HomeMy WebLinkAboutMiscellaneous - 93 RALEIGH TAVERN LANE 4/30/2018 (2)J(,o
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February 18, 2010
North Andover Board of Health
1600 Osgood Street
North Andover, MA 0 1845
Attention: Health Agent
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
Reference: FAST' Wastewater Treatment System - Serial Number: 29725
Attached please find the Field Inspection & Service Report with fiel (test result for
ults f
c
services performed on 2/12/10 at the property of Kurt von Sneidern catedat:93Raleigh
Tavern Lane, North Andover, MA.
Please call if you have any questions or require additional information.
Sincerely,
Wastewater Treatment Services, Inc.
Service Department
Enclosures
Copy to: Kurt von Sneidem
Massachusetts DEP
f
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
13033
A. Installation
Kurt von Sneidern
Owner
93 Raleigh Tavern Lane
Facility Street Address
North Andover
01845
City
Zip
Mailing address of owner, if different:
93 Raleigh Tavern Lane
Street Address/PO Box:
12530
North Andover
MA 01845
City
State Zip
978-208-1107
Telephone Number
B. Authorized Service Provider
Wastewater Treatment Services. Inc.
O&M Firm
44 Commercial Street
Street Address
Raynham
MA 02767
City
State Zip
508-880-0233
Telephone Number
Kevin Usilton
12530
Certified Operator Name
Certification Number
C. Facility/System Information
29725 Bio-Microbics, Inc. MicroFAST.5
DEP ID Manufacturer ID Model Number
8/22/2007 8/22/2007
Installation Date Start of Operation
Approval Type: General Provisional [ ] Piloting [x] Remedial
Seasonal Residence — used less than 6 mo./year: [ ] Yes [x] No
D. Operating Information
2/12/10
Inspection Date
N/A"
Sludge Depth (to be checked yearly)
Previous Inspection Date
Pumping Recommended [x] Yes [I No
0 - .
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
13033
E. Field Testing
Field Inspection:
Color: D gray 0 brown [x] clear D turbid
0 Other (specify):
Odor: 0 musty [x] earthy 0 moldy 0 offensive D turbid
Effluent Solids: [x] no 0 some
pH 7 SU DO 10.21 mg/L Turbidity 1.87 NTU
6 to 9 2 or greater 40 or less
Should a Remedial or General Use system fail the Field Testing, effluent samples shall be
collected per Standard Methods and analyzed for BOD and TSS.
F. Sampling Information
Samples Taken: [ j Influent [ ] Effluent
Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use
nitrogen reducing systems:
ME
Parameters sampled: [ ] pH [ ] BOD ( ] CBOD [ ] TSS [ I TKN [ ] Nitrate [ ] Nitrite
Phosphorus []Spec.Cond. []Ammonia []Alkalinity []OilGrease []VOC ffecalColiform
G. Inspection and Maintenance
Description of any maintenance performed since previous inspection & during this inspection:
Cleaned Filter, Checked Splash Recycle
Notes and Comments:
System needs to be pumped. Very thick scum layer.
2
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
L\ DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
13033
H. Certification
I certify: I have inspected the sewage treatment and disposal system at the address above, have
conducted the required Field Testing and/or sample collection in accordance with Standard
Methods, have completed this report and the attached technology operation and maintenance
checklist, and the information reported is true, accurate, and complete as of the time of the
inspection. I am a Massachusetts certified operator in accordance with 257 CMR 2.00.
10
2/12)
Operator Signature Date
System owner must submit this report, technology O&M checklist, and any required sampling
results to the local board of health and DEP as follows for each inspection performed:
Remedial Use — by January 31 st of each year for the previous calendar year
Piloting Use - within 45 days of inspection date
Provisional Use — by March 31 th of each year for the previous 12 months
General Use — by September 30th of each year for the previous 12 months
Send to:
Department of Environmental Protection
Attention: Title 5 Program
One Winter Street, 6th Floor
Boston, MA 02108
3
I
A
1 9 C 0 R P 0 R A T E 0
8450 Cole Parkway, Shawnee, KS 66227, Phone 913-422-0707, Fax 913-422-0808
e-mail: on site (@ bi om icrobics. co m, www.biomicrobics.com, 800-753-FAST(3278)
FIELD INSPECTION & SERVICE REPORT
For Bio-Microbics Single Hoine FASP System
13033
UNSTALLATION
AUTHORIZED SERVICE PROVIDER
Installation Address: 93 Raleigh Tavern Lane
North Andover, MA 01845
Name: Wastewater Treatment Services, Inc.
Owner Name: Kurt von Sneidern
Mail Address: 93 Raleigh Tavern Lane
North Andover, MA 01845
Mail Address: 44 Commercial Street
Raynham, MA 02767
Phone: 978-208-1107 Fax: e-mail:
Phone: (508) 880-0233 Fax: (508) 880-7232 e-mail:
INSTALLATION INFORMATION
Model No.
Serial No.
)f Installation
Date of last pump out
MicroFAST.5
29725
8/22/2007
EQUIPMENT
YES
NO
MAINTENANCE PERFORMED AND COMMENTS
Electrical Panel(s)
Visual Alarm Operating
X
Audio Alarm Operating
(if present)
x
Blower(s)
Air Inlet Filter Clean
X
Blower Hood Vents Clear
x
Excessive Noise
x
Excessive Vibration
X
Treatment unit(s)
Unusual Odor
x
Pumpout Required
x
Primary Settling Zone
N/A"
Aerobic Treatment Zone
17"
EFFLUENT (optional)
LINUT
RESULT
Estimated Daily Flow
440 gpd
pH (Standard Units)
7
Color
Clear
Temperature
45
Odor
Earthy
Comments: System needs to be pumped. Very thick scum layer.
TECHNICIAN
SERVICE DATE
Kevin Usilton
2/12/10
q
. 2�-MAY-07 14:02 FROM-RENGROD +15088807232 T-295 P-02/03 F-886
INSPECTION An TESTING AG_REEW
" Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax* (508) 880-7232
Agreement entered into by and between Wastewater Treatment Services, Inc. (herein called WTS) and the
FASTO System OWNER (herein called OWnR) for the inspection by WTS of certain equipment of OWNER
which is described below.
Upon acceptance of this agreement at WTS's office, WTS will render the following services only:
Equipment will be inspected at least 2 times per year that this Agreement remains in effect, with the first
inspections beginning These inspections will include-,
1) Testing of the sludge depth in the septic tank.
2) Inspection, power testing and clean/replace intake filter of the air blower.
3) Inspection of the alann system.
4) Inspect overall condition of FAST" System.
5) Notify OWNER of any problems encountered.
6) Service other than routine maintenance will be billed at an hourly rate, plus travel and parts.
WTS shall notify the local Board of Health and Department of Environmental Protection in writing within 24
hours of a system failure or alarm event including corrective measures that have been taken.
OWNER will be billed standard WTS charges for any parts used in repairs or maintenance. Any additional labor
time will be billed to the OVSTER at current labor rates of $78.00 per hour.
Emergency seMce between regular inspections will be provided at standard labor rates during normal business
hours; at time and one-half after 5:00 PM and on Saturdays; and at double time on Sundays and holidays.
Emergency service charges will include a minimum four (4) hours of labor, plus standard WTS charges for parts,
plus mileage and travel charges. The annual rate includes routine maintenance, but does not include repairs
required for damages caused by abuse, accident, theft, acts of third persons, forces of nature, or alterations made to
the equipment, WTS shall not be responsible for failure to render the agreed services if caused by strikes, labor
disputes, non-cooperation by ONMJ;� or other factors beyond the control of WTS.
OWNER understands and agrees that WTS is not responsible for special, incidental or consequential damages,
including but not limited to loss of time, injury to person or property, or equipment failure.
OWNER agrees that WrS may enter OVMR's property and have acceptable access to all areas deemed by
WTS to be necessary or appropriate for WTS to perform its duties bereunder,
Current WYS practice is to send 0VVMR approximately 10 days before expiration ofthe term of the current
contract (1) either a new contract or an offer to extend the current contract's term, and (2) an invoice for one Year
of service. It is OVMR"s responsibility to timely return the payment and either the new contract or the accepted
extension, completed and signed, WTS must receive the payment and document before expiration of the then
current contract year to assure continuous contract coverage. Failure to return such documents on time or to
N -MAY -07 14:03 FROM-REMPROD
T-295 P-03/03 F-886
*40, otherwise comply with this contract, may result in suspension of service, cancellation of the contract and/or
nullification of warranties, at the election of WTS. OWNER may riot assign this contract without the prior written
consent of WTS. It will remain in force until a party cancels by written notice to the other at the address given
herein, or until the contract term expires, whichever is sooner.
MANUFACTURER MODELNO. SERIALNO LOCATION A�MAL RATE PERMIT
Bio-Microbics MicroFAST North Andover, MA $400.00 Remedial
includes (1) Field Test
EQUIPMEE OWNER Z--�rl Wastewater TreMent Services, ILc.
*Signpd by OWNER:
David Foulds
*Address:
93 Raleigh Tavern Lane
*City: State: — Zip: —
North Andover MA 01845
Telephone 978-681-8583
Daytime Telephone-,
Signed:
44 Commercial Street
Raynham, MA 02767
Tele: (508) 880-0233
Fax. (508) 880-7232
Effective Date of Agreement
OWNER understands that (1) ANNUAL RATE payment is for one year only commencing on ft effective date set
forth above and is non-refundable; and (2) Current DEP Regulations require OWNER to maintain a service
agreement for the life of the FA"S i ein. I HAVE READ AND UNDERSTAND THE FOREGOING.
*Signed by OWNER: , t/ If
Field Testing
Onsite testing performed twice per year will be used to demonstrate that the systems are operating at a secondary
treatment standard of 30 mg/L of BOD5 and TSS. The following will be performed:
1) Visual examination of the effluent for color, turbidity and effluent solids.
2) Effluent pH to determine if the waste water is between 6 and 9 standard units.
3) Dissolved Oxygen, 2mg/L or more, to ensure that the system is operating.
4) Turbidity, less tl= or equal to 40 NTU.
If the effluent does not meet effluent quality standards, a grab sample will be collected for laboratory analysis.
Results sent to state and local Agencies as well as the OWNER, OWNER is responsible for providing acceptable
access to effluent for field testing and/or to enable a grab sample to be taken for laboratory testing performed. If
such laboratory sample is required, OWTWR will be responsible for charges incurred. IF REQUIRED, THE
COST FOR THIS ADDITIONAL TESTING WILL BE $180.00NISIT.
Additional Testina
Town Requirements are testing o istal ssure one (1) time per year at a cost of $150.00/test.
*Approval forTesting 52 ""JW'6:4�
HomeowneFs Signature
Operator assigned: William Evete_tt
Telephone; (5081400-3868 *Engineer: New England Engineenng
'Ma'vezoam- J�ea&nmt J&Ym�w' Y/1'C'.
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
August 10, 2010
AUG 10 2010
TOWN OP NORTH MooveR I
Mr. Kurt von Sneidem DEPARTmaw I
93 Raleigh Tavem Lane
NorthAndover,MA 01845
Re: Serial Number: 29725
Location: 93 Raleigh Tavem Lane, North Andover, MA
Dear Mr. von Sneidern:
We understand you do not wish to continue your maintenance contract with our
company. Please be advised the Massachusetts Department of Environmental Protection
requires a maintenance contract be in place for the life of the alternative septic system.
Also, we are required to inform both the state and local agency of your decision.
If you have any questions or need additional information please call our office at
(508) 880-0233.
Sincerely,
Donna L. Callahan
Copy to: Massachusetts DEP
North Andover Board of Health
1600 Osgood Street
NorthAndover,MA 01845
I
B10-MICROBICS
8450 Cole Parkway w Shawnee, KS 66227 w Phone 913-422-0707 w Fax: 912-422-0808
e-mail: onsiteD-biomicrobics.com m www.biomicrobics.com v 800-753-FAST(3278)
PRODUCT REGISTRATION "PORT
Product Registration Report must be completed and returned to Bio-Microbics, Inc. in order to effect warranty.
Date of Start -UD F-111,0 ) Date Shini3ed to End User 8/13/07 Serial # 29725
Good Bad NA Good Bad NA
ELECTRICAL PANEL(S) TREATMENT UNIT(S)
Visual Narm Operating 2/1/ 13 13 Air vent clear L3
Audio Alarm Operating 0 C3 Septic tank level El
BLOWER(S) Septic tank meets min. size El
Wired for correct voltage 1� C3 Septic tank filled to L3
operating level
Inlet/outlet piped correctly Air Lift Operation U
Filter element installed U Recirculation tube in place El� L3
Blower hood secure U Fasteners tight L3
Blower works correctly U WATER -TIGHT JOINTS
Treatment unit to septic tank
Blower located within 100' of El Lj L3
treatment unit
Air line clear U Entrance tube to insert cover Ll L)
Air inlet screen clear L3 Insert to insert cover U
Blower hood vents clear D Discharge line connection 0/ L3
Factory AUtMorizea 1-ersonne%,;�-- drzg�;��
Firm: Wastewater Treatment Services, Inc.
OWNER
NAME
David Foulds
ADDRESS
93 Raleigh Tavern Lane
CITY/STATE/ZIP
NorthAndover,MA 01845
PHONE/FAX
SIO-MICROBICS DISTRIBUTOR
NAME
Wastewater Treatment Services, Inc.
ADDRESS
44 Commercial Street
CITY/STATE/ZIP_
Raynham, MA 02767
PHONE/FAX
508-880-0233 FAX: 508-880-7232
INSTALLER
NAME
Creative Builders
ADDRESS
58 Water Street
CITYISTATE/ZIP
North Andover, MA 01845
SEP 9 A PP
PHONE/FAX
978-682-4948
LUVI
CONSULTING ENGINEER (if applicable)
TOWN OF NQP"rL4 A 11 "1 "�v
NAME
New England Engineering
L_2��'.AUH D-z"'A,'�TME-NT'-
ADDRESS
CITY/STATE/ZIP
North Andover, MA 0 1845
PHONE/FAX
978-686-1768
Good Bad NA Good Bad NA
ELECTRICAL PANEL(S) TREATMENT UNIT(S)
Visual Narm Operating 2/1/ 13 13 Air vent clear L3
Audio Alarm Operating 0 C3 Septic tank level El
BLOWER(S) Septic tank meets min. size El
Wired for correct voltage 1� C3 Septic tank filled to L3
operating level
Inlet/outlet piped correctly Air Lift Operation U
Filter element installed U Recirculation tube in place El� L3
Blower hood secure U Fasteners tight L3
Blower works correctly U WATER -TIGHT JOINTS
Treatment unit to septic tank
Blower located within 100' of El Lj L3
treatment unit
Air line clear U Entrance tube to insert cover Ll L)
Air inlet screen clear L3 Insert to insert cover U
Blower hood vents clear D Discharge line connection 0/ L3
Factory AUtMorizea 1-ersonne%,;�-- drzg�;��
Firm: Wastewater Treatment Services, Inc.
tAORTH
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4"U'D 16
6 0
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co,
C.9
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
r'FRTIIFICA rr(F 0 E. C09VID I- T q Xff
As of-.
October 5, 2007
This is to certify that the individualsubsurface disposalsystem receiveda
S3T1STXCT0RT1-rffS(PECT10Yof the:
Tuffy RepairedSeptic System
Oy:
Roben (Daig(e
A t:
93 &k�yh Tavern Lane
91jap 10 7.0 - (Parcel 116
Yorth,4ndover, W,4 01845
The Issuance of this certificate shaff not be construed as a guarantee that the system wiff
function satisfactorify.
Susan T Sauyer
Public Yfealth Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townof no rtho n dove r.com
T1
TOWN OF NG�' Z q ANDOVER
4,
Office of COMMUNITY DEVELOPMENT AND SERVICES 0
0
HEALTH DEPARTMENT #-'
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACRUSETTS 0 1845 Ss c u
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
QNSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: .16 r1x
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:,.�N/';�'I/
DATE OF BED BOTTOM INSPECTION:
MAP: LOT:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
�EPTIC TANK
E]Existing septic tank properly abandoned
ElInternal plumbing all to one building sewer
[]Topography not appreciably altered
one access
filter is pres(
F-1 Hydraulic cement around inlet & outlet
Wastewater System Documentation — Feb 2006
Page 1 of 6
it
Bottom of ta
F-1
Weep hole r
1500 gallon
H-10 loadin(
E]
Water tightn
(Visual or V;
F-1
Inlet tee inst
F-1
Outlet tee (g
centered un,
F�
24" inch cov
one access
filter is pres(
F-1 Hydraulic cement around inlet & outlet
Wastewater System Documentation — Feb 2006
Page 1 of 6
it
#4
TOWN OF NORT114- ANDOVER Tk
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
HEALTH DEPARTMENT I 14K
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845 c u
Susan Y. Sawyer, REHS/RS 978.688.9540 - Phone
Public Health Director 978.688.8476 - FAX
1115:103,114
Comments:
SOIL ABSORPTION SYSTEM
El
Comments:
Installed on stable stone base
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers; provided (not required)
Bottom of SAS excavated down to soil layer, as
provided on plan
F-1 Size of SAS excavated as per plan
F-1 Title 5 sand installed, if specified on plan
F-1 3/4-1 Y2" double washed stone installed
El 1/8-1/2" (peastone) double washed stone installed
Laterals installed and ends connected to header
Laterals vented if impervious material above
El Orifices @ 5 & 7 o'clock positions
Gravel -less disposal systems: type, number and
location as per plan
Elevations of laterals installed as on approved plan
40 Mil HDPE barrier installed
Retaining wall (boulder / concrete / timber/ block)
F-1 Final cover as per plan
Wastewater System Documentation — Feb 2006
Page 3 of 6
05
b&ORTH
I �- i-"4*N
0
16
LANG
oc�m.
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
QNSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: M OT -
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
/C. � -"
Y�F' ; "�� Yf&
INSPECTIONS
TANK INSPECTION: 117)
LIP 9
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
0
Existing septic tank properly abandoned
D
internal plumbing all to one building sewer
0
Topography not appreciably altered
Comments:
SEPTIC TANK
Bottom of tank hole has 6" stone base
Weep hole plugged
1500 gallon tank has been installed
H-1 0 loading Monolithic construction
Watertightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
El
Inlet tee installed, centered under access port
El
Outlet tee (gas baffle or effluent filter installed,
centered under access port
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 fox 978.688.8476 Web www.townofnorthandoverarn
M
IAORTH
06
A
0
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
Hydraulic cement around inlet & outlet
Comments:
PUMPCHAMBER
Ej Bottom of tank hole has 6" stone base
F1 Weep hole plugged
Combo Tank installed. Size:
1000 gallon Pump Chamber installed
H-10 loading Monolithic construction)
Inlet tee installed, centered under access port
Pump(s) installed on stable base
E] Alarm float working
El Pump On/Off floats working
E] Separate on/off floats
Ej Drain hole in pressure line
24" inch cover to within 6" of final grade installed over
pump access port
Water tightness of tank has been achieved
Visual testing
E:1 Hydraulic cement around inlet & outlet
Comments:
DISTRIBUTION -BOX
El
installed on stable stone base
El
Inlet tee (if pumped or >0.08'/foot)
E:1
Hydraulic cement around inlet & outlets
0
Observed even distribution
0
Speed levelers provided (not required)
Comments:
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.lownofnorthondover.com
tkqRTH
0,(t
4 t
4 coc"KmawKK - A* j
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
SOIL ABSORPTION SYSTE_"eneral)
0 Bottom of SAS excavated down to 6 in into C soil
layer, as provided on plan
Size of SAS excavated as per plan
14) .
C
"f"14
El Title 5 sand installed, if specified on plan
F1 40 Mil HIDPE barrier installed
Retaining wall (boulder / concrete / timber/ block)
Final cover as per plan
Comments:
SOIL I BSORPTION SYSTEM (Gravel -less Chambers)
Brand and Model of Chamber Infiltrator Quick 4
Number of chambers per row — 9
Number of rows (trenches) 3
F-1 Laterals installed and ends connected to header (and
vented if impervious material above)
Elevations of laterals and chambers installed as on
approved plan
Comments:
CONTROL PANEL
Comments:
F] Alarm & Pump are on separate circuits
F-1 Alarm sounds when float is tripped
Fj Location of control panel:
F1 Rated for exterior if placed outside
0 Alarm signal located inside
1600 Osgood Street, North Andover, Mossochusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
10 0
L MI
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
SYSTEM ELEVATIONS
1600 Osgood Street, North Andover, Mosso(husetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.(om
INVERT INFIELD
PLAN INVERT ELEV.
Benchmark
Building Sewer OUT
Septic Ta nk IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 INV
Lateral 1 TOP
Lateral 2 INV
Lateral 2 TOP
Lateral 3 INV
Lateral 3 TOP
Lateral 4 INV
Lateral 4 TOP
1600 Osgood Street, North Andover, Mosso(husetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.(om
f
'6
0-
0
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Suction line 222(2)
100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5. 02).
3 As defined in 3 10 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland
bylaws
1600 Osgood Street, North Andover, Mosso(husetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
Tank
SAS Sewer
El
Property line
10
10
El
Cellar wall
10
20
El
Inground pool
10
20
El
Slab foundation
10
10
El
Deck, on footings, etc
5
10 --
El
Waterline
10
10 101
Private drinking well
75
1001 50
Irrigation well
75
100
El
Surface Water
25
50
D
Bordering Vegetated Wetland
Salt Marsh, Inland / Coastal Bank3
75
100
Wetlands bordering surface
water supply or trib. (in Watershed)
150
150
F
Trib. to surface water supply
325
325
El
Public well
400
400
El
Interim Wellhead Prot. Area
El
Reservoirs
400
400
El
Drains (wat. supply/trib.)
50
100
El
Drains (intercept g.w.)
25
50
Drains (Other) Foundation
10(5)
20(10)
Drywells
20
25
Suction line 222(2)
100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5. 02).
3 As defined in 3 10 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland
bylaws
1600 Osgood Street, North Andover, Mosso(husetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
AS -BUILT CBECKLIST
LOT NUMBER, STREET NAME
ASSESSORS MAP I & PARCEL NUMBER
LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
ORIGINAL STAMP & SIGNATURE
IWERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
LOCATION & ELEVATIONS OF BENCHMARK USED
lift
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41W
Ir
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Olt
Jv
4V- 7t
j�C"g,
tz, 4,
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FINAL GRADE INSPECTION
Date:-
a"LOAMED?
La-�SEEDED?
Li COVER PER PLAN?
/P'/,, c -he -c -k
G�
ddir
&
t
lot ot
1-0
Ilk
oil
I'd
da -
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Map -Block -Lot
Commonwealth of Massachusetts - I - 07. - A- - 0 - 11 - 6 --------
Permit No
Board of Health BHP -2007-0125
North Andover - FEE
" -4-11 ... P.I. 4)/Z)U.UU
IS.." ... F.I. ------------------------
SAC 0 Disposai Works Construction Permi
Permission is hereby granted -Robert K-.- Daigle, jr ---------------------------------------------------------------------------------
to (Repair) an individual Sewage Disposal System.
at No 93 RALEIGH TAVERN LANE -------------- --- ---------------------------------------------------
--------------------------------------------------- s Construc tion Permit No. BHP -2007-012 Dated Ma, 18, 2007
r- -, � y ---------------------
as shown on the application for Disposal Work ------------ q
----------- ---------------- --------------------
Board of Health
issued On: May --1 8-2007 ----------------------------- - ------------
--------------------- ----------
05/09/2007 10:57 9786888476 HEALTH
Application for Septic Uisposal SVstern
Construction Permit - TOWN OF
fIRT14 ANTT-%nAFP'P MA AIQAr,
PA E 7 /02
TODAY 2ATYEE � 4P
Omponent
ImpoManit:
Whon fillitiq out
,
f -
A fication is hereby made for a permh- to;
0 Construct a new on-site sewage disposal system*
RECEIVED
RE EIVED
orrm nn th e
CO(npi.1te
.e, jjq
,e
only (lie tab key
Repair or replace an eKisting on-slite sewage, disposal syst.em*
i
MAY ;7
17 200
a
LHEALTH
to move your
rursor .. do not
El Repair or replace an ex�slthng system component – What? __-- -
- —
use the reiJim
key,
0 T
TOWN OF NORTH ANDOVER
A. Facility 1091mation DEPARTMENT
:
. . ......... .... ... ..... . .. ....
2, *TYPE OF 3EPTIC SYSTEM*�
Fj Pump 0 Graqjtly (choose on--e--)-
Pump system, attach copy of electoca�
permit to appoication—
Conventionai 8 yStern (p�pe and %tone systeM)
FU Infiltrator or Siodiffuser (Gravel -Less) (Attach 3 cOPY Of
your certification to InStall t
C. I Pressure OistiribuUon S.A.S. (No ID -sox) (Attach Draft Maintort3nice
b type Of System.
r
. Agreem
-LP
rtt)
nt)
FA . ressure Dosed (D -Box Presen,11.) S.&S.
2. Owner Information
n CL
... . .........
Name,
Addre7s (if d6i
.......... ..... ... ..
City/Town A4 6)
7�6-6 d
...........
C7 3,) ........... ... .
tolop one NUMhof
3. Instayer Pinformation
lebb"'r 7� k
bA4
N A 1,11 Al
A 'I rc
d reii, 9-- . ... ...
VIA
G �F-3 -3 - C eW
4- Pes&qoier Info-rmation
n, C-,
A C) i Ire.% r,
deeil-T( V -e
Name of Com'P-'i"ny"'-
0
S/JO ... I ... 6114011cel—f
ip Code
f'F,116�nF,*"`f�-jm- ber (CP11 Phone # 11Y�Q'S�;Eje
Nam('O Compin
21�-
1 Z-4--
/Ua CA--�
A)01
Staff"
7 Code
Y
Telophone NUM6er . .....
Application for 1)ISPO'll SY-I.Orrl Cnnotructian permit page 1 of2
05/09/2007 10:57 9786888476
41 ConStruction
ORTHAI
.'emu,
PAGE 2 OF 2
HEALTH
it - TOWN ap
A. Facility lnfnrmmf,-,,n cQntinued....
!XR�S�UIIWIM ErResidential Dwelling or 13COrnmercial
Agreement
PAGE 01/02
TO'DAYS �DATE_
$ 250.00 — Full Repair
$125.00 - COMPonent
rh@ Undersigned agrees to ensure the construction and Maintenance of the Are -described
on-site sewage disposal system in accordance with the provisions of Vile S of the
Environmental Code, as wall as the Local Subsurface Disp s I R gulat,
, and not to place the system in operation until a Certificate Of COMPlIfince has
North Andover 0 a 0 Ons for the Town Of
been issued by this soard 6f Health,
"Pr)
Application Approved By� (Board of Health Representative)
'Kam
Application Disapproved for the following reasons:
. ........ ... ..... ....... .. . ....... . ..... . ....... ._..._ . ................ ...........
For Office Use Only:
.I. Fee Atm, cbed? YCS NQ__
2 Proje c t Af
.WggC., obU
ff
at,
on F0. -M A trachedp
YC52 No
4. FOMdarion As-BIilt? (,;..W construction ronly).. j Yes )VO Z.
(same Sc2le as approvedpl,111) Yes Nq._
9- FIOOtPlansP (now construction only).
Y'"_ No
Application fOr Disposaj SYMeM Construction Permit - PagG 2 Of 2
SEPTIC SYSTEM IT�STAL�ER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(Address of septic systa) Forplansby —kenoln-da-w-i
Relative to the application of ?0 bee- - k. L
installer's name) V_ And dated
Dated 07
L
/(I oday's date)
With revisions dated
I understand the f6flowing obhgations for management of this project:
(EnKneer) U (J
(Unginal date)
(Last revised date)
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans pjjor to
performing any work on a site. -1must have the a1212roved plans and the permit on site when any work
being done. is
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection, without co=letion of the items in accordance
with Title 5 and the Board of Health Re2ulations m9i result in a $50.00 fin -e being levied against me and/or
my cornpaiiy_.
a. Bottom of Be - Generally, this is the first (V� inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspecti n - Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdet)t(o),townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which *installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade - Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simPle excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, sialficant fines to all persons involved ate also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other
components.
As the installer, I understand that I am solely responsible for the installation of the system as 12er the
approved 121ans. No instructions by the homeowner, general contractor, or agy other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: h,-, r, "700,q— (Today'd-Date)
1�e—o
(Narne- — tint gne
e — e
0/1 oil (I
Commonwealth of Massachusetts Official Use Only
Permit No. 77 -5— 7 4/"
Department of Fire Services I
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS I[Rev. 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRJNT IN INK OR TYPE ALL INFORMATION) Date: ?- lcl-o -)
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) '13 Anfle�C(L —fo-,je(-,N L,-\,
Owner or Tenant
Telephone No.
Owner's Address Ta u -ec-
Is this permit in conjunction with a building permit? Yes No E] (Check Appropriate Box)
Purpose of Building e2�A Utility Authorization No.
Existing Service 1610 Amps Pct 0 /,;L oVolk Overhead El Undgrd 2 No. of Meters i
New Service — Amps Volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
This certifies that
has pennission
Date .....
.TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
)e--
7,0-r,,F Z /,r"&
................ ..... ........
perforni ......... 4 1 7(. .........
...... .............
A /" -
wiring in the lb�lding of ............ ��011e- E
................... 0 ....... ; ...........
at ...... �3 .7, �-zmwx
36-a-!a� — .1 031-7)�j-
Fee ..................... Lic. No, -,.,,,w_,, ........
�:�, North Andover
........... 01 .......... .....
ELEcmcAL iNspEcTo
Check #
detail Aesired, or as required by the Inspector of Wi.
7574 )y municiptl policy.)
with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner—,7� ��e� e performance of electrical work may issue unle
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: fNSURANCE [I BOND EJ OTHERE] (Specify:)
I certify, under the pains andpenallies ofperjury, that the information on this application is true and complete.
FIRM NAME: C O'n S -� C CA J, LIC. NO.: 9,&-4QtJ—j
Licensee: Signature LIC. NO.:
(If applicable, enter "exempt " in the license number I Bus. Tel. No.: 411!5 -
Address: /0 X�70* Coe-& I/ der 7-Zo 5, , A Alt. Tel. No.: 1 -7 J -
*Per M.G.L c. 147, s. 0-61, security work requires Department of Public—Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [I owner El owner's agen
Owner/Agent
Signature Telephone No._ PE"IT FEE. $
rollowinp, table mav he waived hv the In.vnprtnr nf W.
No. of Total
Transformers KVA
Generators KVA
id.
No. of Emergency Lighting
Battery Units
FIRE ALARMS
INo. of Zones
VoT.—W—Detection and
Initiating Devices
No. of Alerting Devices
K.W.
No. of Self -Contained,
Detection/Alerting Devices
Local F-1 Municipal 0 Other
7�—Cbnnjection
Siicurity Systems:*
No. of Devices or Equivalent
Data Wiring:
No. of Devices or Equivalent
Telecommunications Wiring:
No. of Devices or Equivalent
Date.:':�
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ......... ...............
has permission to perform .. ... ... ... .. ........................
wiringin the building of ...... ... ...... ................................................. ...........
. ....... 0 Aknd ver, Mass.
........ 7 . . ... ............. N rth
Fee(=:5'5�10 ............ Lic. No. .......... .............. ..... .... ................
Check# /01;/ LECTRIC SPE W C -E I �VE D-
-- - 7--
7410
Cq U� y 5 7� jz
C, /�
MAy 2 5 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Ma�j 25 2007 10:50 CREnTIVE BUILDERS 97888779GI
MAY -23-07 WED 01:35 Pfl INFILTRATOR SYST FAX NO, B60577 7001
SYS-FEIVIS INC
Environm
mly that
This is to cc
has salisfactorily, Completed the required tqrajn/_q6p1ogram for 16�jinstallation of
the INFILTRATOR" loachIng chamber sysiern for on-site Wastewater disposal
applications. This person is certified to inst 11 th INPILTRATOR chamber system
as set forth by the rules of the 'd
AI�X' M/ 'e��_ DePArtmeAt of Health.
67AT
Thiscertilicatiwpxplres on 4,(v
(nstaller Signature Infiltralior WRep senlat . 11v . e5S I . gnature
Corporare Office,
P,O 80 7158 - 9 BuSiness Park Rad - Did Gvbrook, CT 06475 * (860) 577-700D - Fax (860) 577�7001
wwwInfiffratmystains,com
Instal Ier Infil
Name (reint)
Business
Date: _4_Wff4_
Address-- A tit)
City � State / zip
County
Email
Phone Fax
Cell
Systems Installed �er year
Average Job Size (LF) - r
Installation Type (%) - Stone & Pipe _ Infiltrator Other
Gravel PricefTon Tons/IDOFT
Pipe Price/LF
Where do you gel your tanks and other s-�ptic malcriats fiorn?
Would you like 3 cost comparison done Would you like to schedule
using our product in the future? a derro of our product?
C1 Yes 0 No 171 Yes 11 No
Co,ilkstion uawtai -,d., oao�,,AG 2
RECEIVED
MAY 2 5 2007
TOWN O�- NORTH ANDOVER
HEALTH DEPARTMENT
P. 02
P.
TOWN OF NORTH ANDOVER T,4
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36
NORTH ANDOVER, MASSACHUSETTS 01.845
9-11K688.9540 - Phone
Susan Y. Sawyer, REHS/RS 978.688.8476 F . AX
Public Health Director E-MAIL: liealthdei.)t�'(.i',,,towiiofnorthaiidovei�.coni
WEBSITE:
SEPTIC PLAN SUBMITTAL FORM I-Rf7-171VED
Date of Submission:— Feb cnq FEB 2 8 2007
(N OF NORTH ANDOVER
Site Location: To J(f iq Ll-cfn No, Ald EA LTH DEPARTMENT
'J
Engineer: Ten in i -a otod T - T. �-7
0 -- o
New Plans? Yes Vf22�5PIan Check # Oncludes I't submission and one re-
review only)
Revised Plans?Yes $75/Plan Check #
Site Evaluation Forms Included? Yes L,— No
Local Upgrade Form Included? Yes &,-�No
Telephone#: Fax #: 302 bl 32
E-mail:— - I Y�'c
j
Homeowner
Name: oulds
Do A
OFFICE USE ONLY
When the sub ission is complete (including check):
Date stamp plans and letter
> Complete and attach Receipt
> L,.,'/.___Copy File; Forward to Consultant
> 1// Enter on Log Sheet and Database
AIV
NEw ENGLkNDENGINEEMG SERVICES, INC.
600 Osgood Street
lk—,Rtuilding 20 Suite 2-64
North Andover, MA 01845
Tel: (978) 686-1768 * Fax: (978) 327-6138 February 8, 2007
Project # 1278
Ms. Sue Sawyer
North Andover Board of Health
1600 Osgood Street
-j
North Andover, MA 01845 LFEB 2 8 2007
Re: 93 Raleigh Tavern Lane, North Andover
Local Health Bylaw Variance Request T'ov�'N OF NO
TOWN OF NORTH ANDOVER
HE R
HEALTH DE T�
ALT8 OsPARTMENT
Dear Ms. Sawyer,
The purpose of this letter is to request that the above referenced property be included in
the upcoming Board of Health meeting agenda to discuss the following variance:
Local Health Bylaw Variance ftuest
Reduction in offset distance between a leach bed and a wetland from 100 feet required to
5 1 feet.
If you have any comments or questions please do not hesitate to contact this office.
Sincerely,
Benjamin C. Osgood, r. P.E.
President
NEw ENGLANDENGINMMNG SERVICFS, INC.
600 Osgood Street
lk—,Building 20 SUite 2-64
North Andover, MA 01845
Ibl: (978) 686-1768 * Fax: (978) 327-6138
Ms. Susan Sawyer
North Andover Board of Health
1600 Osgood Street
No. Andover, MA 0 1845
Re: 93 Raleigh Tavern Lane, No. Andover
Local Upgrade Approval Request
Dear Ms. Sawyer,
February 27, 2006
Project # 1278
FEB 2 8 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
The purpose of this letter is to request that the above referenced property be included in
the upcoming Board of Health meeting agenda to discuss the following Local upgrade
approval request:
Local Upgrade Approvals Required:
Allow the use of a sieve analysis to determine loading rate in lieu of performing a
percolation test. Title 5, section 15.405(l).
If you have any comments or questions please do not hesitate to contact this office.
Sincerely,
/4
B/eljammC. Osgid, Jr. P.E.
President
.P. 4.
i '11y,
j�
L
IINWI.jj�'
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth f PA ssachusetts
City/Town of kro, - N over
Form 9A — Application for Local
I A A D .0 Q .9 7W
U p dWdb'A��roval
�HEALTOWN Ol- NORTH ANDOVER
TH DEPARTMENT
i- - __ �d
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.
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or noncontorming
septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CIVIR
5.404(l), is not feasible.
310 CMR 15.403(4) requires the system owner to provide a copy of the local upgrade approval to the
appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource
Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before
commencement of construction.
System upgrades that cannot be performed in accordance with 310 CIVIR 15.404 and 15.405, or in full
com pliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CM R 15.410
through 15.417.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved
capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CIVIR 15.000.
A. Facility Information
1. Facility Name and Address:
David & Virginia Foulds
Name
93 Raleigh Tavern Lane
Street Address
North Andover
City/Town
2. Owner Name and Address (if different from above):
Same as above
Name
City/Town
Zip Code
3. Type of Facility (check all that apply):
E Residential El Institutional
4. Describe Facility:
MA
State
Street Address
State
Telephone Number
EJ Commercial
Anstallation of a subsurface sewage disposal system
5. Type of Existing System:
El School
01845
Zip Code
[] Privy E] Cesspool(s) E Conventional 0 Other (describe below):
Form 9A Application for Local Upgrade Approval.doc - rev. 5/02 Application for Local Upgrade Approval* Page 1 of 4
A- 0.
Commonwealth of Massachusetts
City/Town of
Form 9A — Application for Local Upgrade Approval
o
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
A. Facility Information (continued)
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Leach Field
7. Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility:
B. Proposed Upgrade of System
unknown
gpd
440
gpd
440
gpd
1. Proposed upgrade is (check one):
El Voluntary F] Required by order, letter, etc. (attach copy)
El Required following inspection pursuant to 310 CMR 15.301:
Unknown
date of inspection
2. Describe the proposed upgrade to the system:
Install new septic tank, pump, and leach field. Tank includes Micro Fast Treatment Device.
3. Local Upgrade Approval is requested for (check all that apply):
F� Reduction in setback(s) — describe reductions:
F� Reduction in SAS area of up to 25%: SAS size, sq. ft. % reduction
El Reduction in separation between the SAS and high groundwater:
Separation reduction ft:
Percolation rate min./inch
Depth to groundwater ft.
Form 9A Application for Local Upgrade Approval.doc - rev. 5/02 Application for Local Upgrade Approval, Page 2 of 4
Commonwealth of Massachusetts
Q City/Town of
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
B. Proposed Upgrade of System (continued)
El Relocation of water supply well (explain):
Z Other requirements of 310 CIVIR 15.000 that cannot be met —describe and specify sections of the
Code:
DE A seive analysis was performed to determine loading rate in lieu of performing a percolation test per
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CIVIR 15.405(l)(i)(1). The soil evaluator must be a member
or agent of the local approving authorhjj�
High groundwater evaluation determined by:
Evaluator's Na ne (type or print) Signature Date of evaluation
C. Explanation
Explain why full compliance, as defined in 310 CIVIR 15.404(l), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CIVIR 15.000 is not feasible:
No other available location on lot.
2. An alternative system approved pursuant to 310 CIVIR 15.283 to 15.288 is not feasible:
Form 9A Application for Local Upgrade Approval.doc - rev. 5/02 Application for Local Upgrade Approval* Page 3 of 4
Commonwealth of Massachusetts
City/Town of
Application for Local Upgrade Approval
Form 9A
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
C. Explanation (continued)
3. A shared system is not feasible:
No other adiacent is available.
4. Connection to a public sewer is not feasible:
Public sewer is not available in the area.
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
El Application for Disposal System Construction Permit
El Complete plans and specifications
El Site evaluation forms
El A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CIVIR 15.405(2).
El Other (List):
D. Certification
1, the facility owner, certify under penalty of law that this document and all attachments, to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for submitting false information, including, but not limited to, penalties or fine and/or
imprisonment for deliberate violations."
2/27/06
Facility Owners Signature Date
Benjamin C. Osgood Jr., P.E.
Print Name
New England Engineering Services, Inc.
Name of Preparer
1600 Osgood St Bldg 20 Suite 2-64
Preparer's address
MA 01845
State/ZIP Code
2/27/06
Date
No. Andover
City/Town
(978)686-1768
Telephone
Form 9A Application for Local Upgrade Approval.doc - rev. 5/02 Application for Local Upgrade Approval* Page 4 of 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
Commonwealth of Massachusetts
City/Town of
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
Form 9A is to be submitted to the Local Board of Health for the upgrade of a failed or nonconforming
septic system with a design flow of less than 10,000 gpd, where full compliance, as defined in 310 CIVIR
5.404(l), is not feasible.
310 CM R 15.403(4) requires the system owner to provide a copy of the local upgrade approval to the
appropriate Regional Office of the Department of Environmental Protection, Bureau of Resource
Protection, Title 5 Permitting Program, upon issuance by the local approving authority and before
commencement of construction.
System upgrades that cannot be performed in accordance with 310 CIVIR 15.404.and 15.405, or in full
compliance with the requirements of 310 CIVIR 15.000, require a variance pursuant to 310 CIVIR 15.410
through 15.417.
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of
a new design flow to a cesspool or privy, or the addition of a new design flow above the existing approved
capacity of an on-site system constructed in accordance with either the 1978 Code or 310 CIVIR 15.000.
A. Facility Information
1. Facility Name and Address:
David & Virainia Foulds
Name
93 Raleigh Tavern Lane
Street Address
North Andover
City/Town
2. Owner Name and Address (if different from above):
Same as above
Name
City/Town
Zip Code
3. Type of Facility (check all that apply):
FEB 2 8 2007
TOWN OF NORTH ANDOVI
HEALTH DEPARTMENT
MA 01845
State Zip Code
Street Address
State
Telephone Number
Z Residential El Institutional El Commercial
4. Describe Facility:
Installation of a subsurface sewaae disoosal system
5. Type of Existing System:
L - Privy El Cesspool(s) Conventional
El School
[I Other (describe below):
Form 9A Application for Local Upgrade Approval.doc - rev. 5/02 Application for Local Upgrade Approval, Page 1 of 4
Commonwealth of Massachusetts
City/Town of
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
A. Facility Information (continued)
6. Type of soil absorption system (trenches, chambers, leach field, pits, etc):
Leach Field
7. Design Flow per 310 CMR 15.203:
Design flow of existing system:
Design flow of proposed upgraded system
Design flow of facility:
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
unknown
gpd
440
gpd
440
gpd
El Voluntary R Required by order, letter, etc. (attach copy)
El Required following inspection pursuant to 310 CMR 15.301: Unknown
date of inspection
2. Describe the proposed upgrade to the system:
LA!P�L-L j;f.P-nC T�41UX. P,)AA.P, 416� Z.9A-CH r44F&P.
I-AAJ 0, Ij C j -o x, Cg> P". cloc;' r—#+S-f 7-46457-A4 C- A-17 Pt -.4 C. e
3. Local Upgrade Approval is requested for (check all that apply):
F-1 Reduction in setback(s) — describe reductions:
El Reduction in SAS area of up to 25%:
SAS size, sq. ft. % reduction
El Reduction in separation between the SAS and high groundwater:
Separation reduction
Percolation rate
Depth to groundwater
ft.
min./inch
ft.
Form 9A Application for Local Upgrade Approval.doc - rev. 5/02 Application for Local Upgrade Approval, Page 2 of 4
Commonwealth of Massachusetts
City/Town of
Application for Local Upgrade Approval
Form 9A
o
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
B. Proposed Upgrade of System (continued)
D Relocation of water supply well (explain):
Other requirements of 310 CIVIR 15.000 that cannot be met— describe and specify sections of the
Code:
A seive analysis was performed to determine loading rate in lieu of performing a percolation test per
DEP Policy BRP/DWlVl/PEP-P00-4
If the proposed upgrade involves a reduction in the required separation between the bottom of the soil
absorption system and the high groundwater elevation, an Approved Soil Evaluator must determine the
high groundwater elevation pursuant to 310 CIVIR 15.405(l)(i)(1). The soil evaluator must be a member
or agent of the local approving authority.
High groundwater evaluation determined by:
Evaluator's Name (type or print) Signature Date of evaluation
C. Explanation
Explain why full compliance, as defined in 310 CIVIR 15.404(l), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CIVIR 15.000 is not feasible:
No other available location on lot.
2. An alternative system approved pursuant to 310 CIVIR 15.283 to 15.288 is not feasible:
An alternative system would be const prohibitive.
Form 9A Application for Local Upgrade Approval.doc - rev. 5/02 Application for Local Upgrade Approval* Page 3 of 4
Commonwealth of Massachusetts
City/Town of
Form 9A - Application for Local Upgrade Approval
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.
C. Explanation (continued)
3. A shared system is not feasible:
No other adiacent is available.
4. Connection to a public sewer is not feasible:
Public sewer is not available in the area.
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
El Application for Disposal System Construction Permit
0 Complete plans and specifications
El Site evaluation forms
El A list of abutters affected by reduced setbacks to private water supply wells or property lines.
Provide proof that affected abutters have been notified pursuant to 310 CMR 15.405(2).
El Other (List):
D. Certification
1, the facility owner, certify under penalty of law that this document and all attachments, to the best of my
knowledge and belief, are true, accurate, and complete. I am aware that there may be significant
consequences for submitting false information, including, but not limited to, penalties or fine and/or
imprisonment for deliberate violations."
FaciAf Owner's Signatu Date
��r
Benjamin C. Osgood Jr., P.E.
Print Name
New England Engineering Services, Inc.
Name of Preparer
1600 Osgood St Bldg 20 Suite 2-64
Preparer's address
MA 01845
State/ZIP Code
2-J z -7/377
Date
No. Andover
City/Town
(978)686-1768
Telephone
Form 9A Application for Local Upgrade Approval.doc - rev. 5/02 Application for Local Upgrade Approval, Page 4 of 4
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"0 il and Plant Nutrient I esting Lab
West Experiment Station
University of Massachusetts
Amberst, MA 0 1003
413.545.2311
http://www.umass.edu/plsoils/soiltest
TEXTURAL ANALYSIS RESULTS
Customer Name: New England Engineering Services
1600 Osgood St., Suite 2-64
North Andover, MA 01845
Sample ID: 69781
Customer Designation: 93 Raleigh Tavern Lane, No. Andover
USDA SIZE FRACTIONS
main Fractions Size (mm) Percent
Sand
0.05-2.0
61.4
Silt
0.002-0.05
30.4
Clay
< 0.002
8.1
Total
< 2.0
100.0
Sand Fractions Size (mm) Percent
Very Coarse
1.0-2.0
7.8
Coarse
0.5-1.0
9.6
Medium
0.25-0.5
13.1
Fine
0.10-0.25
20.6
Very Fine
0.05-0-10
10.3
0.05
#270
61.4
Silt Fractions
Size (mm)
Percent
Coarse
0.02-0.05
13.7
Medium
0.005-0.02
11.4
Fine
0.002-0.005
5.3
30.4
USDA Textural Class = sandy loam
Gravel Content
COMMENTS:
01/02/07
PERCENT OF WHOLE SAMPLE PASSING
Size (mm) sieve #
2.00
#10
B8.5
1.00
#18
81.6
0.50
#35
73.1
0.25
#60
61.5
0.10
#140
43.3
0.05
#270
34.1
0.02
20 um,
22.0
0.005
5 um
11.9
0.002
2 urn
7.2
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Thursday, March 22, 2007 9:46 AM
To: Daniel Ottenheimer (E-mail); Marianne Peters (E-mail)
Subject: 93 Raleigh Tavern Lane
Importance: High
Hello,
This property is on our agenda tonight for the Variance and LUA requests. Can you give me an update on the status of the
plan review? I know someone is going to ask me ....... Thanks!!
Awl R10041lds,
^1*0-oa Q
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA o 1845
'2978.688-9540 - Phone
A 978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofilorthandover.com
93 Raleigh Tavem Lane
DelleChiaie, Pamela
From:
McKay, Alison
Sent:
Thursday, March 22, 2007 11:35 AM
To:
Sawyer, Susan
Cc:
DelleChiaie, Pamela; Merrill, Pamela
Subject: RE: 93 Raleigh Tavern Lane - Agenda Item - 3.22.07
Hi Susan,
Page I of 2
The wetland line is all set on RTL. The Commission just continued the last meeting pending DEP review. I have
a decision drafted for next week's meeting of the 28th. I plan on issuing the decision as soon as next Thursday
after our meeting upon the Commission closing the public meeting on Wed.
Let me know if you have further questions or concerns in this regard.
Alison
----- Original Message -----
From: Sawyer, Susan
Sent: Thursday, March 22, 2007 11:27 AM
To: McKay, Alison
Subject: FW: 93 Raleigh Tavern Lane - Agenda Item - 3.22.07
Alison,
93 RTL is on our agenda for tonight. I understand they have filed with your office. Do you have any
comment on the wetland line? Has it been reviewed yet?
thx
Susan
----- Original Message -----
From: DelleChiaie, Pamela
Sent: Thursday, March 22, 2007 10:56 AM
To: Sawyer, Susan
Subject: FW: 93 Raleigh Tavern Lane - Agenda Item - 3.22.07
Hi Susan,
FYI below...
----- Original Message -----
From: Dan Ottenheimer [mailto:info@millriverconsulting.com]
Sent: Thursday, March 22, 2007 10:45 AM
To: DelleChiaie, Pamela; 'Marianne Peters (E-mail)'
Subject: RE: 93 Raleigh Tavern Lane
Pam,
Plan review was completed yesterday. The design engineering has no major issues, but there were a few
small items which were outstanding. I called New England Engineering yesterday and left a message
about what they needed. I said if they could get this to your office and our office it would move things
along rather than having to issue a plan disapproval letter for these items.
They needed: a revised Application for Local Upgrade Approval, the sieve analysis report, and a draft O&M
agreement for maintenance of the treatment unit and the pressure distribution system.
3/27/2007
93 Raleigh Tavern Lane
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Tuesday, April 10, 2007 11:13 AM
To: Daniel Ottenheimer (E-mail)
Cc: Sawyer, Susan
Subject: FW: 93 Raleigh Tavern Lane
Page I of 2
Hi,
Kim from Ben's office said she sent these directly to you. Are you all set? When can we expect the plan review
letter? Thank you.
Pamela
----- Original Message -----
From: Dan Ottenheimer [mailto:info@miliriverconsulting.com]
Sent: Thursday, March 22, 2007 10:45 AM
To: DelleChiaie, Pamela; 'Marianne Peters (E-mail)'
Subject: RE: 93 Raleigh Tavern Lane
Pam,
Plan review was completed yesterday. The design engineering has no major issues, but there were a few small
items which were outstanding. I called New England Engineering yesterday and left a message about what they
needed. I said if they could get this to your office and our office it would move things along rather than having to
issue a plan disapproval letter for these items.
They needed: a revised Application for Local Upgrade Approval, the sieve analysis report, and a draft O&M
agreement for maintenance of the treatment unit and the pressure distribution system.
Hope that helps,
Dan
Mill River
consulting'
Daniel Ottenheimer, President
Mill River Consulting, Inc.
On -Site Wastewater Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www.millriverconsulting,com
dano@rnillri.vereonsulting.pQrn
From: DelleChiaie, Pamela [mailto:pdellechiaie@townofnorthandover.com]
Sent: Thursday, March 22, 2007 9:46 AM
To: Daniel Ottenheimer (E-mail); Marianne Peters (E-mail)
Subject: 93 Raleigh Tavern Lane
Importance: High
Hello,
4/10/2007
93 Raleigh Tavem Lane
Page 2 of 2
This property is on our agenda tonight for the Variance and LUA requests. Can you give me an update on the
status of the plan review? I know someone is going to ask me ....... Thanks!!
j6.-s,(Ro#,=ds,
AMNAM ZP.0A0.0eW1,aA0 (D
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA o 1845
2978.688-9540 - Phone
A 978.688.8476 - Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
4/10/2007
t
Page I of I
DelleChiaie, Pamela
From: Dan Ottenheimer [info@millriverconsulting.com]
Sent: Monday, April 16, 2007 12:46 PM
To: Neeseng@aol.com;'Dan Obrzut'; Grant, Michele; Marianne Peters; DelleChiaie, Pamela; Sawyer,
Susan
Subject:,O Raleigh Tavern Lane
-0
North Andover Health Department & New England Engineering Services,
We have received and reviewed the supplemental information provided for 97 Raleigh Tavern Lane. Thanks for
sending them along.
We had asked to have the sieve analysis included and did not see that in what was provided. Please provide that
report. Additionally, the Form 9A provided was missing page 4 and the document also was the older version of
the form. I have attached the newer version for your use.
Thanks,
Dan
Mill River
consulting
Daniel Ottenheimer, President
Mill River Consulting, Inc.
On -Site Wastewater Management Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www.millriverco.nsulting.com
dano@millriverconsulting.com
4/27/2007
4
93 Raleigh Tavem Lane
DelleChiaie, Pamela
From:
McKay, Alison
Sent:
Thursday, March 22, 2007 11:35 AM
To:
Sawyer, Susan
Cc:
DelleChiaie, Pamela; Merrill, Pamela
Subject: RE: 93 Raleigh Tavern Lane - Agenda Item - 3.22.07
Hi Susan,
Page I of 2
The wetland line is all set on RTL. The Commission just continued the last meeting pending DEP review. I have
a decision drafted for next week's meeting of the 28th. I plan on issuing the decision as soon as next Thursday
after our meeting upon the Commission closing the public meeting on Wed.
Let me know if you have further questions or concerns in this regard.
Alison
----- Original Message -----
From: Sawyer, Susan
Sent: Thursday, March 22, 2007 11:27 AM
To: McKay, Alison
Subject: FW: 93 Raleigh Tavern Lane - Agenda Item - 3.22.07
Alison,
93 RTL is on our agenda for tonight. I understand they have filed with your office. Do you have any
comment on the wetland line? Has it been reviewed yet?
thx
Susan
----- Original Message -----
From: DelleChiaie, Pamela
Sent: Thursday, March 22, 2007 10:56 AM
To: Sawyer, Susan
Subject: FW: 93 Raleigh Tavern Lane - Agenda Item - 3.22.07
Hi Susan,
FYI below
----- Original Message -----
From: Dan Ottenheimer [mailto:info@millriverconsulting.com]
Sent: Thursday, March 22, 2007 10:45 AM
To: DelleChiaie, Pamela; 'Marianne Peters (E-mail)'
Subject: RE: 93 Raleigh Tavern Lane
Pam,
Plan review was completed yesterday. The design engineering has no major issues, but there were a few
small items which were outstanding. I called New England Engineering yesterday and left a message
about what they needed. I said if they could get this to your office and our office it would move things
along rather than having to issue a plan disapproval letter for these items.
They needed: a revised Application for Local Upgrade Approval, the sieve analysis report, and a draft O&M
agreement for maintenance of the treatment unit and the pressure distribution system.
4/27/2007
16
93 Raleigh Tavern Lane
Hope that helps,
Dan
M River
C 0 n S Ujilp-9
Daniel Ottenheimer, President
Mill River Consulting, Inc.
On -Site Wastewater Managenient Services
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www.millriverconsulting.com
dano@millr.iv-e-rconsulting.com
From: DelleChiaie, Pamela [mai Ito: pdel lech ia ie@townofnortha nclover.com]
Sent: Thursday, March 22, 2007 9:46 AM
To: Daniel Ottenheimer (E-mail); Marianne Peters (E-mail)
Subject: 93 Raleigh Tavern Lane
Importance: High
Page 2 of 2
Hello,
This property is on our agenda tonight for the Variance and LUA requests. Can you give me an update on
the status of the plan review? I know someone is going to ask me ....... Thanks!!
t9ow(RagazAk,
pmwoea
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA o1845
2978.688-9540 - Phone
A 978.688.8476 - Fax
http:././www.towpofnorthandover.com
healthdept@townofnorthandover.com
4/27/2007
TOWN OF NORTH ANDOVER
Office of COM M UNITY DEVELOPM ENT AND SERVI CES 0 0
'�-
HEALTH DEPARTMENT
1600OSGOOD STREET; BUILDING 20; SUITE2-36
NORTH ANDOVER, MASSACHUSETTS 01845
Susan Y. Sawyer, REHS, RS
PublicHealth Director
APPL I CATION FOR SOIL TESTS
978.688.9540 ..Phone
978.688.8476 -- FAX
healthde)t Qt!pw thandover.corn
nof nor'
Aivtownofnorthandover.corn
DATE: MAP& PARCEL: - io7A AJ il�.
ia -C --
LOCATION OF SOIL TESTS. q3 Ta (69 h ` ve(n LM
OWNER I'a FLOIdS (Contact#. bLL-111'op
: J)a6d VL�
APR-ICANT: Contact #.
ADDRESS. q3 71alriqY1 '10'varl LUC �o- "Vtv"'
& L I' M A
ENGINEER: n3owd T,(. Contact# Tj-WV1q10R
CERTIFIED SOIL EVALUATOR: Tw�(W;111
lnterxWUseofLand: Residentiai Subdivision 6;;SZng�IeF �flyHo�me'�Commerciail
IsThis-. Repair Testing: Undeveloped Lot Testing:_ Upgrade for Addition:
7�—
In the Lake Cochchewick Watershed? Yes No Ix
THE FOLLOWING MUST BE INCLUDED WITH THISFORM
> Proof of land ownership (Tax bill, or letter from owner permitting test)
> 8.5-x 11 -Plot plan& Location of Testinq (Please indicateteEt pit siteson the plan)
> Fee of $425.00 per lot for new construction. Ths ooversthe minimum two deep holes and
two percol ati on tests requi red for each di sposail area Fee of $360. per lot for repairsor up -grades.
GENERAL INFORMATION
> Only Certified Soil Evaivatorsmay perform deep hole inspections
> Only Masis. Registered Sanitariansand 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 lead two deep holes and at lead one percolation test, at thediscretion of theBOH
representative.
> Full payment vvill be required for ail additional testswithin 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
shawi ng the location of ail I tests (i nd udi ng aborted tests).
> Within 60 days of testing soil evaluation f orms; shall besubmitted.
Please Do Not Write Below This L ine
N.A. Conservation Commission Approval Date:
Signature of Conservation Age�t
Date back to Health Departmert: (starnp in): &
WL011(AWA5 K Wk Ct- fKDp"�K111. 6F Pool
P'4'(t- 6f tt?bt U-Waoot — rwr�- la�tv a, 6� TP5 t
wilt �Jau-�C' -� j�� L01 *6-tl'
7
N
ZOO
Ae
jfA
SA
0-9
N-Fz . . . . . . ..............
pvr�
r4
o 4 N
400ioe
.03
-0�
00
00 10
0
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V14v
.44
40
Page I of I
DelleChiaie, Pamela
From: Lisa LeVasseur [lisal@miliriverconsulting.com]
Sent: Friday, October 20, 2006 1:24 PM
To: Sawyer, Susan; 'Marianne Peters'; DelleChiaie, Pamela; dano@millriverconsulting.com
Subject: 93 Raleigh Tavern Soils
Are attached
Lisa LeVasseur
Mill River Consulting
Your Complete Sourcefor Onsite Wastewater Management
2 Blackburn Center
Gloucester, MA 01930-2259
978-282-0014 or 1-800-377-3044
fax: 978-282-0012
www.millriverconsulting.com
10/20/2006
� � �
u �
`� � . �, � � h.,
� � � ��
S' ` �,, � �
y ' -�: --,� ----- ---�-------- -----
'� , � � o.
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�`
S h � �
�` � �� � \�
���
""'
Page I of 1
DelleChiaie, Pamela
From: Marianne Peters [mpeters@millriverconsulting.com]
Sent: Thursday, September 21, 2006 9:44 AM
To: Dan Ottenheimer; 'Lisa Kozel LeVasseur'; Marianne; Grant, Michele; DelleChiaie, Pamela; Sawyer,
Susan
Subject: Re-perc for 93 Raleigh Tavern Rd. sched Sept. 29
The perc test that was aborted yesterday @ Raleigh Tavern Rd has been rescheduled to 9:00 a.m. on Sept. 29th;
so, we'll start the reperc @ 9:00, THEN go to Stonecleave (see my earlier e-mail saying Stonecleave was at
9:00 .... ), then to Wintergreen, etc.
Please call if questions.
I
Marianne Peters
Mill River Consulting
2 Blackburn Center
Gloucester, MA 01930
978-282-0014 ph
978-282-0012 fx
www.mill-r-iverconsulting.pom-
9/21/2006
Page I of I
DelleChiaie, Pamela
From: Marianne Peters [mpeters@millriverconsulting.com]
Sent: Thursday, September 28, 2006 11:48 AM
To: Dan Ottenheimer; 'Lisa Kozel LeVasseur'; Marianne; Grant, Michele; DelleChiaie, Pamela; Sawyer,
Susan
Subject: Soil Results - 93 Raleigh Tavern Lane
Attached are the soil results from 93 Raleigh Tavern Lane.
- - ----------------------------- --- ----
Marianne Peters
Mill River Consulting
2 Blackburn Center
Gloucester, MA 01930
978-282-0014 ph
978-282-0012 fx
www.millriverconsulting.com
9/28/2006
Wnr
uJQW-L- to �02.r
TOWN OF NORTH ANDOVER *jORTH
"'10 "
Office of COMMUNITY DEVELOPMENT AND SERVICES
0
HEALTH DEPARTMENT
400 OSGOOD STREET
44no
NORTH ANDOVER, MASSACHUSETTS 0 1845 HUS
S 14U
Susan Y. Sawyer, REHS, RS 978.688.9540 — Phone
Public Health Director 978.688.8476 — FAX
)c -P 10 2006
healthdept@,townofnorthandover.com
www.townofnorthandover.com
APPLICATION FOR SOIL TESTS
DATE: /3 '�a j &
LOCATH
OWNER:
MAP & PARCEL: -IL174 ldhl(o
APPLICANT: Ad4a 2 Contact 4:
ADDRESS:
ENGINEER: Adjd ontact
— G e::— c 2f M& -110 8
CERTIFIED SOIL EVALUATOR:
Single Family Home Commercial
Intended Use of Land: Residential Sub ivision
Is This: Repair Testing:_Iz Undeveloped Lot Testing:_ Upgrade for Addition:
In the Lake Cochichewick Watershed? Yes No 4�-�
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM
> Proof of land ownership (Tax bill, or letter from owner permitting test)
> &5" x 11 " Plotolan & Location of Testinz (please indicate testpit sites on the plan)
> Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of $360.00 per lot for repairs or 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 I"-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 Agplawl Date--- ;?C0 G
Signature of Conservation Agent:���.�.�
Date back to Health Department: (stamp in):
V W oe
IV
0
46
JL
CA
it
IN
k4
tj
6*0
0
49.
IV
Y
oil,
01
Page I of I
DelleChiaie, Pamela
From: Marianne Peters [mpeters@millriverconsulting.com]
Sent: Friday, September 15, 2006 9:39 AM
To: Dan Ottenheimer; 'Lisa Kozel LeVasseur'; Marianne; Grant, Michele; DelleChiaie, Pamela; Sawyer,
Susan
Subject: 0 Salem & Raleigh Tavern Soil Dates Scheduled
Soil Evaluations for the 2 following sites have been scheduled with Ben Osgood
0 Salem Street — Sept. 20 @ 9: 00 a.m.
93 Raleigh Tavern Lane — Sept. 20 @ 1:00 p.m.
As soon as the other 2 are booked, I'll let you know. Thanks.
Lo
Marianne Peters
Mill River Consulting
2 Blackburn Center
Gloucester, MA 01930
978-282-0014 ph
978-282-0012 fx
www.millriverco.nsulting.com
9/15/2006
jiaa
Azo �--.
Af
Az
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I Ll
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'� 41a
0
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
1. NAME
2. ADDRES PAU LOT NO. TEL. f
v
3. NO. OF BEDROOMS--- DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
3"o
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
-'Wassachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
A. Installation
-David Foulds
Owner
93 Raleigh Tavern Lane
Facility Street Address
North Andover
city
Mailing address of owner, if different:
93 Raleigh Tavern Lane
Street Address/Po Box:
North Andover MA
City State
978-681-8583 ext.
Telephone Number
B. Authorized Service Provider
Wastewater Treatment Services, Inc.
O&M Firm
44 rnmmercial Street
Street Address
Raynham
City
508-880-0223 ext.
Telephone Number
Michael Dillen
Certified Operator Name
MA
State
9394
RECEIVED
9
TOWN OF NORTH ANDOVER
01845 HEALTH DEPARTMENT
Zip
11173
Certification Number
C. Facility/System Information
29725 Bio-Microbics, Inc.
DEP ID Manufacturer ID
Installation Date
Approval Type:
08/22/2007
Start of Operation
General Provisional 0 Piloting
Seasonal Residence — used less than 6 mo./year: 0 Yes
D. Operating Information
02/20/2008
Inspection Date
2'
Sludge Level
DEPMicroFASTnew.doc - 3/25108
01845
Zip
02767
Zip
MicroFAST.5
Model Number
Remedial
No
lyrevious Inspection Date
Pumping Recommended Yes No
Page 1 of 3
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems 9394
E. Field Testing
Field Inspection
Color: gray 0 brown
other (specify):
Odor: musty earthy
Effluent Solids: 9 no some
pH 7.0 SU
V EV U
X clear 0 turbid
0 moldy
DO 5.6 mg/L.
2 or greater
0 offensive 0 turbid
Turbidity 9.06 NTU
40 or less
Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected
per Standard Methods and analyzed for BOD and TSS.
F. Sampling Information
Samples Taken 0 Influent n Effluent
Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use
nitrogen reducing systems:
440
gpd
Parameters sampled: OpH OBOD OCBOD OTSS OTN 0 Other (list below)
Other I
Other 2
G. Inspection and Maintenance
Other 3
Description of any maintenance performed since previous inspection and during this inspection
Cleaned Filter, , , Checked Splash Recycle,
Notes and Comments: House is for sale.
DEPMicroFASTnew.doc - 3/25/08 Page 2 of 3
-- W
M - assachusetts Department of Environmental Protection
Bureau of Resource Protection - Title 5
DEP Approved Inspection and O&M Form for Title 5 I/A
Treatment and Disposal Systems
9394
H. Certification
I certify: I have inspected the sewage treatment and disposal system at the address above, have
conducted the required Field Testing and/or sample collection in accordance with Standard Methods,
have completed this report and the attached technology operation and maintenance checklist, and
the information reported is true, accurate, and complete as of the time of the inspection. I am a
Massachusetts certified operator in accordance with 257 CMR 2.00.
Michael Dillen 02/20/2008
Operator Signature bate
System owner must submit this report, technology O&M checklist, and any required sampling results
to the local board of health and DEP as follows for each inspection performed:
Remedial Use — by January 31st of each year for the previous calendar year
Piloting Use — within 45 days of inspection date
Provisional Use — by March 31 s' of each year for the previous 12 months
General Use — by September 301h of each year for the previous 12 months
Send to:
Department of Environmental Protection
Attention: Title 5 Program
One Winter Street, 6 th Floor
Boston, MA 02108
DEPMicroFASTnew.doc - 3/25/08 Page 3 of 3
IF,
B 10
_F,
8450 Cole Parkway w Shawnee, KS 66227 m Phone 913-422-0707 u; Fax: 912-422-0808 9394
e-mail: onsiteabiomicrobics.com m www.biomicrobics.com m 800-753-FAST(3278)
FIELD INSPECTION & SERVICE REPORT
For Bio-Microbics Single Home FASTS System
INSTALLATION
AUTHORIZED SERVICE PROVIDER
93 Raleigh Tavern Lane
Installation Address: NorthAndover,MA 01845
Name: Wastewater Treatment Services, Inc.
Owner Name: David Foulds
Mail Address:
93 Raleigh Tavern Lane
NorthAndover,MA 01845
Mail Address: 44 Commercial Street
Raynharn, MA 02767
City State Zip
Phone: 978-681-8583 Fax e-mail
508-880-0233 508-880-7232
Phone Fax e-mail
INSTALLATION INFORMATION
Model No. Serial No. Date of Installation
Date of last pump out
MicroFAST.5 29725 08/22/2007
EQUI PMENT YES NO MAINTENANCE PERFORMED AND COMMENTS
Electrical Panel(s)
Visual Alarm Operating X
Audio Alarm Operating X
(if present)
Blower(s)
Air Inlet Filter Clean X
Blower Hood Vents Clear X
Excessive Noise X
Excessive Vibration X
Treatment unit(s)
Unusual Odor X
Pumpout Required: X
Primary Settling Zone 2"
Aerobic Treatment Zone 2"
EFFLUENT (optional) LIMIT RESULT
Estimated Daily Flow 440 gpd.
pH (Standard Units)
Color Clear
Temperature 46.8
Odor Earthy
Comments: House is for sale.
TECHNICIAN
SERVICE DATE
Michael Dillen
02/20/2008
March 25, 2008
North Andover Board of Health
1600 Osgood Street
North Andover, MA 01845
Attention: Health Agent
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
REdE-1-V-E—D
APR 0 9.2008
7 -OWN OF MO
HEALTH D�ERTH ANC)OVER
Reference: FASTO Wastewater Treatment System - Serial Number: 29725
Attached please find the Field Inspection & Service Report with field test results for
services performed on 02/12/2008 at the property of David Foulds located at 93 Raleigh
Tavern Lane - North Andover, MA.
Please call if you have any questions or require additional information.
Sincerely,
Wastewater Treatment Services, Inc.
Service Department
Enclosures
Copy to: David Foulds
Massachusetts DEP