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Town of North Andover, Massachusetts Form N®.2
®e 00RTIy BOARD OF HEALTH
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$iewus 4 � DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant r
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Site Location
Reference Plans and Specs.✓"' " '/ ", , a °
ENGINEER
DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
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Site System Permit No.
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Tows of North Andover %AORTH
Office of the Health Department
Community Development and Services Division
27 Charles Street
�AAT[q
North Andover,Massachusetts 01845 s ACHU
Sandra Starr Telephone(978)688-9540
Public Health Director Fax(978)688-9542
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
Inspected on 12/28/01
This is to certify that
the individual subsurface disposal system
constructed Q or repaired (X)
by
John Shaki
at
37 Acme Road
has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North
Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily.
Arian J.LaGrasse
Board of Health Inspector
BOARD Or APPEALS 688.9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
I
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System ( ) constructed;
( repaired:
by
located at '
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit# ' dated with an approved design
flow of 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:
Engineer Re�prese tative
Final inspection date: 11` 1_ >/ e. ~>�,c,
Engineer Representative
Installer Lic.#: Date:
Design Engineer: _� Date: . """
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PAGE 1 OF 5
Commonwealth of Massachusetts
Application for cal Uasr.�ade knnrova-
Title 5, 310 CMR 15.000
DEP Approved form required by 310 CMR 15.403(1)
i ��,..;�,±d to Local Anorovina Aut�ority/Board of Health: For the upgrade of a failed or
nonconforming system with a design flow of <10,000 gpd, where full compliance, as defined in
310 CMR 15.404(1), is not feasible.
To be sub tn�tled eo DEP: For the upgrade of a failed or nonconforming system with a design flow
of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full
compliance, as defined in 310 CMR 15,404(1), is,not feasible,
NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the
addition of new design flow to a cesspool or privy or'the addition of new design flow above the
existing approved capacity of a system constructed in accordance with either the 1978 Code or 310
tMR 15.000.
1) Facility/system owner
f 1
Name LAiA
Address
Phone e
Address of acility ?:l 6a; 1' t2
2) Applicant*(if different from above)
Name
Address
Phone
3) Type of face
_ tdential ®commercial school
institutional
(Specify)
arm AMOVED Torus.UWM
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PAGE 2 OF 5
4) Type of existing system
privy cesspools) ,,/conventional system
Other (describe)
Type of soil absorption system (trenches, chambers, pits►etc.)
e
5) Design flow based on 310 CMR 15.203
i
a) Design flow of existing system gpd
Approved? des approval date J "
no why?
b) Design flow of proposed upgraded system gpd
c) Design flow of facility4� p, gpd
6) Proposed upgrade of existing system is
a) Voluntary
Required by order, letter, etc. (attach copy)
Required following inspection required by 310 CMR 15,301 (provide date
inspection form was submitted to the approving authority) (e-14--c4 (date)
b) .Describe the proposed upgrade to the system
7—d
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c) Which of the following are applicable to the proposed upgrade?
tSA Reduction of setbacks) (list setbacks to be reduced with proposed setback distances)
Percolation rate of 30-60 minutes per.inch (state actual Pere rate)
D6!APMOViO IOUM-12MI95
PACE 3 OF 5
IvA, Up to 25% reduction in subsurface disposal area design requirements (state required
& proposed size)
4A Relocation of water supply well (identify well, describe relocation)
r
Reduction of required separation between bottom of SAS & high groundwater
(specify proposed reduction & perc rate) 3 4. �rl
= Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the
Code)
Systom upgrades that cannot be performed in accordance with 310 CMR 15.404 &
15»405, or in full compliance with the requirements of 310-CMR 15.000, require a
variance pursuant to 310 CMR 15.410.15.417.
7) 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 ground water elevation pursuant to 310 CMR
15.405(1)(i)(1). The evaluator must be a member or agent of the local approving authority:
Distance from soil absorption system to high groundwater
feet
As determined by:
Evaluator's name
Evaluator's signature " '
Date of evaluation_�7 Z-S-e-f
MmY s0Y6AYwn lanYfiB Y4f®9NH
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PAGE 4 OF 5
8) Notice to Abutters 1
No application for upgrade approval in which the setback from property lines or a
private water supply well is reduced shall be complete until the applicant has
notified all abutters whose property or well is affected by certified mail at least ten
days before the Hoard of Health meeting at which the upgrade approval will be on
the agenda. Such notice shall include the date, time and place where the upgrade
approval will be discussed.
If the Department is the approving authority, then such notice to abutters must be
completed prior to the date of submission of the application to the Department.
The notices to abutters shall include a copy of the completed application form and
shall reference the standards set forth in 310 CMR 15.402 through 15.405.
List of affected Abutters:
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
Abutter Name Date notified
Address
9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each
section must be completed):
a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible:
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b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible:
W"MOV u Forty-tit"195
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PAGE 5 OF 5
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C) a shared system is not feasible:
d) connection to a sewer is not feasible:
10) An application for a disposal system construction permit, including all required attachments
(e.g. plans & specifications, site evaluation forms), must accompany this application. Is the
DSCP application attached? _yes iAno
6
11) 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 knowing violations."
Facility owner's signature Date
Print Name
171 I a., 6► eLrz o e 6--I aw i r- !� r me
Name of.preparer Date
Telephone # & address of preparer
NOTE: Title 5, 310 CMR 15.403(4), requires,the system owner or operator to submit to the
Department a copy of the local upgrade approval upon issuance by the Board of Health and prior
to commencement of construction.
DW AMovW row•damns
Town of North Andover �
Office of the Health Department
o$4t4�° ,•.°��®
Community Development and Services Division
27 Charles Street
North.Andover, Massachusetts 01545 ass"CHU
Sandra Starr Telephone(978)688-9540
Health Director
Fax(978)688-9542
October 17, 2001
William Dufresne
Merrimack Engineering Services
66 Park Street
Andover, MA 01810 if,
Re: 37 Anne Road, North Andover, MA 01845
Dear Mr. Dufresne:
This letter is to notify you that the following variance has been granted for the site at 37
Anne Road.
• Separation to groundwater from 4 feet to 3 feet
Please note that with this variance (separation to groundwater) that no additional rooms
may be added to the dwelling unless it is tied into sewer. The Board of Health requires
that a deed restriction be placed on the deed with a copy to the Board of Health before a
Certificate of Compliance can be issued.
With this variance the plans for the septic repair dated 10/09/01 are approved.
If you have any questions,please feel free to contact this office.
Sincerely,
Sandra Starr, R.S.,C.H.O.
Health Director
cc: Pratt
File
SS/aem
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
. INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property relative kz the application
Uu� plans by Me ro and
dated revisions dated
I understand the following obligations 1oco9aougeoocu{oftbiaproject:
I. As the installer Iuzo obligated k> 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 iu not ready then item two shall beapplicable,
2. As the installer am required 10 have the necessary work completed prior to the uppUoub]u
ioopncdunu as indicated below. I nodecatoud that o:goeadng an iu»pucdou' without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result iou$50.UO fine being levied against uzycompany.
u) Bottom of Bed - 8eomruUy first ioupoodou nnlono there is a zoroioiuQ nmO which uboo|d be Jouo
first. Installer must request the inspection but does not have 0o6opresent.
6) Final ivapoodou — Eopjoocr umut first do their inspection for o|ovudooa' dux, etc. As-built or
verbal OK from oogioeox uzuui he ao6oit0cd to Board of Health, after which iuo<ulkx uu|Ja for
inspection time. Installer must be pcouooi for this inspection. With pump system all olooU6oul
work must 6n ready and able,o cause pump to work and alarm Wfunction.
c) Final Grade—Installer must request inspection when all grading ixcomplete. Does not have io6c |
on site. |
3. As the installer Iunderstand that persons or companies not uoauniuted with my company may |�
not perform the work required by my company to complete the installation of the system
identified in the attached application for installation. Iburther understand that work -� others
unlicensed to install septic myotonm in North Andover can constitute reasons for denial of the
uymtoru, and/or ,evonodnu or uoxpcmuiou of my license in the Iovvo of North Andover y]uu �
significant fines to all persons involved. �
4. As the {uxtnUec I nodora(uud that I must be on site during the yorfomuuuoe of the following �
construction steps:
u) Determination that the proper elevation of the excavation has been reached.
6) Inspection of the sand and stone to6uused.
o) Final inspection by Board of Health staff.
d) IuotuOudou of tank, D-box, pipes, xt000' vent, pump chamber, retaining wall and other
components.
5. As the installer Iunderstand that I uo, solely responsible for the iomiul]uiion of the oyxtnou as
per the approved plans. No instructions by the homeowner, general contractor, nc any other
persons shall absolve meuf this ob|igu1ion �
. �
Undersigned Licensed Septic Installer �
Date'
Disposal Works Construction Permit#
. �
Location: Owner's Name: l, urz, .
Ntap/Parcel° "7r-) y° Address:
Af
Installer,. , /
Tel �
,r. New tsisol® Repair v'
Date: wetlands 'low,Zone]][
_ Soil Symbol Soil Mme
�• ®Soil Class
Deep Observation Hole Logs
Elevation Depth Soil Horizon Soil Texture Soil Color Soil Aiottling % Gravel,Stones,etc;
l
0 0
__._ .... . _ v, FIV,
V 6VIII.�
sww�+ f as
i Wit/, f ea0 eA IAkt,f'
Parent hfaterial o 60'% Depth to Bedrock °'" Standing Water in the Hole: weepinm from Pit Facc -- +
ESHGN�:
l
1
Parent Material Depth to Bedrock Standing water in the Hole: Nvee inQ ESHGW:
p .from Pit Faee
Date _ Percolation Tests
Obsen'ation Hole# -
Depth of Pere
Start Pre-soak
Time at 12"
Time at 9"
Time at 611
Time(911-611) I I
Rate Min/Inch
Performed Bv° 122