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Home My WebLink AboutSeptic Plan Submittal Form - Miscellaneous - 500 BOXFORD STREET 2/28/2020 TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSCOOD STREET; SUITE 2035 NOR-1.11 ANDOVER, MASSACHUSETTS 01845 978.688.9540— Phone 978.688.8476—FAX E-MAIL: healthdept(�,northandoverma.gov WEBSI"TE: http://www.northandovenna--ov SEPTIC PLAN SUBMITTAL FORM Date of Submission: Site Location: 5049 Engineer: New Plans? Yes V" $275/Plan Check # 12D (includes I't submission and one re- review only) Revised Plans?Yes $125/Plan Check# RECEIVED Site Evaluation Forms Included? Yes Wo'-" No JUN p j 2016 Local Upgrade Form Included? Yes No TOWN OF NORTH ANDOVER Aq/L G. A-'e4a LC--DV HEALTH DEPARTMENT Telephone#: 976'do A -3 0 2 8 Fax #: ,�j� �+,/ E-mail:_ �✓"��7.� G' ��ca/ j/y/''/ 'z O� . JcJ�J" Homeowner Name: 29��A) OFFICE USE ONLY When the submission is complete (including check): Date stamp plans and letter Complete and attach Receipt Copy File; Forward to Consultant Enter on Log Sheet and Database Commonwealth of Massachusetts City/Town of North Andover Percolation Test Form 12 i Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used but: the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. filingng'mut forms is wnen A. Site Information out on the computer, use ony the tab Michael Donovan, Thomas$Catherine Donovan key to rrrove your Owner Name cursor=do not 500 Boxford Street-Map 105C Lots 41 &42 �Ci d 2 01 use the return — _-- key: Street Address or lot 0 North Andover MA 01845 City/Town State — Zip Code Contact Person(if different from Owner) Telephone Number " B. Test Results 1212115 11,00 am. 1212l15 11:00 a.m. Data. Time Date Time Observation Hole# Perc 3 Perc 4 Depth of Perc 50" 5616 Start Pre-Soak I t:45 12:29 End Pre-Soak 12:00 12:.44 Time at 12° 12:00 12:44 Time at 9" 1204 �. 12:46 Time at 6" 12:08 _ _w 12:48 Time(9"-6") 4 Mins _ _- 2 Mlns Rate(Min./Inch) <2 Mln./Inch <2 Min./Inch" ----- Test Passed; ® Test Passed. Test Failed-, ❑ Test Failed: Q Steve Eriksen. Test - -- Performed eyi Issac Rowe-North Andover Board of Health --- - Board of Health Witness Comments: t5form12 doc•08/15 Perc Test•Page 1 of 1 Commonwealth of Massachusetts N City/Town of Noah Andover -. Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Thomas&Catherine Donovan - _.__ Owner Name "-- -- 500 6oxford Road Map 105G Lot 42 Ma�wwt;r Street Adores, _ --- North Andover Ma. 01845 _ally - — State by Code B. Site Information 1. (Check one) ® New Construction ❑ Upgrade ❑ Repair 2. Soil Survey Available? ® Yes ❑ No If yes: Web Soil Survey 2638 Hinckley Loamy Sand Source $oil 4ap Unit Slope& Droughtiness Sal Name Soil t irnitatiom Glacial Outwash Outwash Plain feologic/Parent Material Landform 3. Sufficial Geological Report Available?❑ Yes ® No If yes: YSar Publir&neW.5ource Pudlioatwn scale map unit 4. Flood Rate Insurance Map Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes No If Yes,continue to*5. 5. Within a velocity zone? ❑ Yes ® No 6. Within a Mapped Wetland Area? ❑ Yes ® No MassGIS Wetland Data Layer 7. Current Water Resource ConditionsyVptond Typo (USGS): 12/15 Range: ❑ Above Normal ❑ Normal 2 Relow Normal MwWYear 8. Other references reviewed: t5form 11 test 3 and 4•rev.8J1.5 Form 11-$oil$WWbility A*gpgprrtent forOn•Site Sewafla Disposal •Pqr.1 of a Commonwealth of Massachusetts a , City/Town of North Andover Form 11 - Soil Suitability� ty Assessment for On-Site Sewage Disposal 04�r�- j` C. On-Site ReVieW (minimum of two holes required at every proposed primary and reserve disposal area) Deep Observation Hole Number: DH-3 12/2115 11:00 a.m. Rain Rate Tame Weather ---- 1. Location Ground Elevation at Surface of Hale: See Plan Latitude1ongitude: 42 40 04N / 71 03 0.68W feet Description of Location; Existing single family lot -shown on the plan as Lot 2 Test 3 _ 2. Land Use Cleared backyard area None 0.3a� (a.g.,woodiand,agric uitural field,vacant lot,etc.) Surf cv.Stonec{e_g.,—Cobbles,zto ,botiltlgrF,p!o•) 0-30 l°�) Grass, rubus and multiflora rose Outwash plain Toeslope Vegetaticxt (ar�dr4rrt� Porrpion on Landscape,(su.UK BS,FS.TS) 3. Distances from: Open Water Body >50 ft. Drainage Way >50 ft. Wetlands >50 ft. feet feet feet. Property Line > loft. Drinking Water Well > 100 ft Other feat feet — tee 4. Parent Material. Glacial Outwash Unsuitable Materials Present. Q Yes No If Yes. ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) Q WeathOred/Fractured Rock ❑ 500roa S. Groundwater Observed: ❑ Yes ® No If yes: Depth weeping from Pit Depth Standing Woler in yoic Estimated Depth to High Groundwater. 73" inches elevation t5form11 test 3 and d-rev.a;15 Form 11—Soil Suitability Assess+npnt for On-Ste Sewsee Diepgsal -page 2 of 6 Commonwealth of Massachusetts City/Town of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal G. On-Site Review (continued) Deep Observation Hole Number: DH-3 Redoximorphic Features Coarse Frapmo Depth(in.) Soil HorizorV Solt Matrix:Color. m _.. 500 Texture %by Volume Soil Layer Most(Mansell) - (USDA) Soil Struawre Consistence Other Depth Color Percent Gravel Sbbles. (>Moisc) limes 04" ,Ap 10 yr 212 FSL Granular Friable 9-1 a" Bw 10 yr 4/4 FSL Weak Blocky Friable 18-84" C1 2.5y 514 73" T5 yr W 15% Med Co rse 400/6 Single Grain Loose j -- i Additional Notes: t5form11 test 3 ana 4,rev,8/15 Form 11—Soil Suitabibty Assessmer<t fqr on-a Sewage Dispo9al -Pagq 3 pf 6 Commonwealth of Massachusetts -j City/Town of North Andover 4� Form 11 - Soil Suitability Assessment for On-Site Sewage disposal C. On-bite Review (continued) Deep Observation Hole Number. DH-4 12015 _. 11:00 a.m. Rain Date Tine Weather 1. Location Ground Elevation at Surface of Hole: See Plan LatitudelLongitude; 42 40 04 N t 7103 0,68 W feet 2. Land Use Cleared backyard area None (e.g.,wacrdland.Agricultural field,vacant lot,eta) Sud 4w Stones(e.g.,cobbles,storms,bould, 0-3%D Grass, rebus and mult-Mora rose Outwash plain `ecc.} slop"(�1. geon �06SIOpe Vetati Lanotorm Position on landscape(SV SH,8-6,FS, 3. Distances from: Open Water Body >50 ft. Drainage Way >50 ft. feet Wetlands >50 ft. Property Line > 10 ft. Drinking Water Well >100 ft, t feet Other 4. Parent Material: Glacial Outwash teat feet --- Unsuitable Materials Present: ❑ Yes 0 No If Yes: ❑ Disturbed Sal ❑ Fill Material ❑ Impervious Layer(s) ❑ WeatfteredfFractured Rock ❑ Bedrock 5. Groundwater O¢served: ❑ Yes ® No if yes: _ Estimated Depth to High Groundwater. 78" Depth weeping horn P-R pops Standing Water in Hale inches elevation t5tonnl I test 3 snd 4•rev,8115 Form 11 Soil Suitability Assawnent for On-She S.ow#ge Disposal -Pago 4 of 8 Commonwealth of Massachusetts Citylrown of North Andover s Form 11 • Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Nurn0er. DH-4 Radoxirnorphic Features Coarse Fraww Depth(in.) Soil Hor¢on/Soli .Matrix:Color- Soil Texture %by Volume Soil Layer Moist(Mundell) __ _ (USDA) Soil Strutttae Consistence outer Depth Color Percent vel Cobbles Stones (Moist) 0-81, AP 10 yr 2/2 FSL -- Granular Friable: 8-18` Bw 10 yr 4/4 FSL Weak Blogky Friable 18-901, C1 2.5y 514 78 7.5yr 6/6 15% CS$115 30% Single Grain Loose Stratified 1 Additional Notes: t5forrnl t cest 3 and 4 rev.8/15 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal Psge 5 of a Commonwealth of Massachusetts w �� -- Cityffown of North Andover -V V Farm 11 - Soil Suitability ,Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: 00s. Hole#DH-3 Ops. Hole#DH-4 ❑ Depth observed standing water in observation hole fr�ches inches ❑ Depth weeping from side of observation hole inches inaaa Depth to soil redoximorphic features (mottles) 73" 78" ides inches -- - --_ ❑ Depth to adjusted seasonal high groundwater(So) (USES methodology) inches ; Index Wetl Number Reacting Data Sr,=So-[Sr X(OWo-OWrwc)/OWrj Obs. Hole# Sc. Sr OWc QWrW QWr Sn Obs. Hole# Sc Sr OWE OWE OINr Sh E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ® Yes ❑ No b. If yes, at what depth was it observed? Upper boundary. 18" Lower boundary. W inches inches c. If no; at what depth was impervious material observed? Upper boundary: Lower boundary: iru hes inches t5form11 tent 3 and 4•rev.i/15 FQun t 1—Sod Suitability Assessment for On-SiteSowap Disposal •Page 6 of 8 Commonwealth of Massachusetts C4frown of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: DH-6 1212/15 _ 11:00 a.m. _ Rain Date Time Weather 1. Location Ground Elevation at Surface of Hole: between test Latitude/Longitude: 42'40'04"N / 71'02' 0.68"W 3 and 4 2. Land Use Cleared backyard area None 0-3% (e.g.,woodland,agricultural field,vacant lot,eto.) Surface Stones(e.g,,cobbies,stones,boulders,etc) Slope(Yo) Grass, rubus and mulbflora rose Outwash Plain Toeslope Veget.won Larworm Position on"ndwapo(SU,SH,BS,FS, 3. Distances from: Open Water Body > 50 ft. Drainage Way >50 ft. Wetlands >50 ft. feet f"t foot Property Line > loft. Drinking Water Well > 100 ft Other feet feet feat 4. Parent Material: Glacial Outwash Unsuitable Materials Present: Cl Yes ® No If Yes- ❑ Disturbed Soil ❑ Fill Material ❑ Impervious Layer(s) ❑ YYeathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ® Yes ❑ No If yes: Estimated Depth to High Groundwater: 90" Depth Weeping horn Pit Depth Standing Water in Hole inches elevation taforml 1 test 5 and 6•rev. 8/15 Form 11--Soil Suitability Assessment for On-Site Sewag*Disposal •Page 4 cf 8 1` Commonwealth of Massachusetts City1rown of North Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: PH-6 Redoximorptk Features Coarse Fragments Depth(in.) Sail Horizon(Soil Matrix:Color• Soil Texture •/.6y Volume Soil Layer Moist(Munsell) (USDA) _ SailStrurAws Coam"ODC'N Other th Color srysnt naval Stones ("st) 0-8" Ap 10 yr 2/2 FSL Granular Friable 8-18" Bw 10 yr 4/4 FSL - Weak BlocKy Friable 18-105" C1 2.5y 514 90" 7.5yr 6/6 15% CS&G 30% 15% Single grain Loose Additional Notes: t5farml 1 test 5 and 6•rev.8f15 Form 11—Soil Suitability Assessment for On-Site Sewage Dwposai -page 5 of 8 Commonwealth of Massachusetts _ = City/Town of North Andover Farm 11 - Soil Suitability Assessment for On-Site $eWage Disposal D. Determination of High Groundwater Elevation 1. Method Used: Otis. Hole#DH-5 Obs. Hole 1;DH-o ❑ Depth observed standing "rater in observation hole inches v►ct�es - ® Depth weeping from side of observation hole gp° achas�---- inches E Depth to soil redoximorphic features (motues) 54" W ❑ Depth to adjusted seasonal high groundwater(Sn) riches (USGS methodology) ins index Well Number Reading Oats Sn=Sr—[Sr X(OWc—OWrr'U)/OWrj Obs. Hole# SC Sr OWe QWrV'a,r Oyyr Oas. Hole# Sc Sr OWc OWrnu OWr SO E. Depth of Pervious Material 1. Depth of Naturally Occurring Perviqu5 Material a. Does at least four feet of naturally occurring pervious material exist in ail areas observed throughout the area prapo4tw for the soil absorption system? ® Yes ❑ No b. if yes,at what depth was it observed? Upper bouncary. 1$" Lower boundary: 105" c- If no, at what depth was impervious material observed? Upper bouncary: Loww boundary: inrhgc iricnes t5iorrn i 1 test 5 and 6•rev.W15 Fans t 1—Soil S +yt Y.A§SaSstnerlt for Qa S, Sgwa,a Dlaposo •page 6 of a Commonwealth of Massachusetts Cityffown of North Andover Form 11 - Soil Suitability Assessment for On-Site SOWage Disposal F. Board of Health Witness Isaac Rowe Nortn Andover Name of Board pf Hea►th Wit4ess - -- — Bga[d of!-laaWt G. Soil Evaluator Certification I certify that I am currently approved 4y the Department of Environmental Protection pulOuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistenYwiktl the r4gWred traiNrIg,expertise iaN OwWrilync'e described in 310 CMR 15.017. I further certify that the results of my soil ev"jation,as Indicated in the Soil Exatuation Farm, are accurate and in accordance with 310 CMR 15.100 through 15.107. agaCNA i i r "' %� � 12/3/15 sianawra of al Evaluator Dave — Steven Eriksen WO/16 Typed of Printed Hama of Soil Evaluator 1 Licenses Expiration Date of Ltc$rtse Note: in accordance with 310 CMR 15.018(2)this form must be submitted to the approvulg authority within 50 Uys,.of the daW of field tasting,and to the designer and the property owner with Percoialion Tes,Form 12. t5iom111 test 5 and 6•raw.&15 Form 11-Soil Suitability,Asces"r*ior Qn-Site Saxaye Dispo&W •P%,7 of 6 Commonwealth of Massachusetts = ; Cityffown of Borth Andover Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Field Diagrams Use this sheet for field diagrams. 15form 1 1 test 3 end 4•rev.8115 Form 11—Soil Suita6Yity Assessment for Qn-Site Sewage Di$posel •Page a of 8