HomeMy WebLinkAboutMiscellaneous - 74 WILLOW RIDGE ROAD 8/24/2015 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: F '
IMPORTANT: Applicant must complete all items on this page
LOCATION ;
Print.
PROPERTY GINNER
Print: ", 100 Year Old Structure yes no
MAP NO: , PARCEL: ,ZONING'DISTRICT:!' Historic Distriet' yes no
Machine'Shop Village yes no
TYPE OF IMPROVEMENT. PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑AcJd+tion ❑ Two or more family ❑ Industrial
R'Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District
❑Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name: Phone:
Address:
Supervisor's Construction License: Exp. Date:
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F.
Total Project Cost: $ 1C,?f,C200 FEE: $
Check No.: Receipt No.: -_
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner, ` " Signature of contractor
Plans Submitted FJ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
- Plar_s Submitted ❑ 'Plans-Waived1l .Certified Plot Plan ❑ Stamped Plans
TY kE-OP.SEWERAGEDISP_OEAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ .. Swimming Pools ❑
Well ❑ . .Tobacco Sales ❑ Food Packaging/Sales ❑
Private(septic tank,-etc._ ❑- permanent Dimpster.on-Site ❑
THE-FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
.._.DATE REJECTED- ..-'_ DATE APPROVED
PLANNING & DEVELOPMENT 0 F1
COMMENTS
_CONSERVATION Reviewed on Signature
COMMENTS
�C
HEALTH Reviewed on � � ' �� Signature
COMMENTS �� ( � - -'
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Con nection/Siianature& Date Driveway.Permit
DPW Toiv>s Engineer: Signature:
Located 384 Osgood Street
F]RE.DEP RTM NT Terrmp Dumpster on site yes no
Located-at 124 Mair, Street
Fire Departmentsignature/date
COMMENTS
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Commonwealth of Massachusettsf
Ilk Executive Office of Environmental Affairs
► pr rrtment of .. �
Environmental Protection � q
VAlllem F.weld
Governor
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Trudy Coxe
Secrete y EOEA
`s
David B.Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
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Property Address: A`� '"'i ° Address of Owner:
Date of Inspection: a �I�, �,�� (If different)
Name of Inspector:
Company Name Address and Telephone Number:
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CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
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Passes
— Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Date:
Inspector's Signal te� � � r �y
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The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing tfrrs
inspection If the system i4 i Shared system or has a desigri flog+ of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent thr; system owner and copies sent to the buyer, it applicable and the approving dutliuiit�.
INSPECTION SUMMARY:
Check A, B, C, or D
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR F5.301
Any failure criteria not evaluated are indicated below.
BI SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired, The system, upon completion of the replacement or riepair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
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(revised 8/15/95) 1
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One Winter Street s Boston,Massachusetts 02148 a FAX(617)556-1049 a Telephone(61 7)292-SSW
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IC,� Ponied on Rrcyded Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
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Property Address:
Owner: q
Date of Inspection: m `
BI SYSTEM CONDITIONALLY PASSES (continued)
® Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s).' The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septc'tank'and soil absorption system and is within 50 feet of a private:water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
PPM
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct a
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
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Owner: Sf ,. 2
Date of Inspection:
DJ SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
® Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times
pumped
T Any portion of the Soil Ab
sol tion T,S y"stem, ce ool or ri(v.
y is below the
high groundwater elevation.
_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
® Any portion of a cesspool or privy is within a Zone I of a public well.
® Any portion of a cesspool or privy is within 50 feet of a private water supply well,
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
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The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public i;ivaler'supp(y" 111...
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
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(revised 8/15/95) 3
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM k
PART B
CHECKLIST
Property Address:
Date of Ins ection: f '
Owner:
P
Check if the following have been done:
mping information wasm!equested of the owner, occupant,end Board of Health,
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
Burin that at period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
/ 1, , ° or V5 e-,
As built plans have been obtained and examined. Note if they are not available with N/A.
( The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout. Win„
_All system components, excluding the Soil Absorption System, have been located on the site.
-The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or k
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
—The facility o',%ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
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(revised 8/15/95) 4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
r Property Address:
Owner:
Date of Inspection: ;
FLOW CONDITIONS '
RESIDENTIAL:
Design flow: gallo s
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):
Laundry connected to system es or no):
Seasonal use (yes or no): /
Water *ti readings, if available:
Last date of occupancy: f
of t”
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flaw: allons/day
Grease trap present: (yes or no)®
Industrial Waste Holding Tank present: (yes or no)�
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
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GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)"14 c 5`
If Yes, volume pulped rcfq gallons
Reason for pllmoing:
TYPE O"YTEM
Sep1,ic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
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APPROXIMATE AGE of all components, date installed (if known) and source of information: '
Sewage odors detected when arriving at the site: (yes or no), /a
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(revised 8/15/95) 5
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: f 141 1114W
Owner;
Date of Inspection: ;
9 x,
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: —concrete—metal ®FRP®ather(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
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DISTRIBUTION BOX: ag!
(locate on site plan)
Depth of liquid level above outlet invert '
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Comments:
(note if level and distrbuticr equal, evidence of solids carryover, evidence of leakage into or out of box, etc,)
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PUMP CHAMBER: '
(locate on si plan)
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Pumps in Working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION (continued)
Property Address `
Owner;
Date of Inspection:
SEPTIC TANK ;.
(locate on site Ian)
Depth below grade:
Material of construction: —concrete —metal ®FRP—other(explain)
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Dimension , sludge a9
Sludge
Distance from top o�� to bottom of outlet tee or baffle:,L
Scum thickness: tM'
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liqpid level in relation to out invert, structural
integrity, evidence of leakage, etc.) �" t « '
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GREASE TRAP:_
(locate on site plan)
Depth below grade:
Ma(drial of construction: _.concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom 0 «um tn bottom of outlet tee or baffle:
Comments:
(recommendation for pump)ng, conditigp,of inlet and outlet tees or baffles, depth of liquid level in reflation to outlet jnvert, structural
integrity, evidence'of`leakag'e, etc.l"
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(revised 8/15/95) 6 �
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C 3
SYSTEM INFORMATION (continued)
' '�'� ' a Property Address:
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Owner: ,
Date of Inspection: " r
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SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; exca anon not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: o'
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I� c6g,charnbers,,nur ber, r
` leaching galleries, number:
leaching trenches, number,length:
leaching fields,number, dirriension�:
overflow cesspool, number:
Comrfients: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS:
1, (locate on�site plan) "
Number and cgpfiguration:
Depth-top of liquid to inlet invert:
Depth of solids'layer
Depth of scum layer:
Dimensions of cesspool
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments;Jf riot° ondition ofN oil,,,signs o hydratilic failurej,IeveU of ponding, condition of vegetation, etc.)
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PRIVY:
(locate on site plan)
Materials of construction: Dimensions: y;
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,)
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(revised 8/15/95) 8 t�
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: t t 144 ;A, t
Owner:
Date of Inspection.
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SKETCH OF SEWAGE DISPOSAL SYSTEM;
include ties to at least two permanent references lane
. � dmark'�`ben�marks„� o
locate all wells within 1001' wb
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DEPTH TO GROUNDWATER `
Depth to groundwater: feet '
method of determination or approximation:
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(revised 8/15/95) 9