originally issued Disposal System Construction
Permit is void, installation shall stop, and the applicant shall reapply for a new
Disposal Systems Construction Permit (3 10 CMR 15.020(1)).
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
90 Wintergreen Drive
June 10, 2015
2. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system installer or other representative to ensure that all other state and
municipal requirements are met. These may include review by the Conservation
Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector
and/or Electrical Inspector. The issuance of a Disposal System Construction Permit
shall not construe and/or imply compliance with any of the aforementioned
requirements.
3. The typographical error indicating the leach field width of 25' on page one of the
design plan shall be corrected by either submission of a corrected design plan or the
engineer Vladimir Nemchenok may come to the office and amend and initial the
change on the plans on file at our office. -,,E_ 90b && 6- w/j Ft&n -
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Sincerely,
C�:-,�,--
i
Michele Grant
Health Inspector
Encl. Installers list
cc: Vladimir Nemchenok, PE
File
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
GraA. lM*hele
From: wrdufresne@comcast.net
Sent: Thursday, June 11, 2015 2:07 PM
To: Grant, Michele
Subject: Re: 90 Wintergreen street
Attachments: Shaughnessy.pdf
Michelle
My apologies, here is what we have here, somewhere along the line it was corrected but you got the incorrect
plan. I Will deliver 3 sets of the correct plans tomorrow.
My apologies for the confusion.
0'
From: "Michele Grant" <MGrant cDtownofnorthandover.com>
To: "wrd ufres ne(cDcom cast. net" <wrdufresne(aD-comcast. net>
Sent: Thursday, June 11, 2015 12:45:45 PM
Subject: RE: 90 Wintergreen street
Bill, Please see the attached. This is the plan we have.
Sincerely
Michele E. Grant
Public Health Agent
Town of North Andover
1600 Osgood St I Suite 2035
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email merant(@townofnorthandover.com
Web www.TownofNorthAndover.com
From: wrdufresne@comcast.net [mailto:wrdufresne@comcast.netl
Sent: Thursday, June 11, 2015 1:31 PM
To: Grant, Michele
Cc: Blackburn, Lisa
Subject: Re: 90 Wintergreen street
Michelle
I am A onf-;sed by your e-mail as the plans we have on record here in the office for 90 Wintergreen Drive do not
V.
indicate a leach field width of 25 feet, but in fact 20 feet. The dimension shown in plan view is 20 feet, the text
in plan view calls out a 20'x 30' leach field and the Design Cale's indicate a 20'x 30' leach field, am I
misunderstanding you?
Please clarify.
Thank you
M
From: "Michele Grant" <MGrant a()-townofnorthandover.com>
To: "Bill Dufresne" <wrdufresne cDcomcast.net>
Cc: "Lisa Blackburn"<LBlackburn(a)-townofnorthandover.com>
Sent: Thursday, June 11, 2015 11:34:29 AM
Subject: 90 Wintergreen street
Dear Mr. Dufresne,
The typographical error indicating the leach field width of 25' on page one of the design plan shall be corrected by either
submission of a corrected design plan or the engineer Vladimir Nemchenok may come to the office and amend and
initial the change on the plans on file at our office.
Please indicate how you would like to precede.
Regards,
Michele E. Grant
Public Health Agent
Town of North Andover
1600 Osgood St I Suite 2035
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email mgrant@townofnorthandover.com
Web www.TownofNorthAndover.com
All email messages and attached content sent from and to this email account are public
records unless qualified as an exemption under the Massachusetts Public Records Law.
Visit us online at www.townofnorthandover.com
Blackburn, Lisa
From: Dan Ottenheimer <dano@millriverconsulting.com>
Sent: Wednesday, June 10, 2015 5:32 PM
To: Grant, Michele; Blackburn, Lisa
Cc: 'Isaac Rowe'; Pam Lally
Subject: Plan review, 90 Wintergreen Drive
Attachments: 90 Wintergreen Drive Approval letter June 10 2015.docx
Michele, Lisa -
Attached please find our plan review letter for the onsite wastewater system design at 90 Wintergreen Drive. We are
recommending approval of this design with a condition that a typographical error be amended to prevent any confusion
occurring during the construction.
Please feel free to contact me should you have any questions.
Best,
Dan
Mill River
consulting
{rtg— z,hf—, ♦ Env„on rnrni:t Pe:snitt�ng
Mg6q;p.tl f—,O,i mq m.t Her Hh i0`sU}itn
Daniel Ottenheimer, President
Mill River Consulting, Inc.
6 Sargent Street
Gloucester, MA 01930-2719
978-282-0014 x 802
www.millriverconsultine.com
dano@millriverconsulting.com
Member: Massachusetts Association of Onsite Wastewater Professionals, Massachusetts Environmental Health
Association, Cape Ann Chamber of Commerce, Gloucester Rotary Club, New England Water Environment Association
Grant, Michele
To: Bill Dufresne
Cc: Blackburn, Lisa
Subject: 90 Wintergreen street
Dear Mr. Dufresne,
The typographical error indicating the leach field width of 25' on page one of the design plan shall be corrected by either
submission of a corrected design plan or the engineer Vladimir Nemchenok may come to the office and amend and
initial the change on the plans on file at our office.
Please indicate how you would like to precede.
Regards,
Michele E. Grant
Public Health Agent
Town of North Andover
1600 Osgood St I Suite 2035
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email mgrant@townofnorthandover.com
Web www.TownofNorthAndover.com
1
Blackburn, Lisa
From: Blackburn, Lisa
Sent: Monday, May 18, 2015 1:11 PM
To: Dan Ottenheimer; Isaac Rowe; Pam Lally
Cc: Grant, Michele
Subject: 90 Wintergreen Dr.
Good Afternoon,
I will be mailing out septic plans for 90 Wintergreen Dr.
Lisa Blackburn
Health Department
Town of North Andover
1600 Osgood Street, Suite 2035
North Andover, MA 01845
Phone 978-688-9540
Fax 978-688-8476
Email Iblackburn@townofnorthandover.com
Web www.TownofNorthAndover.com
Q� µOF7N S.Y
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1
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES rpt`
HEALTH DEPARTMENT ,,;,
1600 OSGOOD STREET; SUITE 2035
NORTH ANDOVER, MASSACHUSETTS 01845
978.688.9540 — Phone
Susan Y. Sawyer, REHS/RS 978.688.8476— FAX
Public Health Director E-MAIL: healthdeptna.townofnorthandover.com
WEBSITE: hgp://www.townofnorthandover.com
SEPTIC PLAN SUBMITTAL FORM
Date of Submission: rJ- 1'�5
Site Location: g® w-10—rewi{ 'oa) puuiU '
Engineer: P ri W -I t,� E j
New Plans? Yes /$225/Plan Check # (includes 1St submission and one re-
review only)
Revised Plans?Yes $75/Plan Check #
Site Evaluation Forms Included? Yes—z No
Local Upgrade Form Included? Yes No V
Telephone #: h i1'/, #--61���i -7 �� )��
E-mail 1uer'(
Homeownerjj
Name: , ICA,
OFFICE USE ONLY
RECEIVED
When the submission is complete (including check):
MAY 18 2015
➢ Date stamp plans and letter
TOWN OF NORTH ANDOVER
➢ Complete and attach Receipt
HEALTH DEPARTMENT
➢ Copy File; Forward to Consultant
➢ Enter on Log Sheet and Database
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Commonwealth of Massachusetts
City/Town of North Andover
- Percolation Test
Form 12
�M
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
kkey.+
Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage
Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but
the information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
A. Site Information
Joanne Shauohness
Owner Name
90 Wintergreen Drive
Street Address or Lot #
North Andover MA 01810
City/Town
Contact Person (if different from Owner)
B. Test Results
Observation Hole #
Depth of Perc
Start Pre -Soak
End Pre -Soak
Time at 12"
Time at 9"
Time at 6"
Time (9"-6")
Rate (Min./Inch)
William Dufresne
Test Performed By:
Isaac Rowe
Witnessed By:
Comments:
State Zip Code
(978) 2734657
Telephone Number
5-30-15 12 pm
Date Time Date Time
P-1
84"
12:26
24 Gal's used
<2
Test Passed:
Test Failed: ❑
Test Passed: ❑
Test Failed: ❑
t5form12.doc• 06/03 Perc Test • Page 1 of 1
Blackburn, Lisa
From: Blackburn, Lisa
Sent: Thursday, April 16, 2015 1:43 PM
To: Dan Ottenheimer; Isaac Rowe; Pam Lally
Cc: Grant, Michele
Subject: 526 Winter St.
Attachments: 201504161356.pdf
Good Afternoon,
Attached is an application for soil testing at 526 Winter St.
-----Original Message -----
From: noreply@townofnorthandover.com[mailto:norepiy@townofnorthandover.comj
Sent: Thursday, April 16, 2015 1:56 PM
To: Blackburn, Lisa
Subject: Message from "ComDev-Health-Ricoh"
This E-mail was sent from "ComDev-Health-Ricoh" (Aficio MP C3002).
Scan Date: 04.16.2015 13:55:59 (-0400)
Queries to: noreply@townofnorthandover.com
1
APPLICATION FOR SOIL TESTS
DATE: �� S -1 MAP & PARCEL: Oq F2 �o
LOCATION OF SOIL TESTS: K)T e-�Q WOO '
OWNER: LJOA P P *L-yu&1 a,(*yct Z% —?- &% /
APPLICANT: Contact #:
ADDRESS:
ENGINEER: �.j I�/ �A Contact #:
CERTIFIED SOIL EVALUATOR:(
Intended Use of Land: Residential Subdivisionmg ee Family Home Commercial
Is This: Repair Testing: V//'
/ Undeveloped Lot Testing: Upgrade for Addition: 17 2015
/ T4'
In the Lake Cochichewick Watershed? Yes No V H, _
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
➢ Proof of land ownership (Tax bill, or letter from owner permitting test)
➢ 8.5"x 11" Plot plan & Location of Testine (please indicate test nit sites on the elan
➢ Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of3$ 60.00 per lot for repairs or upgrades.
GENERAL INFORMATION
➢ Only Certified Soil Evaluators may perform deep hole inspections.
➢ Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
➢ At least two deep holes and two percolation tests are required for each septic system disposal area.
➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH
representative.
➢ Full payment will be required for all additional tests within two weeks of testing.
➢ Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health
showing the location of all tests (including aborted tests).
➢ Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval Date. l6,
Signature of Conservation Agent: `
Date back to Health Department: (stamp in):
CA
Gtr & 6 1\ Y\a-N
TOWN OF NORTH ANDOVER
W
Office of COMMUNITY DEVELOPMENT AND SERVICES
;w
HEALTH DEPARTMENT
1600 OSGOOD STREET; SUITE 2035
NORTH ANDOVER, MASSACHUSETTS 01845
Susan Y. Sawyer, REHS, RS 978.688.9540 – Phone
Public Health Director 978.688.8476 – FAX
healthdept(a,townofnorthandover.com
www.townofnorthandover.com
APPLICATION FOR SOIL TESTS
DATE: �� S -1 MAP & PARCEL: Oq F2 �o
LOCATION OF SOIL TESTS: K)T e-�Q WOO '
OWNER: LJOA P P *L-yu&1 a,(*yct Z% —?- &% /
APPLICANT: Contact #:
ADDRESS:
ENGINEER: �.j I�/ �A Contact #:
CERTIFIED SOIL EVALUATOR:(
Intended Use of Land: Residential Subdivisionmg ee Family Home Commercial
Is This: Repair Testing: V//'
/ Undeveloped Lot Testing: Upgrade for Addition: 17 2015
/ T4'
In the Lake Cochichewick Watershed? Yes No V H, _
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
➢ Proof of land ownership (Tax bill, or letter from owner permitting test)
➢ 8.5"x 11" Plot plan & Location of Testine (please indicate test nit sites on the elan
➢ Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of3$ 60.00 per lot for repairs or upgrades.
GENERAL INFORMATION
➢ Only Certified Soil Evaluators may perform deep hole inspections.
➢ Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
➢ At least two deep holes and two percolation tests are required for each septic system disposal area.
➢ Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH
representative.
➢ Full payment will be required for all additional tests within two weeks of testing.
➢ Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health
showing the location of all tests (including aborted tests).
➢ Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval Date. l6,
Signature of Conservation Agent: `
Date back to Health Department: (stamp in):
CA
Gtr & 6 1\ Y\a-N