HomeMy WebLinkAboutMisc - Septic File - 64 Old Cart Way - Miscellaneous - 64 OLD CART WAY 6/7/2022 L.t fL
1
Commonwealth of Massachusetts
City/Town of
System Pumping Record - ,
S st p �..
. Y 9 Nor
Form 4 1 ;."N a ,� o0
DEP has provided this form for use-by local Boards of Health. Other forms may be used; but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left . i rear of ho s Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address � r� /^,� vv �•- �C��"7'v�- („)�
City/rown State Zip Code
I
2. System Owner:
Name
Address(if different from location)
City/Town State --_� �ipy Code
Telephone Number /I
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of f Syst���
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S.
Lowell Waste Water
SignAtufe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left t rear of Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address C �J v� " � lL ��►' � _
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
LA
1. Date of Pumping
p g 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst m: `,- � "`• �" ��
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License N[be.,
Bateson Enterprises Inc
Company APR 16 2013
7. Locationwhere contents were disposed: WN OF NORTH ANDOVER
G.�.S Lowell Waste Water EALTH DEPARTMENT
Sign tufe 9t Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 4/16/2013
This is to certify that the individual subsurface disposal system has been installed in accordance
with the provisions of Title 5 of the State Environmental Code:
Complete Repair and Construction of an
On-Site Sewage Disposal System
By: Todd Bateson
At:
64 Old Cart Wa
Map 107B Lot 0087
North Andover, MA 01845
The Wuance of this certi icate s not be construed as a guarantee that the system will function satisfactorily.
is ele Grant
Public Health Agent
COPY
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
,SSwCHU PUBLIC HEALTH DEPARTMENT RECEIVED
Community Development Division
1 r' 2013
TOWN OF NORTH ANDOVER TOWN OF NORTH ANDOVER
SEPTIC DISPOSAL SYSTEM—INSTALLATION CE _'-1 CATION HEALTH DEPARTMENT
The undersigned hereby certify that the Sewage Disposal System( constructed;( )repaired;
By:
(Print Name)
Located at: a/r) �
(Installation Address)
Was installed in conformance with the North Andover Board of Health approved plan,originally dated
and last revised on ,with a design flow of
`t 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 boon submitted to the Board of Health.
Bottom of Bed Inspection Date: `[ 2.Q 2Q
Engineer Representative(Signature)
And—Print Name yy, Q
Final Construction Inspection Dater J /
Engineer Representative(Signature)
And—Print.Name�-
r q
Installer: (Signature) Date: � 74d—
And—Print.Name
Enginer: imat" (Signature) Date: 27
And—Print Name
1600 Osgood Street, North Andover,Massachusetts 0184S
Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthandover.com
SUMMARY OF INVERTS BUILDING TIES
SEWER 0 FDTN. 220.77 BLDG. CORNER I A I B I c D NOTE: THIS PLAN & CERTIFICATION IS NOT
SEPTIC TANK IN 220.49 SEPTIC TANK OUT 121,8171.2 I I - - A WARRANTY OF THE SUBSURFACE DISPOSAL
SEPTIC TANK OUT 220.22 DIST. BOX 170.21115.01 1 - SYSTEM. IT IS A RECORD OF THE LOCATION
DIST. BOX IN 219.74 AND ELEVATION OF THE EXISTING SYSTEM
DIST. BOX OUT 219.55 COMPONENTS.
INV. IN CHAMBER 219.50
BOTT. CHAMBER 219.16
"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.
j,'Av,A4Jj/_ "041(z
SIGNATURE OF DESIGNER DATE
jH OF
VLAOIMWM L yG
NEMICHENNOK
FSSIONAL
Ww "Em"
B, PORT
N/F Fr.RGUSON D-M
tow Q�
N/F ERB
(43.S®0 S.F.)
8,14
OZD xpY
CAW r.
AS BUILT PLAN
OF
SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
NORTH "DOVER, MASS./64 OLD CART WAY
AS PREPARED FOR
SAM WOOIYORD TM: 107B
DATE: 4-10-13
TL: 87
SCALE: I"=40'
SDL. 5 0 20 40 80
MERRIMACK ENGINEERING SERVICES
66 PARK STREET
ANDOVER, MASSACHUSETTS 01810
R
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 64 Old Cart Way MAP: 107B LOT: 0087
INSTALLER: Todd Bateson
DESIGNER: Merrimack Engineering Services
PLAN DATE: 1/2/13
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION: 4/8/13 TANK
DATE OF BED BOTTOM INSPECTION:4/8/13
DATE OF FINAL CONSTRUCTION INSPECTION: 4/10/13
DATE OF FINAL GRADE INSPECTION: 4/16/2013
SITE CONDITIONS
NA Contractor reports any changes to design plan
® Existing septic tank properly abandoned
® Internal plumbing all to one building sewer
® Topography not appreciably altered
Comments:
SEPTIC TANK
® Building sewer in continuous grade, on
compacted firm base
X 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
X Water tightness of tank has been achieved by
visual testing
® Inlet tee installed, centered under access port
e
A
® Outlet tee installed, centered under access port
(effluent filter)
® 24" inch cover to finish grade installed over
outlet access port
® Hydraulic cement around inlet & outlet
Comments: 24" cast iron cover installed to within 6' of finish grade over inlet
access port
Comments:
DISTRIBUTION-BOX
® Installed on stable stone base
® H-20 D-Box
NA Inlet tee (if pumped or >0.08'/foot)
® Hydraulic cement around inlet & outlets
® Observed even distribution
® Speed levelers provided (not required)
Comments:
SOIL ABSORPTION SYSTEM (General)
X Bottom of SAS excavated down to C soil layer,
as provided on plan
X Size of SAS excavated as per plan
X Title 5 sand installed, if specified on plan
NA 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
NA Retaining wall (boulder/ concrete /timber/ block)
❑ Final cover as per plan
Comments: Total overdig 21'.3" x 54'. Also, not staked out yet. Please measure
house to bed.
SOIL ABSORPTION SYSTEM (Gravel-less Chambers)
® Brand and Model of Chamber: Low Profile
Quick 4 Infiltrator Chambers
® Number of chambers per row: 11
® Number of rows (trenches): 4
Comments: Total Chambers = 44
FINAL GRADE
® Loamed
® Seeded
® Cover per plan
I
Comments:
DOCUMENTS NEEDED
® Certification of Installation Form submitted
By engineer and signed and dated by
Engineer and installer
® As-Built Plan
IL
BM = 224.69
HR = 1.75
HI = 226.44
SYSTEM ELEVATIONS
ROD AS-BLT INVERT DESIGN INVERT
ELEVATION ELEV ELEV
Benchmark
Building Sewer OUT 5.32 220.77 220.70
Septic Tank IN 5.60 220.49 220.50
Septic Tank OUT 5.86 220.23 220.25
Distribution Box IN 6.35 219.74 219.70
Distribution Box OUT 6.53 219.56 219.53
Lateral 1 TOP 6.59
Lateral 1 INVERT 219.50 219.48
Lateral 2 TOP 6.60
Lateral 2 INVERT 219.49 219.48
Lateral 3 TOP 6.59
Lateral 3 INVERT 219.50 219.48
Lateral 4 TOP 6.58
Lateral 4 INVERT 219.51 219.48
To of Chamber 6.57 219.87 219.87
Bottom of Bed/Chamber 7.25 219.19 219.20
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Tank SAS Sewer
Z Property line 10 10
Z Cellar wall 10 20
Z Inground pool 10 20
Z Slab foundation 10 10
Z Deck, on footings, etc 5 10 --
Z Waterline 10 10 101
Z Private drinking well 75 1001 50
Z Irrigation well 75 100
Z Surface Water 25 50
Z Bordering Vegetated Wetland
Salt Marsh, Inland/Coastal Bank3 75 100
Z Wetlands bordering surface
water supply or trib. (in Watershed) 150 150
Z Trib. to surface water supply 325 325
Z Public well 400 400
Z Interim Wellhead Prot. Area
Z Reservoirs 400 400
Z Drains(wat. supply/trib.) 50 100
Z Drains(intercept g.w.) 25 50
Z Drains(Other)Foundation 10(5) 20(10)
Z Drywells 20 25
Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02).
3 As defined in 310 CMR, 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA
wetland bylaws
Blackburn, Lisa
From: Blackburn, Lisa
Sent: Tuesday, April 09, 2013 5:47 PM
To: Dan Ottenheimer; Isaac Rowe; Pam Lally
Subject: 64 Old Cart Way
Attachments: 64 Old Cart Way.doc
Good afternoon,
We have received the OK from Merrimack Engineering for 64 Old Cart Way. Please contact the installer Todd Bateson
(978-475-4786)to set up a final inspection. Thank you.
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
r............................................................................................................................................................................
64 OLD CART WAY Reference No: BHJ-2012-000042
De artment: Permit No: BHP-2013-0613
p
North Andover BOARD OF HEALTH
.............•- ccoun o
;
Fee Type: A t Septic Account Rev
DWC-Full Repair PERMIT Receipt No: REC-2013-001282
......................................................................................... ....................................
Paid By: Paid in Full On: Tue Apr 02,2013
WOOLFORD, SAMUEL W GAIL E DELANE -"" - - - - .................
.................................................................... Check No: 7320
Received By: ....................................
Lisa Blackburn
DEPARTMENT'S COPY Amount: $250.00
........................................................................................................................................::::::::::..........................�
: .ti. Commonwealth of Massachusetts Map-Block-Lot
j— `' •• 107.B0087
BOARD OF HEALTH -----------------------
North Andover
CERTI TE OF COMP IA CE
THIS IS TO CERTI Y,That the dividual Sewage Dispo al System epair)
T-odd- - --Bateson
------ - - - -------------- ------------------ ------------------------ -------------------- -
Installer
at No 64 OLD CART
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as descri ed in the
application for Disposal Works Construction Permit No. -BHP-2013-06- - 1 - Dated ___April_02,_2013-------
------------ -- -----
------------------------------------ --
Printed On: Apr-02-2013 BOARD OF HEALTH
AIIAI��
• Commonwealth of Massachusetts Map-Block-Lot
107.B0087
BOARD OF HEALTH Permit No
North Andover BHP-2013-0613- ----
------------- -----
FEE
$250.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-Bateson- ---------- -- ------- -------------------------------------------------------------------------------------------
to(Repair) an Individual Sewage Disposal System.
at No 64 OLD CART WAY ;y, C ---- -_
as shown on the application for Disposal Works Construction Permit No. BHP-2013-061 Dated April 02, 2013
---------------------- ------------------------------
-----------------------------------------------------------------
Issued On: Apr-02-2013 BOARD OF HEALTH
Application for _Septic Disposal �V7
�°? a•4 •` s Construction Permit — TOWN OF TODAY'S DATE
"1
ORTH ANDOVER MA 01845, 2so,ti —Full Repair
"► '^,,.,� �'` 0-Component
yS��cNus�i
Important: Application is hereby made fora permit to:
When filling out F1Construct a new on-site sewage disposal system*
forms on the
computer,use Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component—What?
cursor-do not
use the return A. Facility Information
key.
Address or Lot#
/gyp.- A-_j_-,� ECIE
� City/Town
2.- *TYPE QF SEPTIC SYSTEM*: Z 2013
j ❑ Pump Ejgravity (choose one)
***If pump system,attach copy of electrical permit to application*** TOWN OF NORTH MDOVSR
HEALTH DepARTMENT
❑ Conventional System (pipe and stone system)
N411trator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present)S.A.S.
2. Owner Information
Name
GA �' pd Gf��-
Address(if different from above)
Cityrrown State V�J(� Zip Code
Telephone Numpper
3. Installer Information
Name Name of Company
Address y
1%4-- OW 16
City/Town State Zip Code
�/7� 703
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
Applicati•on..forSeptic Disposal System
c TODAYS DATE
p Construction -Permit �-=TOWN -OF -
* °• } �� OR'T'H ANDOVER AIA 01845 $.250.00-Full Repair
CA~�• t $125.00.-Component
�S
PAGE 2 OF 2
A. Fadility.information continued.... ,
5. Type-of SOding: esidential Dwelling or OCommercial
B. Agreement
The unders/gned agrees to.ensure the construction and maintenance of the afore-described
on-site sewage disposal system In accordance with the provlslons of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system In operation unt l a Certificate of Compliance has
} been issued this Board of Health.
Name Date
Applicatio pp ro ry
: (Board of Health Representative)
Date
Aj(olication Mappro ed.for the following reasons:"
For Office Use On'IV:
1. Fee Attached?: Yes�' No
2.• FrojectMartager Obhgadan Form Attached? Yes No
System-? Hso3,�ttach caREof lectrical M mit.• Yes No '--'���
4. Foundatior2As BurIt.?(hew construction-ro�l}r Yes_ No
Same —
( scale as appro�edplaxs) .
S. Floor.Mws?(hew constructlon only)
Appifi aitidn for ptsposal System onat'ruatt h Permft Range 202
SEP'�'IC.IC - ALLLg'PR0JECT 11�T�GEMEN't' OBLIGATIONS
for the construction for�the septic SysIte.m fot.the proper y at
As the•North Andover-licensed installer
•
For plans by
(Ad4ress of septic system) (Engineer)
Mative to the-application of And dated
(In'stauer's name) �dngmal MR7.
Dated —�—��j With revisions dated
o s dale) (Last revised date)
I understand the following obligations for management of•this project: ,-
1. As the installer,I am.obligated to obtain.aH permits and Board offHealth approved plansp QT to
performing any.'
on a site; I must IIa__ a���apnrov--ed plans and the permit on site when anv work is
et
2. As the instiller,•I must call for aaq and id-insptcdons: I£homeawner,contractor,•project maiidger, or any
other.person not associated with my company schedules an inspection and the system is not ready,then
item three-shall•be.applicable.
As tiiw rtsta�r,I am teq*ed to,have.the oecessgry.work•completed•prior,to the.applicable inspections as
iztdcated betow items' accordance
d s mc•as d' or
Bo'tioYn of 3.ed, eneraily,this'is the•fixst tlI-M'spectloa finless.there is a retaining wall,which
shovltt-be done rsf: The install must toques#tlae inspection but sloes not have to be present.
b g 'ara' ' t- rctiori—Euneer must first;do tl�e stxspectton for elevattans;tie$,etc.
As-Milli:of•ver'bal OK(or a-ma.to: altl+den i owno .fthaii&'Vrr.cam):from the engineer must
be stibniitied•to:the.Board•ofHealth,after•wl ehinstaller calIs f'or.an inspection time. Installer must
bepresent for this inspection, pith a pump System,41.electdcalww ik.znusfbe ready andable to
cause;pumtp.to^arork atad•,alarti i•to f lliction..
c. —installer must request'inspection when ill grading.•is'complete.,• Installer'does not
have to be•on=site.'
4. As-the installer,'I understand that only I• nay pet:form the work'(other than:rimpk excavation)and_1 arri required
to complete the.*nstallatitin of the system identified in the att'<ached.application for installation:I f-uth r..
dunders nd-that to, ternover can cons to e
xea :. . . _ u o Taavnsons for d6iaf� stern ca0ot •ar x4ngr
Cant
_lorthAnd _sue fiInes
I4 1 rnna i y t .af
5.. As tlie.instiller,1 understand that•.I rnu§t'be•on'* doting the•perftisrnance of the•following construction,
steps:..
a: Det�=w' s doxi t1wt.the ptmper elevation of the extcam on has been reached.
A Inspection of the"sand and striae-to be used
c. Finalr`rrspectr'oa by Boar$of.Kealth staffor consultant.
d. Installation.•of tank,D Box pipes,stone, vent,pump chamber,retarting wall and other
components
G. As 62 instiller.,1 1,u%j&rstand that 1:am s6l*responsibIc for e installation of the system as per the
a b olve
me pf•this oblig don.
Undersigned Uceased Septic.Installer:
• 5��'fL`EDj��
•
North Andover Health Department
(ommunity Development Division
January 18, 2013
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover, MA 01810
Re: Subsurface Sewage Disposal System Plan for 64 Old Cart Way(Mal)107B,Lot 87)
Dear Mr. Nemchenok:
The proposed wastewater system design plan for the above site dated January 2, 2012 (corrected
to January 2, 2013) and received on January 14, 2013 has been reviewed. The plan is approved
provided you send an email indicating why 44 (830 sf) Infiltrator Chambers are proposed instead
of the required 40 (755 sf) Infiltrator Chambers. This office will have no concern with more than
the required Infiltrator Chambers if that is the decision of the designer.
Please feel free to contact the office with any questions you may have.
Since y,
Susan Y. Sawyer, RE /RS
Public Health Director
cc: Sam Woolford
File
Page 1 of 1
North Andover Health Department, 1600 Osgood Street, Building 20, Suite 2-36,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
I
6360
pORTq
Town of North Andover
�`;'• HEALTH DEPARTMENT
�S34cHuse< ]j
CHECK #: DATE: I I
LOCATION: ( a,4 00, ( 1
H/O NAME:
CONTRACTOR AME:
Type of Permit or License: (Check box))
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service- Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
)< Septic-Design Approval $�
❑ Septic Disposal Works Construction(DW0 $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink- Treasurer
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36
NORTH ANDOVER,MASSACHUSETTS 01845 4CHU
978.688.9540-Phone
Susan Y.Sawyer,REHS/RS 978.688.8476-FAX
Public Health Director E-MAIL:healthdet)t@townofnorthandover.com
WEBSITE:http://www.townofnorthandover.com
SEPTIC PLAN SUBMITTAL FORM
Date of Submission:-
Site Location: 44 0 12
Engineer: Ojl w Rtr!zt�0L-UkAd4-=
New Plans? Yes V'-�$225/Plan Check# I I Z.6, (includes I"submission and one re-
review only)
Revised Plans?Yes $75/Plan Check# RECEIVED
Site Evaluation Forms Included? Yes V"' No JAN 14 2013
Local Upgrade Form Included? Yes No / AM TOWN OF NORTH ANDOVER
I
11 HEALTH DEPARTMENT
Telephone#: _5' —Fax#: q4
E-mail: W V:�fQ Ll Ov CQ"426T� t,
Homeowner
Name:
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
�I
Commonwealth of Massachus0ft DECEIVED
City/Town of North Andover
3 Form 11 - Soil SUitabillty Assessment for On-Site Sewage Disposal JAN 14 2013
TOWN OF NORTH AND ��
A. Facility Information
�'� L UtPARTMENT
Sam Woolford
Owner Name
64 Old Cart Way 1076/87
Street Address Map/Lot#
North Andover MA 01845
City State Zip Code
B. Site Information
1. (Check one) ❑ New Construction ® Upgrade ❑ Repair
2. Published Soil SurveyAvailable? Yes Aug 11, 2008 1:15,840 300
® ❑ NO If yes: Year Published Publication Scale Soil Map Unit
Montauk
Soil Name Soil Limitations
3. Surficial Geological Report Available? ❑ Yes ® No If yes: Year Published Publication Scale Map Unit
Geologic Material Landform
4. Flood Rate Insurance Map
Above the 500-year flood boundary? ® Yes ❑ No Within the 100-year flood boundary? ❑ Yes ❑ No
Within the 500-year flood boundary? ❑ Yes ❑ No Within a velocity zone? ❑ Yes ❑ No
5. Wetland Area: National Wetland Inventory Map Map Unit Name
Wetlands Conservancy Program Map Map Unit Name
6. Current Water Resource Conditions (USGS): 12/2012 Range: ❑ Above Normal ® Normal ❑ Below Normal
Month/Year
7. Other references reviewed:
Soil Evaluation Forms.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8
( _ l
Commonwealth of Massachusetts
9 City/Town of N®rth Andover
Form 11 - Soil Sultablllty ,assessment for On-Site Sewage Disposal
C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area)
40
Deep Observation Hole Number: T-1 Date 12 Tim Rainy
Date Tme Weather
1. Location
Ground Elevation at Surface of Hole: 219.5 Location (identify on plan): see plan
2. Land Use
Residential lot none 3-8
(e.g.,woodland, agricultural field,vacant lot,etc.) Surface Stones Slope(%)
lawn Ground Moraine side slope
Vegetation Landform Position on Landscape(attach sheet)
3. Distances from: Open Water Body >100 Drainage Way >100 Possible Wet Area >100
feetfeetfeet
Property Line 30 Drinking Water Well >100 Other
feet feet feet
4. Parent Material: Till Unsuitable Materials Present: ® Yes ❑ No
If Yes: ❑ Disturbed Soil ® Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
5. Groundwater Observed: ❑ Yes ® No If yes:
Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater: 51 215.2
inches elevation
Soil Evaluation Forms.doc-rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal -Page 2 of 8
Commonwealth of Massachusetts
City/Town of North Andover
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number: T-1
Redoximorphic Features Coarse Fragments
Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil
Depth(in.) Layer Moist(Munsell) (USDA) Cobbles& Structure Consistence Other
Depth Color Percent Gravel Stones (Moist)
0-29 A& Fill
29-40 B 10YR4/6 S.L. Massive Friable
40-108 C 2.5Y5/4 51" 7.5YR4/6 >5 S.I. 10 10 Massive Friable
Additional Notes:
Soil Evaluation Forms.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal Page 3 of 8
Commonwealth of Massachusetts
City/Town of North Andover
E Form 11 - Soil Sultablllty Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number: T-2 12-21-12 9am rainy 40
Date Time Weather
1. Location
Ground Elevation at Surface of Hole: 219.4 Location (identify on plan): see plan
2. Land Use Residential lot none 3-8
(e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%)
Lawn Ground Moraine Side Slope
Vegetation Landform Position on Landscape(attach sheet)
3. Distances from: Open Water Body feet Drainage Way >100 Possible Wet Area >100
feetfeet
Property Line 35 feet Drinking Water Well >100feet Other feet
4. Parent Material: Till Unsuitable Materials Present: ® Yes ❑ No
If Yes: ❑ Disturbed Soil ® Fill Material ❑ Impervious Layer(s) ❑ Weathered/Fractured Rock ❑ Bedrock
5. Groundwater Observed: ❑ Yes ® No If yes:
Depth Weeping from Pit Depth Standing Water in Hole
Estimated Depth to High Groundwater: 50 215.2
inches elevation
Soil Evaluation Forms.doc•rev. 1110 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 4 of 8
Commonwealth of Massachusetts
City/Town of North Andover
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
C. On-Site Review (continued)
Deep Observation Hole Number: T-2
Redoximorphic Features Coarse Fragments
Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil
Depth(in.) Layer Moist(Munsell) (USDA) Structure Consistence Other
Depth Color Percent Gravel Cobbles& (Moist)
Stones
0-17 A& Fill
17-36 B 10YR4/6 S.L. Massive Friable
36-112 C 2.5Y5/4 50" 7.5YR4/6 >5 S.L. 10 10 Massive Friable
Additional Notes:
Soil Evaluation Forms.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8
zN1_ Commonwealth of Massachusetts
City/Town of North Andover
6
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
I iF
D. Determination of High Groundwater Elevation
1. Method Used:
❑ Depth observed standing water in observation hole A. B.
inches inches
❑ Depth weeping from side of observation hole A. B.inches inches
® Depth to soil redoximorphic features (mottles) A. 51 B. 50
inches inches
El Groundwater B.Groundwater adjustment(USGS methodology) inches inches
2.
Index Well Number Reading Date Index Well Level
Adjustment Factor Adjusted Groundwater Level
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: 29/ 17 Lower boundary. 108 / 112
inches inches
Soil Evaluation Forms.doc•rev. 1/10 Form 11 —Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8
Commonwealth of Massachusetts
City/Town of North Andover
Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal
F. Certification
I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil
evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017. 1 further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form,
are accurate and in accordance with 310 CMR 15.100 through 15.107.
12-21-12 _
Signature of Soil Evaluator Date
William Dufresne SE#640 5-9-96
Typed or Printed Name of Soil Evaluator/License# Date of Soil Evaluator Exam
Isaac Rowe Mill River Consulting North Andover
Name of Board of Health Witness Board of Health
Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and
to the designer and the property owner with Percolation Test Form 12,
Soil Evaluation Forms.doc-rev. 1/10 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8
I
<L\ Commonwealth of Massachusetts
EffteffMg City/Town of North Andover
Form I I - Soil Suitability Assessment for On-Site Sewage Disposal
Field Diagrams
Use this sheet for field diagrams:
i
1
u Soil Evaluation Forms.doc•rev. 1111 Form 11 —Soil Suitability Assessment for on-Site Sewage Disposal •Page 8 of 8
Commonwealth of Massachusetts
City/Town of North Andover
w Percolation Test
Form 12
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.
Important:When filling out A. Site Information
forms on the
computer, use Sam Woolford
only the tab key Owner Name
to move your 64 Old Cart Way
cursor-do not Street Address or Lot#
use the return
key. North Andover MA 01845
City/Town State Zip Code
&� (978) 884-5115
Contact Person(if different from Owner) Telephone Number
B. Test Results
12-21-12 10am
Date Time Date Time
Observation Hole# P 1
47"
Depth of Perc
Start Pre-Soak 10:11
End Pre-Soak 10:26
Time at 12" 10:26
Time at 9" 10:38
Time at 6" 10:54
Time (9"-6") 16
Rate (Min-/Inch) 6
Test Passed: ® Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
William Dufresne
Test Performed By:
Isaac Rowe
Witnessed By:
Comments:
t5form12.doc•06/03 Perc Test•Page 1 of 1
71
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS -
"DARK STREET • ANDOVER,"UACIIUSETTS 01410 TEL(617)I75-3W.3MS7?l.
Blackburn, Lisa
From: Isaac Rowe [irowe@millriverconsulting.com]
Sent: Tuesday, December 18, 2012 10:41 AM
To: Blackburn, Lisa
Cc: 'Susan Sawyer(ssawyer@townofnorthandover.com)'; 'Isaac Rowe'
Subject: RE: 64 Cold Cart Way
Scheduled for Friday, Dec 21st.
Thanks,
Isaac M. Rowe, R.S.
Project Manager
Mill River Consulting
6 Sargent Street
Gloucester, MA 01930-2719
Phone: (978) 282-0014
Fax: (978) 282-1318
irowe(@millriverconsulting.com
www.millriverconsulting.com
-----Original Message-----
From: Blackburn, Lisa [mailto:LBlackburn(@townofnorthandover.com]
Sent: Monday, December 17, 2012 3:15 PM
To: Dan Ottenheimer; Isaac Rowe; Pam Lally
Subject: 64 Cold Cart Way
As built plans to go along with soil test application
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 lblackburn(@townofnorthandover.com
Web www.TownofNorthAndover.com
-----Original Message-----
From: noreply(atownofnorthandover.com [mailto:noreply(@townofnorthandover.com]
Sent: Wednesday, December 12, 2012 11:32 AM
To: Blackburn, Lisa
Subject:
This E-mail was sent from "RNPOA428C" (Aficio MP C5000) .
Scan Date: 12.12.2012 11:31:48 (-0500)
1
Blackburn, Lisa
From: Blackburn, Lisa
Sent: Monday, December 17, 2012 3:15 PM
To: 'Dan Oftenheimer'; 'Isaac Rowe'; 'Pam Lally'
Subject: 64 Old Cart Way
Attachments: 20121217144329481.pdf
Application for Soil Testing. Please contact. I fill send email over the as built plan also
that goes with this.
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 lblackburn(@townofnorthandover.com Web www.TownofNorthAndover.com
-----Original Message-----
From: noreplv(@townofnorthandover.com [mailto:noreplv(&tbwnofnorthandover.com]
Sent: Monday, December 17, 2012 2:43 PM
To: Blackburn, Lisa
Subject:
This E-mail was sent from "RNPOA428C" (Aficio MP C5000) .
Scan Date: 12.17.2012 14:43:29 (-0500)
Queries to: noreply(@_townofnorthandover.com
Please note the Massachusetts Secretary of State's office has determined that most emails to
and from municipal offices and officials are public records. For more information please
refer to: http://www.sec.state.ma.us/pre/`preidx.htm.
Please consider the environment before printing this email.
TOWN OF NORTH ANDOVER NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; BUILDING 20; SUITE 2-36
NORTH ANDOVER, MASSACHUSETTS 01845 CHU
,Susan Y.Sawyer,REHS,RS 978.688.9540—Phone
Public Health Director 978.688.8476--FAX
healthdeptoo townofnorthandover.com,-
www.townofnorthandover.fom
APPLICATION FOR SOIL TESTS
DATE: MAP&PARCEL: UK10F NORTH ANDOV.-R
LOCATION OF SOIL TESTS: (21-P
OWNER: !!�A )fl "W(-WVW Contact#: &'70 1 S
APPLICANT: �40 Contact
ADDRESS:
ENGINEER:ill LL,al&12�k�j Contact &A,0475-3555- --e—ZO
I I t /
CERTIFIED SOIL EVALUATOR: A 76)
Intended Use of Land: Resident* I'Subdivision Single Family me Commercial
Is This: Repair Testing: Upgrade Resident`
Lot Testing for Addition:�
In the Lake Cochichewick Watershed? Yes No I v-
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 Tesdn-e(please indicate test pit sites on the plan)
> Fee of$425.00 per lot for new construction. This covers the minimum two deep holes and
two percolation tests required for each disposal area. Fee of$360.00 per lot for repairs or 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.Dgte:
I
Signature of Conservation Agent.
Date hack to Health Department: (stamp in):
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS -
"PARK STREET 0 AHDOVK MASS'ACHUSETTS 01810 TEL(617)473-.3SSS.373.3721,
TOWN OF . m
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DATE OF PUMPING: 7 QUANTITY PUMPED : t. GALLONS
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NATURE OF SERVICE: ROUTINE_.zEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIM
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
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