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HomeMy WebLinkAboutMiscellaneous - 109 RALEIGH TAVERN LANE 1/14/2016 To of North Andover ORInt 'a. ", � Office of the Health Department Community Development and Services Division o 27 Charles Street you North Andover,Massachusetts 01845 CH 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 04/22/03 This is to certify that the individual subsurface disposal system constructed () or repaired (X) by George Henderson at 109 Raleigh Tavern Lane 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. Bri J. LaGrasse Health Inspector BOARD OF APPEALS 688-9541 BUILDING 698-9545 CONSERVATION 688-9530 MALTI-1688-9540 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 ate 1 Lv 1-4 was installed in conformance with the North Ando v Board of Health approved plan, System Design Permit# d .6� dated sw with an approved design flow of 5 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 CUR 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: e i ' —02 Engineer Representative P Final inspection date: Engineer Representative Installer: T, �, �1 ..n �� _ Lic.#: Date: Design Engineer: -z! U---�� Date: . ' "` = I BOARD OF HEALTH NORTH ANDOVER, MA 01845 1 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE#_ZL.L, � ... LOCATION; / �'r ��c r b �i 61 ii ' �r r LICENSED INSTALLER: k... _. SIGNATURE: TELEPHONE# p CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 160.00 Fee Attached? Yes No Project Manager Ob. Yes NoT Foundation As-Built? Yes No Floor Plans? Yes No Date: Approval I r I PAGE 1 OF 5 J Commonwealth of Massachusetts t t Application for cal UPQrade Approval Title 5, 310 CMR 15.000 DEP Approved form required by 310 CMR 15.403(1) vi I Authority/Boards eat : 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 e„>,n,9rted to 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 new that includes the flow above the Addition of new design flow to a cesspool or privy or the addition of n design itio approved capacity of a system constructed in accordance with either the 1978 Code or 310 existing pP 6MR 15.000. 1) Facility/system owner Name Address A L Phone # Address of facility ll c,�l �"'` `1 'T�� � r 2) Applicant'(if different from above) Name Address Phone # 3) Type of fac" residential ®commercial ®school institutional (Specify) DEP AMOVED FORM-nW193 PAGE 2 OF 5 4) Type of existing system rivy cesspool(s)—/Conventional system Other (describe) Type of soil absorption system (trenches, chambers, pits*etc.) 5) Design flow based on 310 CMR 15.203 system 4 e sting sys e &Io gpd a) Design flow of * i approval date �PV, Approved? yes no why? b) Design flow of proposed upgraded system jye gpd c) Design flow of facility--jW— 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) (date) b) Describe the proposed upgrade to the system c) Which of the following are applicable to the proposed upgrade? Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per.inch (state actual pert rate) Da APPROVED FORM•IV07MS Y m Y PAGE 3 OF 5 Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) AA Relocation of water supply well (identify well, describe relocation) a Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the Code) System upgrades that cannot be perforated 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 DEP APPROVED FORM-12/6"S PAGE 4 ®F 5 8) Notice to Abutters 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 Board 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. ® then such notice to abutters must be If the Department is the approving authority, 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: N� b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible: DEP APPROVED FORM-121071!5 j PAGE 5 OF 5 1A 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 s 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." Fa ility ow 's signature Date Print Name 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. DU APPROVED FORM-12167195 Town of North Andover f t,nRr)., OFFICE OF ° COMMUNITY UNITY D V LQ a'MENT APM SERVICES to t 27 Charles Street 0 North Andover, Massachusetts 01845 1 ... Uy``��y WILLIAM J. SCOTT Director (978)688-9531 Fax (978)688-9542 November 18, 1999 William Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 RE: 109 Raleigh Tavern Lane Dear Mr. Dufresne: This is to inform you that the proposed plans for the repair of the septic system located at 109 Raleigh Tavern Lane,North Andover, dated 11/2/99 have been approved. A variance.has been given for depth to groundwater to allow separation between the bottom of the soil absorption system and the groundwater to be 3 feet instead of the minimum of 4 feet. The property owner should be aware that there can be no additional flow to the system with the granting of this variance, that is: there can be no additional rooms. If you have any questions, please feel free to contact the office at the number below. Sincerely, Sandra Starr,R.S. Health Administrator Cc: N. Ordman File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 AS-BUILT CHECKLIST JAN LOT NUMBER, STREET NAME ASSESSORS MAP& PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS ' LOCATIONS & DIMENSIONS OF SYSTEM, ua TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK r b. FROM LEACH AREA t ✓ LOCATIONS OF DEEP HOLES& PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS,DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS,ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK.&D-BOAC ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW j Z,' ,_ LOCATION&ELEVATIONS OF BENCHMARK USED ' ?I s i y � 7 I � Y to-I IN Ma„app a 7J tivv + r, a ,. w�, w. -Gr�u,,u,� ,rr• ,�:�_, �xa,.� .,.. -,. ...,r . BOARD OF HEALTH TEL. 688-9540 ANDOVER,NORTH a 01846 APPLICATION IL TESTS % DATE: 4 LOCATION OF SOIL TESTS: 161 J Assessor's map & parcel num6er:_ o7 / OWNER: )At\T IV bj TEL. NO.: (A;, - qO ADDRESS: 101 AI,C Irra 1-I ENGINEER: _ei�f "AC-k,' TEL. NO.: CERTIFIED SOIL EVALUATOR: Of en ed u of land: ential subdivision, single family home, commercial Repair to ing 642!- Undeveloped lot testing t C...a. N. Canservatian Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of 275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for renairs,,or-gparades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3, At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two,deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. x d iPLAtr No. 106 AA r. L to D e A.Az lu Au I 7 111 L fers V7 , 4 AS J I 4, AG IL5 erg Ag,'52. by 12j YJ 44,40$ AG.W6 AA 1$4. 34 6v low lu 4 If WdG65 -A I 187 AA Abb 14 lu ldl 16 M4 \ \ t21 AA 4­4 .tp Ya(Z IS5 PAO \kp) JA to% LW Oil 'Dra AA,.p NA 0 erok AA 110 45558 0 k 19 3A. AA .6-k 5.4 G 4p AP 215Z V iL W to I t'M 2. S4M latt A %.Sj,.4 bea 4r.7-7 Ac. % r'7 22 -7 A 231 4 253 -th 1A V67 Nov- 17-9 09: 26x+, Paul D. Tuvb-idle, PE/PL 503-465-0:313 P . 03 November 17, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for 109 Raleigh Tavern Lane Dear Sandra, I find that the design plans dated 11-2-99 adequately address the regulations. I make the following observations: There is a mistake in the buoyancy calculations. The water displaced is 140 CF, not 104, This makes the weight of the displaced water approximately equal to the weight of the empty tank, However, the fact that there is between 1 to 2 feet of cover over the tank, should be enough so that the tank will not float (the calculations should be redone by the design engineer to make sure that this is true). If you have any questions or comments please feel free to contact me. Sincerely Carlton A Brown, PE/PLS Raleigh tavern 109.doc PORT 1 i i i ENGINEERING Civil Engineers& Land Surveyors One Harris Street Newbaryport,NIA 01954 (9713)x'465-13594 F,oRm 11 ® S EVALUATOR FORNI Page I Data-.// No. ..................................... Commonwealth of Massachusetts .......... Massachusetts Wilb A Div Performed BY: ... (2tQ, ................. Witnessed By: ....................................................... ................................. ......... ........................................................................................I................................................. F K 4bet - 0,.',N.. e LO la 7 New construction ❑ Repair Office Review Published Soil Survey Available: No ❑ Yes Year Published L.W Publication Scale Soil Map Unit....U, Drainage Class ... Soil Limitations7...................................................................................... Surficial Geologic Report Available: No Yes ❑ Year Published ................... Publication Scale .............•.... GeologicMaterial (Map Unit) .......................................................................................................................................................... Landform .................................................................................................................................................................................................................... Flood Insurance Rate Map: Above 500 year flood boundary No ❑ Yes Within 600 year flood boundary No yes ❑ Within*1100 year flood boundary No yes El Wetland Area: National Wetland Inventory Map (map unit) ............ ............................................................................................ Wetlands Conservancy Program Map (map unit)........................................................................................ Current Water Resource Condition's (USGS): Month .1&6- Range Above Normal ❑ Normal ❑ Below Normal D Other References Reviewed: ! SL5 QLdD-. troRM it - S EVALUATOR Pago 2 Deep Hale Number . 1.�. . Data:...`A.l. .: � Time:_` !mod' Weather .`UV t Looation (Identify on site plan) �� _. :r ...�.a... ....... ..� ._.._.. ............ ...... "....._.._.��..._..��� _� w...._ Land Use ` r.. r _� �. Slope 146) 0-:2`� surface 8tbnee .... ............._.... _ �........ . .....,......r...................._...............—.............. ... � .� .....�....� Lartdform ......... ......._ ................................... ..........�.��........�....... .� .�.........� position on landscape (sketch an the book! .........� Distanoee from- ° Open Water Body Zk�a- feat Dralnago way-Z(! ' '� feet, c Porslbla Wot kas 72- i feet Proparty Una ,.... feat Drinklnp Water Weft.70. '�•• feet Other ...................................... Depth from 6urfr►a Boa Itai:on f d T kw Sol lrt VAIM (8tn�oturl, �u, a yet, ltnatu,�l tUSQA1 (MAurwstq Parent Material!geologic! ......_._._.... .._.................................. Depth to 8adrock: . Weeping from Pit Face: nwnrh t Gr uo ndwetar: Standing Water In the Hole: p ® � N Estimated Gassonal High Ground Water: . voRhi it d SOIL EVALUATOR age ` h1�la? BV�B'W • ' ~ 1`Ime:....�..1��,,�``�r�--�.., Weather �,-�...,...... _. , - Daep Nole Number�'�'•• Oat®:.....�......,..... .. Location (Identify on alto plan) ........... ...a..........a......._.._.................................................... � _ .� .....�....�_ L nd Use yed - slope (4b1 Surface Stones ...... ^- '......... , Vegetation .......................... _.,,..�.v ,.� . . ..............r..,......�....,....���...............�...� �...........�..,_ _� ,......... _ Landform......................... �� t �Y .... ......................................,.. ..............a....................... ................ .�............. position on landscape (sketch on the back) _.._... .. ��w��� _ �..�. _�..,..��.... .�_.� ............... .. ...._ ........_�_ .M. ... Dlataa00 from: Open Water Body 2't feet Drainage WAV..71 feet, t PoealWe Wat Aree ... feet Property Line A.�.�' feet Drinking Water Well feet Other.,.............•........................ DEEP OBISERYNTION '110LE LO Wpte `urtta 6otl t{ai:on 8 IUeDJ►1• 71 AM BoN 1ADttUnp rgtruaWrlI sou{Aab Qr�ve ov C L /OYi9-1i<4 d-v��G g/ t e • e e Parent Material(geologic) ••• _...._...................... .L�C K....,...,..._.............................. Depth to Badrook: � �.✓���� ® th tQ Gr�undwator, Standing Water In the Nola: ../ -1Neapin® from Pit Face: ..•• ` `"e` a Estimated Seasonal Nigh Ground Water: .. �' FORM 11 SOIL EVALUMR age eta � a fore ► I! le MAthnd Used.:. Depth observed standing In observation hole....w....__ inches Depth weeping from side of,observation hole Inches 0 Depth to soil mottles :. Inches Ground water adjustment ..•. feet Index Weil Number Reading.Data Index well level Adjustment factor Adjusted ground water level _........ � nth of Naturally Occurring Pawl ouMeterlgl Does at least four feet of naturally occurring pervious material exist In.ell areas observed throughout the area proposed for the soil absorption system? If not, what Is the'depth of naturally occurring pervious material? I certify that on �-'` (ptdetel I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required tralning, expertise and experience described In 310 CMR 16.017. Signatur , _ Date FORM 12 - PERCOLATION M N LTH MASSACHUSETTS Massachusetts Pemolation Test Date: Time: ObservatioEHale Depth of P Ll C.1 Start Presoak ,, end Pre-soak Time at 12" ' Time at 8" f Time a� 6" Time W-6 1 Ll< a (late Mln./inch Site Passed Site Failed Performed By: &W, Witnessed By: Comments: ................................. BOARD OF HEALTH TEL. 633®9540 NORTH ANDOVER, MASS. 4 APPLICATION FOR SOIL TESTS DATE: I`l LOCATION OF SOIL TESTS: ff t ei Assessor's map & parcel number: OWNER• )Aj\,� 1 t:�jg&j TEL. NO.:� C Y 14 ADDRESS: I 'A IX, I `1. V ENGINEER: feet Ud TEL. NO.: CERTIFIED SOIL EVALUATOR: en ed u of land: r idential subdivision, single family home, commercial Repair to ing Undeveloped lot testing NSA. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of IL76.00 per lot for egw construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. 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). 7. Within 60 days of testing soil evaluation forms shall be submitted. SEPTIC PLAN SUBMITTAL LOCATION: I ©f] Y1.A Le---Iw +I NEW PLANS: $125.00/Plan REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: NO DATE: I I-1 Z--9`t DESIGN ENGINEER: �i w Iii L�'Yt N��►—i r;'lr is Is e 1C 6 t)F e'v i JQ DATE TO CONSULTANT: *If you want your plans expedited, please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Part Engineering. When the submission is all in place, route to the Health Secretary. PLAN' NO. 106 \ A at Ito t2ya teat e Air• FES 0 17 AS Ar. is 52 46 920 ts tt2 124 IN AA t A"6 ua.4oA Z AS Wa z U bf 01 lu IM 'AAr.46 S 187 4 ,wry AA A,Abb -9 It4 \ 14 so,, -Sc. () 47 49 9/ M4 \ \ tro Ilk t21 AA 4-L 40 1.—, AA, AA A, o VA- %ax ory tot tw 99 97 too All-'t AA 140 45559 AA S_ AA OZ A^^ 16 b (01 lz G 6 35 A ULM. !h v IX <-10 k I LL Ludi vs U) 4, 57 278 4%7-7 AC. A-10 st IV,I .tos• ST