HomeMy WebLinkAboutMiscellaneous - 185 INGALLS STREET 11/30/2015 North Andover Health Department
(ommunity and Economic Development Division
August 28, 2015
Rolland Muise
186 Ingalls Street
North Andover,MA 01 845
Re: Subsurface Sewage Disposal System Plan for 186 Ingalls Street(Map 106B,Lot 47)
Dear Ms. Muise:
The proposed wastewater system design plan for the above site dated June 30, 2015 with a final
revision date of August 7, 2015. and received on April 20, 2015 has been approved.
The design plan has been approved for use in the construction of a new on-site septic system for
a 3-bedroom home utilizing a Quick 4 Low Profile Infiltrator Chamber system. This design plan
approval is valid until August 28, 2017.
During this time, a licensed septic system installer must obtain a permit and complete this work,
and a Certificate of Compliance be endorsed by the installer, designer and the Town of North
Andover. In the event an imminent health problem, such as sewage backup into the dwelling is
occurring, the North Andover Board of Health may reduce the time period for which this plan is
valid.
At a regularly scheduled meeting of the Board of Health,this plan received the following
approvals by the members.
Local Upgrade Approvals:
• To reduce the setback from the soil absorption system to the cellar wail from 20' to 15'
• To reduce the separation distance from the soil absorption system to the estimated
seasonal high ground water table from 4' to 3.5'
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North.Andover, MA 0 1845 Phone: 978.688.9540 Fax: 978.688.8476
i
i
186 Ingalls Street August 28, 2015
This approval is also subject to the following conditions:
1. If site conditions are found in the field to be different from those indicated on the design
t
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. It is the responsibility of the applicant and/or the applicant's septic system designer,
septic system 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.
Please feel free to contact the office with any questions you may have. We look forward to
working with you to obtain a wastewater treatment and dispersal system which will be in
compliance with all regulations and assure protection of public health and the environment of
North Andover.
Sincerely,
.w
ichele Grant
Health Inspector
Encl. Installers list
cc: Vladimir Nemchenok, P.E., Merrimack Engineering Services
File
Page 2 of 2
North Andover Ylealth Department, 1.600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
Grant, Michele
To: V1adimirNemchenok; jmuise1@verizon.net
Cc: Blackburn, Lisa; K4ERRENG@aoiconTwndufoesne@comcasLnet
Subject: 186 Ingalls
Dear Vladimir,
Ax per our conversation yesterday, |'vereoeivedvvordbamkhnmourChainnonofthe8oard, DcTrovvbridge. He will
allow 186 Ingalls to be presented as a walk-on in front of the board, on Thursday,August 27 th 2015. |f you so choose to
appear, please let us know, aa Dr.Trowbridge would like advance notification.
Many Thanks,
Michele E.Grant
Public Health Agent
Town of North Andover
16OO Osgood 8^ | Suite 2O35
North Andover,mYAU1O45
Phone 978.688.9540
Fax 978.688.8476
Email
Web www.TownofNorthAndover.com �
�
�
1
Blackburn, Lisa
From: Blackburn, Lisa ;
Sent: Thursday, August 20, 2015 3:52 PM 1
To: Dan Ottenheimer;Isaac Rowe; Pam Lally
Cc: Grant, Michele; rjmuisel@verizon.net
Subject: FW: 186 Ingalls Street
Attachments: 186INGALLS ST.-NORTH ANDOVER2.pdf, 186INGALLS ST.-NORTH ANDOVER.pdf, 186
Ingalls.pdf
Revised septic plans for 186 Ingalls Street.
From: wrdufresne@acomcast.net fmailto:wrdufresneCcucomcast.net]
Sent:Thursday, August 20, 2015 3:47 PM
To: Blackburn, Lisa
Cc: Grant, Michele
Subject: 186 Ingalls Street
Lisa
As requested, attached are electronic copies of the revised 186 Ingalls Street Plan
Thanks,
Bill
i
i
I
MERRIMACK ENGINEERING SERVICES, INC, 1
PROFESSIONAL ENGINEERS o LAND SURVEYORS PLANNERS
66 PARK STREET• ANDOVER,MA 01810• (978)475-3555,373-5721 • FAX(978)475-1448 • E-MAILinfo@merrimackengineering.com
i
August 19, 2015
Michelle Grant �;RECE;,IVE
Health Inspector
1600 Osgood Street, Suite 2035 P ((' r" ?0115
North Andover, Ma 01845
Wk('4`hCOR'V H ALNVE'Ft
RE: 186 Ingalls Street
Dear Michelle,
We are in receipt of your review letter for the above referenced site dated 7-29-15.
We have revised the plans with regard to items 1-4 of your letter.
With regard to your additional comments that you encourage us to review, please note
that before we start every septic system upgrade job, we have a site visit with the owners
and review the property as a whole, specifically, we measure the height of the sewer pipe
fiom the top of foundation where it exits the dwelling in cases where it is visible, and in
this case, it was visible, so we are confident in its approximate height. Additionally, we
take notice of the location of existing wells on and off the property. On the day of soil
testing we again verified well locations on the lot located to the immediate south and to
the east as we were aware of that well location having completed a septic system upgrade
of that property last year.
Enclosed herewith are 3 copies of the revised septic system upgrade design, we feel we
have met all the requirements of Title 5 and the North Andover BOH and have
adequately addressed your concerns and respectfully request the design be approved as
re-submitted.
Very truly yours, /
IN AY
Vladimir Nemchenok,P.E.
Merrimack Engineering services, Inc.
s
•
North Andover Health Deportment
(ommunity and Economic Development Division
July 29, 2015
Vladimir Nemchenok
Merrimack Engineering Services
66 Park Street
Andover, MA 01810
Re: Subsurface Sewage Disposal System Plan for 186 Ingalls Street(Map 106B,Lot 47)
Dear Mr.Nemchenok:
The proposed wastewater system design plan for the above site dated June 30, 2015 and received
on July 14, 2015 has been reviewed. Unfortunately,the plan cannot be approved until the
following items are corrected. The specific section in Title 5: 310 CMR 15.000, or North
Andover regulation that is not met by this design follows each item where applicable.
1. The pipe between the septic tank and distribution box is labeled as "FM"which implies a
pressurized force main,though no such piping is proposed on any other part of the
design. Please clarify this notation to avoid confusion during the construction process.
2. Please clarify which brand and model of gravel-less chamber is being proposed. They
are identified as "Quick 4 Standard Plus LP", "Standard LP" and"Quick 4 LP" on
various sections of the design plan.
3. Please specify the requirement for annual maintenance on the proposed effluent filter
(3 10 CMR 15.227(7)).
4. Please provide a percolation test log on the design plan(3 10 CMR 15.220(4)(i))
i
Lastly, while not a reason for disapproval you are encouraged to review and assure yourself of
two items:
1. That the nearby properties truly do not have a well located within 100' of the proposed
soil absorption system as indicated in Note 13 on your design plan.
2. That the building sewer elevation is as you indicate it to be on your design plan. If this
estimated elevation is incorrect then the entire may not be able to be constructed as you
proposed.
Page 1 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
I
I
These two items are being called to your attention so you can be aware and hopefully make 1
certain there are not issues which arise with this project.
Please feel free to contact the office or Mill River Consulting at 978-282-0014 with any j
questions you may have. We look forward to working with you to obtain a wastewater treatment
and dispersal system which will be in compliance with all regulations and assure protection of
public health and the environment of North Andover.
Upon resolution of the items described above,please schedule the requested Local Upgrade
Approvals on a future meeting agenda of the North Andover Board of Health where you can
present them at a hearing of the Board of Health members for their consideration.
Sincerely,
Michele Grant
Health Inspector
cc: Roland Muise
File
Page 2 of 2
North Andover Health Department, 1600 Osgood Street, Suite 2035,
North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476
Y'
TO' N OF N011T°1I ANDOVER
Office of COMMt)NITY 1 EVE1_et P :E TAN S ,RVK,'F..eS
HEAL'Fli ]DEPARTMENT
1600 OSGOOD STREET; S1,31 E 2035
978,6M9540---Phone
Susan Y.Sawyer,REII / 978.688.8476 FAX
Public Health Directow'" [; Pvt�➢� ll��<�E1���9� �r��a�r ��a�a�a��&i�<�sw���wrc r cw,�.r
WVll "a 'fl.N fat //war rrw.too(iiotiio,rt➢iaiidP=:xv r.con
SEPTIC PLAN SUBMITTAL FORM
Date of Submission:
Site Location: 10& °�-
Engineer: W T,- 6M61125MdO6
New Plans? Yes $225/Plan Check# 1570 " (includes 1St submission and one re-
review only)
Revised Plans?Yes $75/Plan Check# RECE IVE
Site Evaluation Forms Included? Yes V/' No
°1O ��OF���W�WNf�W�aV�G h°7 E�Y`�� G"°'a
Local Upgrade Form Included? Yes No
Telephone#: A Fax#: 1
E-mail:
161 u
Homeowner
Name:
OFFICE USE ONLY
When the sub sion is complete (including check):
➢ Date stamp plans and letter
➢ Complete and attach Receipt
➢ t, Copy File;Forward to Consultant
➢ m_,� Enter on Log Sheet and Database
' Commonwealth of Massachusetts
Cityfrown of North Andover
Form 9A — ~ =l~c ~t~ =n 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 senna as that provided here. Before using this form, check with your
local Board of Health Lo 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
15.404(l), is not feasible.
System upgrades that cannot be performed in accordance with 310 CIVIR 15.404 and 15.405, or in full
compliance with the requirements of310CK8R15.00O, require a variance pursuant to310CK0R15.418
through 15.415.
NOTE:iLocal 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 ECEIVED
Important:
When filling out 1. Facility Name and Address:
forms onthe
computer, use Rolland M i Resid OF NORTHANDOVEF�
only the tab key Name JJbK� inu�r*m/��m/
1n move your 188Ingalls Street
cursor'dunot
use the ~^~~`^~~'~`~
��um �
key. North Andover MA 01845 �
City/Town State Zip Code
2. Owner Name and Address (if different from above):
SAME
�
Name Street Add oaoo
City/Town State
(978)685-0241
Zip Code Telephone Number
3. Type of Facility(check all that opp|y):
N Residential Institutional El Commercial El School
4. Describe Facility:
3 Bedroom House
5. Type of Existing System: |
� Privy ��poo|�� � �on�nb�n�| � [�mrN���e �|o�� |
-- ' -- -- -- ` ' |
�
6. Type ofsoil absorption system chambers, leach field, pits, ebc):
Unknown
t5forrn9adoc`rev.7/06 Application for Local Upgrade Approva|^ Page 1of4
Commonwealth of Massachusetts �
City/Town of North Andover
Form 9A - Application
;A 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)
7. Design Flow per 310 CMR 15.203:
Design flow of existing system: unknown
gpd
Design flow of proposed upgraded system 330
gpd
Design flow of facility: 330
gpd
B. Proposed Upgrade of System
1. Proposed upgrade is (check one):
® Voluntary ❑ Required by order, letter, etc. (attach copy)
❑ Required following inspection pursuant to 310 CMR 15.301: date of inspection
2. Describe the proposed upgrade to the system:
Total Replacement(see plan)
3. Local Upgrade Approval is requested for(check all that apply):
® Reduction in setback(s)—describe reductions:
Distance from s.a.s. to fdtn. from 20'to 15'
❑ Reduction in SAS area of up to 25%:
SAS size,sq.ft. %reduction
® Reduction in separation between the SAS and high groundwater:
Separation reduction 0.5
ft.
Percolation rate 10
min./inch
Depth to groundwater 3.5
ft.
t5form9a.doc-rev.7/06 Application for Local Upgrade Approval* Page 2 of 4
Commonwealth of Massachusetts
City/Town of North Andover 1
Form 9A
Application I
� 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) l
❑ Relocation of water supply well (explain):
❑ Reduction of 12-inch separation between inlet and outlet tees and high groundwater
❑ Use of only one deep hole in proposed disposal area
❑ Use of a sieve analysis as a substitute for a perc test
❑ Other requirements of 310 CMR 15.000 that cannot be met—describe and specify sections of the
Code:
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 CMR 15.405(1)(h)(1). The soil evaluator must be a
member or agent of the local approving authority.
High groundwater evaluation determined by:
Isaac Rowe 5-12-15
Evaluator's Name(type or print) Signature Date of evaluation
C. Explanation
Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible. (Each section must be
completed)
1. An upgraded system in full compliance with 310 CMR 15.000 is not feasible:
NA
2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is not feasible:
NA
t5form9a.doc^rev.7106 Application for Local Upgrade Approval®Page 3 of 4
Commonwealth of Massachusetts
MAgamal City/Town of North Andover j
Form Application I 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.
t
C. Explanation (continued)
3. A shared system is not feasible:
NA
4. Connection to a public sewer is not feasible:
None Available
5. The Application for Local Upgrade Approval must be accompanied by all of the following (check the
appropriate boxes):
® Application for Disposal System Construction Permit
® Complete plans and specifications
Site evaluation forms
❑ 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).
❑ Other(List):
D. Certification
"I, 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."
7-13-15
Facility Owner's Signature Dale
Rolland Muise
Print Name
William Dufresne/Merrimack Engineering 7-13-15
Name of Preparer Date
66 Park Street Andover
Preparer's address City/Town
MA/01810 (978)475-3555 x-20
State/ZIP Code Telephone
t5form9a.doc•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4
I
Irr
00
C)
al 0 0
CL
J D z z E
i� = 0
mmm C) (C) '0 CD ❑ ❑ z
Q. N U) ?y urpi
0
0.
as
tU M
U) (1)
(D (1) CD a)
a) C) c c >- >-
b C) 0 0
,3. 00 0) a) t0 t!1
(0 CL 00 0 E E
C:) CU CL w cu E
0 2 0 Fj D z Z 0
=3 C'.
IL a. i�, z
(VI
F-I
0 'FU a)
E
E U)
U) U)
0
a) (D d) 0 C�• 0
> = �c z
D)
Z i 0
:3 m N >
CL C6 d IL 0
.0 cu
(0 cu CI
a)
0 U)
❑ .0 (D > El
m V)
E fa
U)
�
O 0 D 0)
(D a) 0 a CL
min 0 cu Im w
2=
ILL
a)
CL
0) M
a 0 0 z 0 z 0
D z z
E
❑
M "q 0
El CD
0-
a) a)
.2 a)
U)
❑ Z ❑ 29 r-
M 0
a) C'.
(n
0 CI. -0
C)
cu a c .0 16 0
❑3:
:3 :3
a) 0 0 M 0
0 0 z M z a)
0
M 70
Q. 0
E 2
a) 0 0 0
>
< 2
L. m (U (D a)
10 0 a) v (n
co 4— a) E 0)
0 r— w
— a) 0 .2 (n U
a) r_
z T) U) > 0 U) 0 E — 2
E m C a)
cu <
z
(n a)
Z .2 0 > a)
0 0
E 0 E M 0
W 0 r U) Z (5 U) U) U) U) U U- < s U 0 0
o 0 q
U)
05 r C,i cyi 4 L6 (6 P� E
0
U-
0
(U
w
0
I
I
0
0 co
O 0
O C N
® w a� 0 a�
O N n w 0 N
co El
f0
Cl) 0 ❑ C 0
O O (A @ a5 C
Q1
a) v }�- 001 d r
U
2 ro )
a) o �,
® °_
4 0 U)
a) 0 CL L6 (a co w � 0 o (n c
U
�0 �p a" d
CL 0 U=1
O E
a) O O M m cNr�
cO O y a) ton
A n > d
El
a) Q ro
C0 t ro 0 a)
co (o N — 637 to
O O
A
L. 0
N
r N 0
cn W
C �
C O
� ® L
I U ® c L] E
® 0 0 J
U
O
v) o Q m O iu 0
N n Scv �? ro
O tCy v C6 ❑ U7 c
>
r
F CD u.
W
O
0 U
® u c
z CL
J
° ro aci o 6L ®CL
di °
El
1
cn ro ro
c w a)O -a ro
E 0
cn
t� (� cli cvi L6
0
tt_
c
0
^^ m
j W
3 0
C�
I
I,
00
6 0
C`'9
I�.
e �
KU d) a) UI
.H
a LL LL
U o w (n °r
CL C
o
® o
a) (D
dd ® o N
o m Lo
g
�U)
LL ,
M
mo > C)
0 d e- a
CD
C7 �
in
® � I
a�-
c
as LO
A
a
LL
v2 m co
U) ®o 0
to
0
� s
�! 00
® `O
as � 0®
a � = N LO LO
o
0 o � Z T O p
M.
N
w (U
0 of
0 .
qa o
+ o = v7
, aa) �� Q oo U Z
4 (1) o
o ip
0
o 8 e r
00 ev vt ° °
°i+ g N
00 LL N
0
LL
c
UJ
0
i
N co
c, o
0 as w O
A 0
(n ro is
co O El 0
U Q) 0
CL
a) O U)
d U)N ® d?
0)
4)
Q C E C O
LC) o O in
O
o (A 10 C(f3 LYl 0 CL 0 a- � CL o
Ov C
a) -
(ll
O CD C) c�
_O CJ EL a)
C n �'� n w O d
d _
a)) f0 Q
41
'C r-
C 4 07 N
C U)
0 "- p
® ® r
C C
aC) Li9 (ll °® a)
p 0 W LL
to
r
r 0 C
O 06 c E
L6 J C� J
CD .
a)
(B ❑
LO c
N r
f— aa) LL.
Q) O N
® a) C
m
J
C — ® O
Q� O U C C CU 0 v
CL Rt$ a (11 °o 0 O C7 CD
LIM Q v w ai
N
ens ti tU ® ® ❑
t� > - p
O W Q)
cn
w Q) S a
0 ® c 'e
®
L) a u� it n
EL 0
®4 m
O
LL
c
O
'a
i
co
0
E L
°
m
IL
c as a� w 0
raN °
cx
® N'o M m m
O LL L- LL.
U m
C N 41
® � > > N
ov U N
w in
U) ' °
® o
N
c aa)i
o Cr
d r N
Q N
`o v N
d
w ®o p N
U r
[2
O` o
h= LLL to J o
p`- W
LO
c
A
6
S a)
IL
LT-
t> M
�0
E g LO
fc U
0
LO
~ Y
a
®=
F, a) U C N C(,0
N LO
U) > U :3
O O�
®
4 CO RU
Z ® Q m U o
J
O p 0 a
o .0 c N O O
N
N i r 0
p♦��
C) CJ e.a ® O N N N
0
U-
c
>
0
�, cn
a 00
0
a) (D
-C a)
a
o m
o a
0
v)
LO � N
2 oC:) 0
a)
ca or
y cu
(0
a)0 " N N {°
0 ' 0 °
m = m .=_ mm
- - - J o
0
0) a) o
x 2 °
J °)
E
® N
a)
0 to
O �
U)
CD C14
e d N In
_ N
QN7 N �� N N C
.0 c
a LL
J
a)
m
uj 0
o D
a) ® a
O 0) a
m
o o a) o
ca
�° o o
c o
� ° .� a3 o r•
c aa) :3 ?�
o .a) U) =3 n
o v _ °
c o
a� c o
CL
cn a) Z
E w � r•
o o 5 E El oa
w
0 m a)CL
N � 0 c CL
e� ® a) °� o E "r) — o
i� ❑ ❑ ® ❑ q a) a3 sa o
49 U LL a Ld N '...
0
c
0
W
0
l
E o o
() � `° ``)
0 C C 6
ro
"O xx N
UO 8 W w U
O °
h a)
O �
r U a�
ca
CL ro G
() ccu °
a .G o
M c ro
=3
N w o
� ccv
q C c=a O tsi
O >
UU1 CU W °O aroi d o
,0 "C: 3 O C T � (A
C
® N m r CD Q 4
_ O7 O -r '� f0
O w .. O ro
O OU N r lf1 lS7 ® Q W
0
O >.�
O E
>
c Y � wwd
W O w E
L
O O p -, -0
� ) = "r
N ::+ O N
t0 L6 E
CL
O tip' d :
® may, 0
®gyp � :E2 Z
-a� U v
U1 O ® N IX?
O
m L� 3: r G
O M — ® C w S�
s® • Q > C1
2i o
C ? P%
Pl1 0 LO O b `� j CL
� fo � � = -
® U C U io N N
O > ro c
O C r W u) Z 2 w g (a
S
® (� = 2 "® O
i� N o ti-
Zu
:® ® O U E 8 (� m
C
— E U) C
0 a)E ) N c`6 in h z o 0
o '
0
LL
c
0
3;-
cu
�? W
i 'o
f
I
I
0
0
c
a)
rn
is
in
o. I
d w
CL m
ro
3
v
<T
O
.U) ZO
E
N
a)
Q
_A
t�6
U)
1 r
E
0
U-
m
12
LO
CQ
0 = . �°
O
to
1 2 �
U
C)� a�
C) LL E
O
LL
C
ro
W
0
cn
Commonwealth of Massachusetts
City/Town of North Andover
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 Rolland Muise
only the tab key Owner Name
to move your 186 Ingalls Street
cursor-do not Street Address or Lot#
use the return
key. North Andover MA 01845
City/Town State Zip Code
(978) 685-0241
Contact Person(if different from Owner) Telephone Number
B. Test Results
5-12-15
Date Time Date Time
Observation Hole# P-1
Depth of Perc 60.1
Start Pre-Soak 10:42
End Pre-Soak 10:57
Time at 12" 10:57
Time at 9" 11:14
Time at 6" 11:43
Time (9"-6") 29
Rate (Min./Inch) 10
Test Passed: Test Passed: ❑
Test Failed: ❑ Test Failed: ❑
William Dufresne SE#640
Test Performed By:
Isaac Rowe (Mill River Consulting)
Witnessed By:
Comments:
t5form12.doc•06/03 Perc Test-Page 1 of 1
Infiltrator / ti i
I hereby certify that I have been given a copy of the Title 5 I/A technology
approval letter, and the Owner's Manual for the above technology and I
agree to comply with all terms and conditions.
I further certify that I am aware that this design does not allow use of a
garbage grinder in the dwelling and that I understand my requirement to
repair, replace or modify or take any other action required by the
Department or the LAA if the Department or the LAA determines the
system to be failing to protect public health and safety and the environment.
signature: date:
certified by: (please print)
MERRIMACK ENGINEERING SERVICES,INC,
66 PARK STREET•ANDOVER,MASSACHUSETTS 01810