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HomeMy WebLinkAboutMiscellaneous - 415 BOXFORD STREET 9/24/2015 ,AOR 'H 6 0 a � V AG F4U5���� PUBLIC HEALTH DEPARTMENT Community Development Division I FI A F C0914PL-IAXCE As of: ,Vufy 18, 2006 This is to certify that the individuafsu6surface dasposafsystem was Fully Repaired by: ,john Soucy At: 415.BoVordStreet North,4ndover, 9Y,4 01845 The Issuance of this certificate shaff not 6e construed as a guarantee that the system wiff function satisfactorify. } Michele E.Grant Eu6fic Yfeafth Inspector 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com i SFILE COPY I TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES �} •`hr- ' '`°p HEALTH DEPARTMENT 400 OSGOOD STREET ` °* - a'-�•N`/ NORTH ANDOVER, MASSACHUSETTS 01 945 'ss,CH„5�� 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.8476–FAX Public Health Director E-MAIL:healthdept @townofnorthandover.com . WEBSITE•hqp://www.townofnorthandover.com TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System O constructed; (v4repaired; by ov6 '1 Sfct)6 , S600UtC (Print Name) located 15 S o X EoC d STK U l- (Installation Address) was installed in conformance with the North Andover Board of Health approved plan,originally dated Z -Z q - 4 and last Revised on ,with a design flow of Ll `-( 0 gallons per day. The materials used were in conformance with those specified on the approved plan;the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: ° 06 i (Signature) And-Print Name Final inspection date: 6P[z' — Eng' er Representative ignature) And-Vrint Name Installer: (Signature) Date: L _ t And-Pr nt Name t"OF Engineer: 1304W ::n (Signa re)... g x� civil. fl And-Print N�, e A" m t , G �1Y��dkk �� 1 RE C'P'E(VE L)lh fo Commonwealth of Massachusetts SJI'J 6' 200 1 City/Town of �Ooq i o "" a Certificate ®f Compliance l it A.. e i�r �]��(��jlvi_lt,l e Form 3 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. This is to Certify that the following work on an On-Site Sewage Disposal System Important: When filling out ❑ Construction of a new system forms on the Repair or replacement of an existing system computer,use Repair or replacement of an existing system component only the tab key to move your cursor-do not Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP): use the return key. DSCP umber DSCP Date tab Facility Owner ran Street Address or Lot# City/Town State Zip Code Designer Information: Rmiwlx C. D Name Q Name of Comp cv r'_ Soo Date Installer Information: Name Name of Company Signature Date Use of this system is conditioned on compliance with the provisions set forth below: i The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. Approving Authority Signature Date i t5form3.doc•06/03 Certificate of Compliance•Page 1 of 1 %AORTH 0 C4[UL YK WU4KK�A0'0AT§0 PUBLIC HEALTH DEPARTMENT 1 Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 415 Boxford Street MAP:105C LOT: 10 INSTALLER: John Soucy DESIGNER: NEES PLAN DATE: Feb 24, 2006 BOH APPROVAL DATE ON PLAN: 4/6/06 i INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: I DATE OF FINAL CONSTRUCTION INSPECTION: 6/9/06 DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ 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-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ® Inlet tee installed, centered under access port ® Outlet tee (gas baffle or effluent filter) installed, centered under access port 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com I ORT 0 " Ck coc rile"« "wrc« '* CH S I PUBLIC HEALTH DEPARTMENT Community Development Division ® 2 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: Re-used existing tank. New tees installed. PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ 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 ® Alarm float working ® Pump On/Off floats working ® Separate on/off floats ® 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 • Hydraulic cement around inlet & outlet Comments: DISTRIBUTION-BOX ® 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) Comments: 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandaver.com t%ORT14 �' - 0 0 ` °°►are I e �iU � PUBLIC HEALTH DEPARTMENT (ommunity Development Division SOIL ABSORPTION SYSTEM (General) Bottom of SAS excavated down to 6 in into C soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ® Brand and Model of Chamber: Infiltrator Quick 4 ® Number of chambers per row 11 ® Number of rows (trenches) 3 ® 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 ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside ❑ Alarm signal located inside Comments: 1600 Osgood Street,North Andover,Mossarhasetts 01845 Phone 979.688.9540 Fax 978.608.8476 Web www.townofnorthandover.rom V%ORTH v PUBLIC HEALTH DEPARTMENT Community Development Division SYSTEM ELEVATIONS INVERT ON DESIGN PLAN FIELD INVERT ELEV. Building Sewer OUT 96.31 Septic Tank IN 96.10 96.13 Septic Tank OUT 95.78 95.90 Pump Chamber IN 95.68 95.75 Pump Chamber OUT 95.43 95.42 Distribution Box IN 97.19 97.39 Distribution Box OUT 97.02 97.15 Lateral 1 INV 96.92 96.99 Lateral 1 TOP 96.97 Lateral 2 INV 96.92 96.98 Lateral 2 TOP 96.96 Lateral 3 INV 96.92 96.99 1600 Osgood Street,North Andover,Mossochusetts 01845 Phone 978.688.9540 Fox 978.688,8476 Web www.lownofnorthandover.rom t%OR ` c'06 d 0 C US PUBLIC HEALTH DEPARTMENT Community Development Division CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- F-1 Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Bank 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10(5) 20(10) ❑ Drywells 20 25 1 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 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978,688.8476 Web www.townofnorthandover.com ���� ��Y ii b�������� .�� �� 4 �, IIVIVIVN uu � � u ��� � � um�� � � i �, µ � �, �u ��� � � P�w °�� � �¢ ��® �d ��� ��� w �� ��� w° "i�r �ofa � n �...... � i ��di4 �� � p � �' I �4 y'�M � w�' IQ� � � � „.m+� I�' �"�� "" �illy mu � � ��� B � d � � �r uur � �' � �a �� m w wu NCI i � �, �� II�N e� �a� ���« �W i�� ��� ����� ��; � � u Q�,,, Application for Septic Disposal System - �'t,, TODAY'S DATE Construction Permit — TOV N OF $ 250.00—Full Repair '•'�' NORTH ANDOVER, MA 01845 $125.00 - Component ACNWS Important: Application is hereby made for a permit to: When filling out ❑ Construct 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 cursor-do not use the return A. Facility Information key. Address or Lot# --- ---- City/Town - — — 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiff user(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ 1pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) Pressure Dosed (D-Box Present) S.A.S. 2. Owner Information Ir vn. fie, Name A 6 ddress(if different fro�„above) --AI6�— OV VY14—`-- --- ------------- City own State Zip Code ----- Telephone Number 3. Installer Information So pct - — — ✓ —�•. �Q r --- - Name Name of C mpany PdAddressT- 1 City/Town State Zip Code _ f 7( �� Telephone Number(Cell Phone#it possible please) 4. Designer Information - r 4-' Name Name of Company Address -- —----- -- — - ------- - -- — Zip Code City/Town State -- — - — ------- Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 Application for Septic Disposal System v��t 6- o 3 ccy Constructi®n Permit ® TO O� TODAY'S DATE $ 250.00—Full Repair NORTH ANDOVER, A 01845 - Component . PAGE 2OF2 A. Facility Informatio continued.... 5. Type Of Bulldinq: Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been iss d by this Board of Health. _ e _ 4A A _ -- -Date Applicatio;,Approved (Board of Health Representative) Name --- � —. Date � '�' --- --- -----— Application Disapproved fo the following reasons: "or Office Use Only: 1. Fee Attached? Yes '` No 2. Project Manager Obligation Form Attached? Yes No 3. Pump System? If so, Attach copy of Electrical Permit Yes ` No 4, Foundation As-Built? (new construction ronly): Yes_ No (Sa»te scale as approved plan) 5, Floor Plans? (new construction only): Yes_ No e, <„r Page 2 of 2 Application for Disposal System Construction Permit• INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at -�Ea� /1� �` relative to the application o Ao e %`J� dated (UAL for plans by �.,�,�w� _and dated �� L� with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, 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 completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With 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. Does not have to be on site. 4. As the installer I understand that only I may perform the work(other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work 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; significant fines to all persons involved are 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 of Health staff or consultant. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersi ed icensed Septic In aller c Date: 4 �—ly- �� IL y �. CN ao loo 0 a 71 Z F wo t, a �• 41 A'�. °°dP`'h x TOWN OF NOR'rH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES 'A HE.AL,rH DEPARTMENr 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSErrs 01845 CINU Susan Y, Sawyer, REIIS/RS 978,688,9540 Phorre Public Health Director 978M8.9542 - FAX April 6, 2006 Brian Courtney g 415 Boxford Street North Andover, MA 01845 RE: Wastewater System Plan for 415 Boxford Street, Map 105C, Parcel 10 Dear Mr. Courtney, The North Andover Board of Health has completed review of the onsite wastewater treatment and dispersal system design plans for the above referenced property submitted on your behalf by New England Engineering Services dated February 24, 2006 and received by this office on February 27, 2006. The design has been approved for use in the construction of a replacement onsite wastewater system. This approval is valid for three years from the date of this letter and during this time a licensed septic system installer must obtain a permit and complete this work, and a Certificate of Compliance must be endorsed by the installer, designer and the Town of North Andover. The time period for which this plan is valid is reduced to two years from the date of an inspection of the current wastewater system which did not meet the acceptable criteria in the state regulations. The time period for which this plan is valid may be reduced by the North Andover Board of Health in the event an imminent health problem such as sewage backup into the dwelling is occurring. This approval is subject to the following conditions: 1. If site conditions are found in the field to be different from those indicated on the design plan and/or soil evaluation,the originally issued Disposal System Construction Permit is void, installation shall stop, and the applicant shall reapply for a new Disposal Systems Construction Permit(3 10 CMR 15.020(1)). 2. The existing septic tank,is to be pumped, examined for correct size and internal components, inspected for structural integrity,provide with adequate risers and covers if necessary, and tested for watertightness. If the tank is found to be inadequate, it must be replaced. 3. The existing sewer line from the house to the tank,does not meet the required minimum of I% slope. It has been functioning in this manner over the past years and changing this could possibly be difficult or quite expensive. Therefore, if one does not already exist, a cleanout will need to be placed in the sewer line (preferably at the bend in line) or at least immediately inside the house. 4. It is the responsibility of the applicant and/or the applicant's designer, installer or other representative to ensure that all other state and municipal requirements are met. These may include review by the Conservation Commission, Zoning Board, Planning Board, Building Inspector, Plumbing Inspector and/or Electrical Inspector. The issuance of a Disposal System Construction Permit shall not construe and/or imply compliance with any of the aforementioned requirements. 5. The plan does not call for installation of a primary(septic) tank effluent filter but one is recommended. Please be advised that only certain brands of filters are permitted for use in Massachusetts and each is required to follow certain approval criteria. Your designer or installer should work with you to assure a licensed brand is selected for use, if you choose to install one. Your effort to provide a properly functioning onsite wastewater treatment and dispersal system for your property is greatly appreciated. The Health Department may be reached at 978-688- 9540 with any questions you might have. Sincerely, S san Y. Sawyer, REHS/R Public Health Director encl: List of licensed installers cc: New England Engineering Services file NEW ENGLAND ENGINEERING SERVICES i i February 24, 2006 Mrs. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 FEB p 2006 Red 415 Boxford Street, North Andover, MA f0,004��� rld"J���,�� Septic System Design I I Dear Mrs. Sawyer, The following plans and enclosures for the above referenced property are being submitted for approval. 1. (3) Copies of the Septic System Design Flans. 2. (2) Copy of the Form 11 Soil Evaluator Sheets. 3. (2) Copy of the Form 12 Percolation Test 4. (1) Copy of the Septic Submittal Form 5. (1) Check for town approval fees. If you have any comments or questions please do not hesitate to contact this office. Sincerely, 4 Benjamin C. Osgood, President 60 5EECHWWOOD DRIVE-Nof':t`rIl ANDOVER, MA 01845-(978)686-1768..(888)859-7645- FAX(978)885-1099 TOWN OF NORTH ANDOVER of ttORT;nti Office of COMMUNITY DEVELOPMENT AND SERVICES tir •`;4� ` "'`°°p HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER,MASSACHUSETTS 01845 1q ✓°1h Sncausw 978.688.9540—Phone t Susan Y.Sawyer,REHS/RS 978.688.8476—FAX Public Health Director E-MAIL:healthdept @townofnorthandover.com WEBSITE•hqp://www.townofnorthandover.com SEPTIC PLAN SUBMITTAL FORM Date of Submission: Site Location: y 15 X�a�C7/ Engineer: &-r�i�jn C �. off tT, New Plans? Yes t/ $225/Plan Check# (includes I"submission and one re- review only) Revised Plans? Yes $75/Plan Check# Site Evaluation Forms Included? Yes ,/ No Local Upgrade Form Included? Yes No Telephone#: 97Y-&Ro" 19&9 Fax#: E-mail: oee.-s q. a4 1. Cane. Homeowner > Name r. &ad our 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 /VO4 a Percolation Test Form 12 'GSM 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 _Brian Courtney only the tab key Owner Name to move your 415 Boxford Street cursor-do not use the return Street Address or Lot# key. North Andover MA 01845 City/Town State Zip Code r�s Contact Person(if different from Owner) Telephone Number B. Test Results 2/14/06 9:20 Date Time Date Time Observation Hole# PT1 Depth of Perc 50'720" Start Pre-Soak 9:26 End Pre-Soak 9:41 Time at 12" 9:41 Time at 9" 9:45 Time at 6" 9:50 Time (9"-6») 5 MIN. Rate (Min./Inch) <2 MIN. PER INCH Test Passed: ® Test Passed: ❑ Test Failed: El Test Failed: ❑ Benjamin C. Osgood, Jr. Test Performed By. Andrew McBrearty, Mill River Consulting Witnessed By. Comments: t5form12.doc•06/03 Perc Test•Page 1 of 1 E 0 Z oT E ` o <1 ❑ ❑ 0, N Z3 6 O _ o OL -6 E Cl. 0 U) � ® o m o O cn ca -° w. E o _°O 4-O °�^ n t`o N c ' O L _ 0 (m0 "�J `_ O Z ca cu Z V/ ±� O N a O O J U) � m Q L -p 3 N O c`o ,c r El co U (B (n N J cu N (n N ❑ V- N O .in 4 Z Z ❑ 0 in Q O O Q OL El O N Q a m (n N m ❑ N } L O LL O CI. 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Q a) Q C p C C C C a) p p m m m m Z O � a) W U CV C C Q 0 a) m w -0 s a�i m O X o W c (r =3 (n O (/) Q Q � C `^ U) E C � — 2 Q) N Q N N q O a) ct3 � a�i .O N m cl o o O Q 0 C .a p O p Q M C p =3 p C (n C: m W (n U (D j CO N L 'p a) O Z3 C � M ° C Q) Q Q C: S N E ice+ O U) C 0 0 E N a) vI "O in p � a) .0 ®1 L LL C E C v z a) a a N O : O � ° 3 , r O w N 0 m a) � ° O ° m 2 Z a) � Q L C 0 L (n L N > cn y-- U) a) ° -0 O C ° ° ° O � o a) ® L ..0 .0 C a (n a) a) N 5, E O ® � m a r°n 3 O � Q r 1 w' z = E C z It w— (n ns — cn v s' ° ° p m c)•E (n N O z O '� V � 0 o E 0 0 E O m 0 D Q D 0(� U) z Z O .?' O N W LL U U U- G EHSL pET It 0 0 N rn (o a U) U 0 ° 0 CL _N Q 0 3 cn U) 3 c � O /w) L O Y/ C y C� T G r� r Q O _T L � m U) .E.� 0 U) E E 0 LL Q) S W 0 _� o N ®J Q 7 N N E O ® 'O -s O t � C O � r 0 E 4- o 0 U U U- e Page 1 of 1 i DelleDhiaie, Pamela From: Dan Ottenheimer[info @millriverconsulting.com] Sent: Thursday, February 09, 2006 3:02 PM To: amcbrearty @millriverconsulting.com; Lisa Kozel LeVasseur; Marianne Peters; DelleChiaie, Pamela; Sawyer, Susan Subject: 415 Boxford Street soil test= Tues. Feb 14th @ 8:30 Good afternoon, The soil testing for 415 Boxford Street is scheduled for Tuesday, February 14th @ 8:30 a.m. with Benjamin Osgood and Andy. Please call if you have any questions. Thanks, Marianne Mill River Consulting, Inc. Septic System Management Services 2 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 fax: 978-282-0012 2/9/2006 I �f 1 l emu. tp 14 , .y v JJJ f u TOWN OF NORTH ANDOVER °F N°RTti Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 �'SS�C us t� Susan Y.Sawyer,REHS,RS 978.688.9540–Phone Public Health Director 978.688.8476–FAX healthdeptga townofnorthandover.com www.townofnorthandover.com APPLICATION FOR SOIL TESTS DATE: o'l/"/_Q(' MAP&PARCEL: LOCATION OF SOIL TESTS: a Vi. Andme,- OWNER: Contact 5-97s APPLICANT: Contact#: ADDRESS: '5mnt�o— ENGINEER: &00W� Jr• Contact#: 9 70 CERTIFIED SOIL EVALUATOR: ri�.aim 1 Intended Use of Land: Residential Subdivision �gle Family Home Commercial Is This: Repair Testing: Undeveloped Lot Testing: Upgrade for Addition: In the Lake'Cochichewick Watershed? Yes No t/ THE FOLLOWING MUST BE INCLUDED WITH THIS FORM ➢ Proof of land ownership(Tax bill,or letter from owner permitting test) ➢ 8.5"x Il"Plot plan&Location of Testing(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 Date: Signature of Conservation Agent: Date back to Health Department: (stamp in): k n ` . )I,t I`�'.q 64v �;Vr +) n(4k k av:,- ©� grwd 6ik.4vvl �w'