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Home My WebLink AboutMiscellaneous - 470 Lacy Street (3) 17e I-Re- S��E-E,57- 210/105A-001.0-0000.0 n i nry CTRFFr-} T w � �(/ I u� A D North Andover Board of,Assessors Public Access L Page 1 of 1 pORTIi forth Andover Board of Assessors • ( M CMUSet roperty Record Card Click Seal To Return Parcel ID:210/105.A-0035-0000.0 FY:2011 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Search for Parcels Search for Sales No Picture Available Summary Residence Detached Structure Condo Commercial Location: 0 LACY STREET Owner Name: WINDRUSH FARM THERAPEUTIC EQUITATION,INC Owner Address: 30 BROOKVIEW ROAD City: BOXFORD State: MA Zip: 01921 Neighborhood:6-6 Land Area: 23.99 acres Use Code: 017-RES-CH61A Total Finished Area: 3012 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 464,400 493,400 Building Value: 254,800 277,000 Land Value: 209,600 216,400 Market and Value: 443,700 Chapter Land Value: 209554 LATESTSALE Sale Price: 1,000,000 Sale 01/03/2010 Date: Arms Length Sale P-NO-USE-CHNGE Grantor: KITTREDGE,M Code: Cert Doc: 16219 Book: Page: http://csc-ma.us/PROPAPP/display.do?linkld=1711363&town=NandoverPubAcc 6/13/2011 ' North Andover Board-of,Assessors Public Access Page 1 of 1 NoeTM North Andover Board of Assessors of tt��o �1tiC 41 amw. # _ y 'Ss�cMus°s roperty Record Card Click Seal To Return Parcel ID :210/105.A-0035-0000.0 FY:2011 Community:North Andover SKETCH PHOTO Click on Sketch to Enlarge Search for Parcels Search for Sales No Picture Available Summary Residence Detached Structure Condo Commercial Location: 0 LACY STREET Owner Name: WINDRUSH FARM THERAPEUTIC EQUITATION,INC Owner Address: 30 BROOKVIEW ROAD City: BOXFORD State: MA Zip: 01921 Neighborhood:6-6 Land Area: 23.99 acres Use Code: 017-RES-CH61A Total Finished Area: 3012 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 464,400 493,400 Building Value: 254,800 277,000 Land Value: 209,600 216,400 Market and Value: 443,700 Chapter Land Value: 209554 LATESTSALE Sale Price: 1,000,000 Sale 01/03/2010 Date: Arms Length Sale P-NO-USE-CHNGE Grantor: KITTREDGE,M Code: Cert Doc: 16219 Book: Page: http://csc-ma.us/PROPAPP/display.do?linkId=1711363&town=NandoverPubAcc 6/13/2011 g M 4 r f i, I f 1�-.T J ��• .}�.. 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I �� `,tet ln 1 v( >, �F ;�. it -/ , . ��: t s w. x C a.� :� `S'�l 7 � i 'z ,, �,• �j t , ?�, ��' S' �Ir r� r..! i',d t f � � 1 * � 5d' � .S t.. � {{ '� + � f �� ,: f+ may, id$ 4.'�/',�. ^('A. _ j J; .9 ))' ,S �� i � Y 777777,x/ � c$. 6 + . .,�J .ym��' � �� t 1 �l. � � tri. { � ,� [� ' i �� tits '�y�^� � i ✓`� ��.�r,�::«� r 9 s .,t 1C1:y �rt l� �� i r ♦ �' � �' s a 7, r Yl l� . . 1 • 4 TOWN OF NORTH ANDOVER Q, +�► �, Office of COMMUNITY DEVELOPMENT AND SERVICES o•` _ $A HEALTH DEPARTMENT 1600 OSGOOD STREET;BUILDING 20; SUITE 2-36 +° NORTH ANDOVER,MASSACHUSETTS 01845 Susan Y.Sawyer,REHS/RS 978.688.9540—Phone978.688.8476—FAX Public Health Director E-MAIL:healthdent(a-townofnorthandove�r.com WEBSITE ktti)://www.townofnord mdovercom SEPTIC PLAN SUBMITTAL FORM Date of Submission: /?o�JC� MAY =.3 told 10W t "AN0QVffA Site Location: 470 " Engineer: New Plans? Yes/$225/Plan Check# (includes I'submission and one re- review only) Revised Plans?Yes $75/Plan Check# Site Evaluation Forms Included? Yes No�C �v Fl�v'p,>4oF'�orlh Local Upgrade Form Included? Yes NoLr an jonvaZe>,Zia Telephone#:_ljt2 -qty - 1� (,p Fax#: E-mail: h h Homeowner Name: d1D&V-,aokt.--V OFFICE USE ONLY When the sub ' sion is complete(including check): ➢ Date stamp plans and letter ➢ Complete and attach Receipt ➢ —Copy File;Forward to Consultant ➢ Enter on Log Sheet and Database Howard/Stein-Hudson Associates* Inc. ARD TRANSMITTAL LN 38 Chauncy sty N Boston,Massachusetts 02111 t 617.482.7080 Ass 0 IAres f617.482.7417 x Via Courier ❑ Via Overnight Mail ❑ Via Mail To: North Andover Board of Health Date: April 30,2010 Project: Windrush Farm Therapeutic Septic System HSH Project No.: 2009181 From: Thad Berry WE ARE TRANSMITTING THE FOLLOWING: ❑Report x Drawings ❑Diskettes ❑Correspondence ❑Other: Copies Date Descri tion 3 4/28/10 Septic System Desi —Repair Windrush Farm Therapeutic Comments: Soil report and logs have previously been submitted to the B.O.H. �' � ��--✓�'°�� --,Imo' MAY r _ X010 TMOR N*"ASi70VEt� p cc: 1 copy to Windrush Farm Therapeutic ! PA ENT Signa e Z:\MASTERS\FORMS\HSH\Transmittal—cover sheet.doc , J ` u � No. FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, �or`h And cr„, MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - Ll Complete System ❑Individual Components LocationAl /` Owner's Name Map/Parcel# 1Q5AAddress 3® Lot# 60 Telephone# Installer's Name Designer's Name s n" Address Address . Telephone# {� Telephone# q 4I— A Type of Building ger den�4 I l Lot Size %q ABY sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow 550 Design flow provided gpd Plan: Date A Number of sheets_25 Revision Date Title e—= N h )J!!i:1 4 M Description of Soil(s) to J Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation Pt" In r-1 /�© DESCRIPTION OF REPAIRS OR ALTERATIONS qe p l 'L- CX ls1 1 nq IG`V 1e M NJ/ilk APIA) The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to plac a in opera- n until a Certificate of •ompli nce has been issued by the Board of Health. Signed Date Inspections No. C®MMONWEALT14 OF MASSAC14USETTS FEE Board of Health, , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete Svstem 1 commonwealth of Massachusetts City/Town of North Andover Local Upgrade Approval y< Form 913 M V'� DEP has provided this form for use by local Boards of Health if they choose to do so. The Local Upgrade Approval is to be completed by the local Board of Health and a signed copy provided to the system owner. A. Facility Information Important:When filling out forms 1. Facility Name and Address on the computer, use only the tab Windrush Farm Theraputic key to move your Name cursor-do not 470 Lacy Street use the return Street Address key. North Andover MA 01845 QCityf town State Zip Code 2. Owner Name and Address(if different from above): 30 Brookview Road Name Street Address Boxford MA Cityrrown State 01921 Zip Code Telephone Number 3. Type of Facility (check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Design flow per 310 CMR 15.203: 550 gpd 5. System Designer: Thad BerryName ® PE ❑ RS 911 Main Street Wilmington 01887 Address Cityrrown State,ZIP B. Approval 1. Local Upgrade Approval is granted for: ❑ Reduction in setback(s)—specify: ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction 470 Lacy Street,plan date August 5,2010 Local Upgrade Approval* Page 1 of 2 1 Commonwealth of Massachusetts City/Town of North Andover o Local Upgrade Approval Form 9B B. Approval (continued) Reduction in separation between the SAS and high groundwater: Separation reduction ft Percolation rate min./inch Depth to groundwater ft ❑ 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 List local variances granted not requiring DEP approval per 310 CMR 15.412(4): List variances granted requiring DEP approval: North Andover Health Department ) Approving Authority Susan Sawyer, Health Director August 10, 2010 Print or Type Name and Title -Si6nature t Date 470 Lacy Street,plan date August 5,2010 Local Upgrade Approval*Page 2 of 2 Commonwealth of Massachusetts City/Town of North Andover L; a Form 9A - Application 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 same as that provided here. Before using this form, check with your local Board of Health to 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 CMR 15.404(1), is not feasible. System upgrades that cannot be performed in accordance with 310 CMR 15.404 and 15.405, or in full compliance with the requirements of 310 CMR 15.000, require a variance pursuant to 310 CMR 15.410 through 15.415. NOTE: Local 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 CMR 15.000. A. Facility Information Important:When filling out forms 1. Facility Name and Address: on the computer, use only the tab Windrush Farms Theraputic key to move your Name cursor-do not 470 Lacey Street use the return Street Address key. North Andover MA. 01845 � City/Town State Zip Code 2. Owner Name and Address (if different from above): ISI Name Street Address City/Town State Zip Code Telephone Number 3. Type of Facility(check all that apply): ® Residential ❑ Institutional ❑ Commercial ❑ School 4. Describe Facility: Residence for Farm manager and his family. 5. Type of Existing System: ❑ Privy ❑ Cesspool(s) ® Conventional ❑ Other(describe below): 6. Type of soil absorption system (trenches, chambers, leach field, pits, etc): Enviro-Septic Wastewater Treatment System by Preseby Environmental, Inc t5form9a•rev.7/06 Application for Local Upgrade Approval* Page 1 of 4 Commonwealth of Massachusetts City/Town of North Andover v Form 9A - Application for Local Upgrade Approval y . 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: 550 gpd Design flow of proposed upgraded system 550 gpd Design flow of facility: 550 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: Dec 3 2009 date of inspection 2. Describe the proposed upgrade to the system: A new 41.4' x 32' Enviro-Septic Wastewater Treatment System by Preseby Environmental, Inc 3. Local Upgrade Approval is requested for(check all that apply): ❑ Reduction in setback(s)—describe reductions: ❑ Reduction in SAS area of up to 25%: SAS size,sq.ft. %reduction ❑ Reduction in separation between the SAS and high groundwater: Separation reduction ft Percolation rate min./inch Depth to groundwater t5form9a•rev.7/06 Application for Local Upgrade Approval* Page 2 of 4 V Commonwealth of Massachusetts City/Town of North Andover o Form 9A - Application for Local Upgrade Approval y� 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) ❑ 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: 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: Final system layout falls on one of the two deep holes excavated on site. Deep hole locations were determined in the field to minimize impacts to exisitng horse paddocts, access roads and to avoid site lighting. 2. An alternative system approved pursuant to 310 CMR 15.283 to 15.288 is`not feasible: A new 41.4'x 32' Enviro-Septic Wastewater Treatment System by Preseby Environmental, Inc is being used. t5form9a•rev.7/06 Application for Local Upgrade Approval*Page 3 of 4 i w r Commonwealth of Massachusetts City/Town of North Andover a Form 9A — Application 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 same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. C. Explanation (continued) 3. A shared system is not feasible: The other on site system services the offices and facility. 4. Connection to a public sewer is not feasible: There is no public sewer in this area. 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): the abbutters is Windrush Farm and the Trust for the remaining land. 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." Facility Owner's Signature Date Print Name Thad D Berry 8/10/2010 Name of Preparer Date 911 Main Street Wilmington Preparer's address City/Town MA. 978-500-8419 State/ZIP Code Telephone t5form9a•rev.7/06 Application for Local Upgrade Approval* Page 4 of 4 WARD CREATIVE SOLUTIONS EIN EFFECTIVE PARTNERING N A S S O C I A T E S January 27, 2010 Town of North Andover Office of Community Development and Services Health Department 1600 Osgood Street,Building 20, Suite 2-36 North Andover,Massachusetts 01845 Re: Soil Reports,Windrush Farm Therapeutic Equitation 30 Brookview Road Boxford,Massachusetts Map 105A—Lot 10 HSH Job No. 2009181 Dear Sir or Madam: Howard/Stein-Hudson Associates is hereby submitting three copies of the soils report concerning the above-mentioned project for your review and records. The soil Deep Observation Holes and Percolation Test were located in the field by Donohoe and Pankhurst,Inc., and are shown in Figure 1. If you have any questions or concerns,please feel free to contact me at(617)482-7080. Reg , had D. Berry, P.E. Senior Civil Engineer cc: Windrush Farms Therapeutic Equitation Howard/Stein-Hudson Associates,Inc. 38 Chouncy Street,9th Floor 0 Boston,Mossochusetts 021 1 1 ■ t:617.482.7080 ■ f:617.482.7417 ■ www.hshossoc.com Howard/Stein-Hudson Associates,Inc. 363 Boston Street JOB#: 2009181 Topsfield,MA 01983 ---- t 978.986.4688 PAGE: 1- 5 www.hshassoc.com FORM 11 - SOIL EVALUATOR FORM Commonwealth of Massachusetts SOIL SUITABILITY ASSESSMENT FOR ON-SITE SEWAGE DISPOSAL PERFORMED BY: Howard/Stein-Hudson Associates,Inc. -Thad Berry WITNESSED BY: Mill River Consulting DATE OF TESTING: 01/05/10 Location Address or Lot# Owner's Name& Address 30 Brookview Road Windrush Farm Therapeutic Boxford, MA 01921 30 Brookview Road Map 105A Vol. 10 Boxford, MA 01921 OFFICE REVIEW Published Soil Survey NO YES FX Year Published N/A from MassGIS Publication Scale N/A Soil Map Unit N/A from MassGIs Drainage Class Soil Limitations Surficial Geological Report Available NO YES Year Published Publication Scale Geological Material(Map Unit) Landform Flood Insurance Rate Map Above 500-Year Flood Boundary? NO YES Within 500-Year Flood Boundary NO YES Within 100-Year Flood Boundary? NO YES ❑ Wetland National Wetland Inventory Map(Map Unit) Wetlands Conservancy Program Unit(Map Unit) Current Water Resource Conditions(USGS) Month Range: Above Normal El Normal ❑ Below Normal Other References Reviewed New Construction ❑X Repair Best Management Practice Howard/Stein-Hudson Associates,Inc. JOB #' 2009181 363 Boston Street Topsfield,MA 01983 PAGE: 2- 5 t 978.986.4688 r www.hshossoc.com FORM 11 - SOIL EVALUATOR FORM Commonwealth of Massachusetts Deep Hole Number: 1 Date: 01/05/10 Weather: 25 OF Cloudy Location(identify on plan): See Figure 2 Land Use: See Figure 2 Slope(%): See Figure 2 Surface Stones: See Figure 2 Vegetation: See Figure 2 Landform: See Figure 2 Position on Landscape See Figure 2 Distances From: Open Water Body: See Figure 1&2 feet Drainage Way: See Figure 1&2 feet Possible Wet Area: See Figure 1&2 feet Property Line: See Figure 2 feet Drink'g Water Well:See Figure 1&2 feet Other: See Figure 1&2 feet DEEP HOLE OBSERVATION LOG Depth from Soil Texture Soil Color Mer: Surface Soil Horizon Soil Mottling (Structure, Stones,Boulders, inches (USDA) (Munsell) Consistency, %Gravel 011 - 1211 A S.L. 10 YR 3/2 1211 -2611 B S.L. 7.5 YR 5/8 " 26" - 120" C F.S.F. 2.5 Y 6/4 7.5 YR @ 32" Boulders-Large Rocks Receiving Layers: C1 Design Class: II Parent Material(geological) Glacial Till Depth to Bedrock: --- Depth to Groundwater: --- Standing Water in the Hole: --- Weeping from Pit Face: --- Estimated Seasonal High Ground Water: @ 32" 7.5 YR 4/6 MNew Construction a Repair Best Management Practice f-hshassoc.com Howard/Stein-Hudson Associates,Inc. 363 Boston Street JOB#: 2009181 Topsfield,MA 01983 PAGE: 3- 5 978.986.4688 FORM 11 - SOIL EVALUATOR FORM Commonwealth of Massachusetts Deep Hole Number: 1 Date: 01/05/10 Weather: 25 °F Cloudy Location(identify on plan): See Figure 2 Land Use: See Figure 2 Slope(%): See Figure 2 Surface Stones: See Figure 2 Vegetation: See Figure 2 Landform: See Figure 2 Position on Landscape See Figure 2 Distances From: Open Water Body: See Figure 1&2 feet Drainage Way: See Figure 1&2 feet Possible Wet Area: See Figure 1&2 feet Property Line: See Figure 2 feet Drink'g Water Well:See Figure 1&2 feet Other: See Figure 1&2 feet DEEP HOLE OBSERVATION LOG Depth from Soil Texture Soil Color Other: Surface Soil Horizon (USDA) (Munsell) Soil Mottling (Structure, Stones,Boulders, inches Consistency, %Gravel 011 - 1211 A S.L. 10 YR 3/2 1211 -2611 B S.L. 7.5 YR 5/8 26" - 120" C F.S.F. 2.5 Y 6/4 7.5 YR @ 32" Boulders-Large Rocks 4/6 Receiving Layers: C1 Design Class: II Parent Material(geological) Glacial Till Depth to Bedrock: --- Depth to Groundwater: --- Standing Water in the Hole: --- Weeping from Pit Face: --- Estimated Seasonal High Ground Water: @ 32" 7.5 YR 4/6 FlNew Construction ❑X Repair Best Management Practice Howard/Stain-Hudson Associates,Inc. (1 363 Boston Street JOB : 20091 81 Topsfield,MA 01983 PAGE: 4- 5 — t 978.986.4688 hshoss www. haasoc.com FORM 11 - SOIL EVALUATOR FORM Commonwealth of Massachusetts DETERMINATION FOR SEASONAL HIGH WATER TABLE Test Hole Number: 1 &2 Method Used: Depth observed standing in observation hole inches Depth weeping standing in observation hole inches Depth to soil mottles See Soil Logs inches Groundwater adjustment feet Index Well Number: Date: Index Well Level: Adjustment Factor: Adjusted Ground Water: Depth of Naturally Occurring Pervious Material Does at least four(4)feet of naturally occuring pervious material exist in ALL observed soil observation proposed for the soil absorption system? Yes If not,what is the depth of naturally occuring pervious material? Certification I certify that on May 1996 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 training, expertise,and experience as described in 3 l OCMR 15.017. Signature Date 1/6/10 Comments: New Construction ❑X Repair El Best Management Practice Howard/Stein-Hudson Associates,Inc. 363 Boston Street JOB#: 2009181 Topsfield,MA 01983 t 978.986.4688 PAGE: 5- 5 www.hshoss".com FORM 12-PERCOLATION TEST Commonwealth of Massachusetts PERCOLATION TEST Location,Address, or Lot No. DATE: 01/05/10 TIME: 10 a.m.to 2 p.m. Observation Hole# #1 Depth of PERC 50" Start Pre-Soak 10:18 End Pre-Soak 10:33 Time @ 12" 10:33 Time @ 9" 12:09 Time @ 6" 1:45 Time Elapsed(9"to 6") 96 Min. PERC Rtae(minutes/inch) 32 Min./inch *MINIMUM OF 1 PERCOLATION TEST MUST BE PERFORMED IN BOTH THE PRIMARY AREA AND RESERVE AREA. Site Passed Site Failed Performed By: Howard/Stein-Hudson Associates, Inc. -Thad Berry Witnessed By: Mill River Consulting Comments: PERC# PERC# am Mm" 33" aoo o. 'o. at : is p. b ... 0 5011 17" o :o. 41- 0.0 0 New Construction ❑X Repair Best Management Practice Howard/Stein-Hudson Associates,Inc. 363 Boston Street Topsfield,MA 01983 o t 978.986.4688 www hshossoc.com .. r.�. dor 00 1 m Is 34 i '✓J _" -.SIL. __ 1J Q - -:��t1 C✓ 4 %% �t u UL . FIGUP,� I. �OCU5 MAC' 5CALE;: 1"-1000' j .... s� Howard/Stein-Hudson 2s Associates,Inc. .............. i 363 Boston Street Topsfield, MA 01983 t 978.986.4688 www hshassoc.com ........ . ............... n V `yl P.H. #2n P.H. #I i \� r i o MPIC T�5T #I i v ss FI6Ul,9r-- 2, 501 1F-5TING �OCMONS sCA1-s;: I"m150' 501 PATA 255A WIN250f:LOAMY 5ANf7 SOIL GKOUp A O 1'O 3 MPC�Nt 5LOM5 421C CANTON FINS 5ANPY LOAM SOIL GKOLP P 8 TO 15 MPCENT 5LOM5 711C CHM,%ON-POCK OUrCROF-HOLL15 501E GWOUC' f3 COM'L�x 8 TO 19 FMOC�NT 5LOM5 1 DelleChiaie, Pamela From: Isaac Rowe[irowe@millriverconsulting.com] Sent: Friday, May 14, 2010 10:28 AM To: 'Daniel Ottenheimer'; Grant, Michele; irowe@miliriverconsulting.com; 'Marianne Peters'; DelleChiaie, Pamela; 'Randy Burley'; Sawyer, Susan Subject: 470 Lacy Street Attachments: 470 Lacy Street- Disapproval Letter 5-14-10.doc Susan, Please find attached the disapproval letter for the above referenced property. The design looks good for 5 page plan! Most of the comments are related to the newer BOH regulations. If the designer did not include the soil evaluation forms I would add that as a note. Also a LUA is required for only have 1 test pit in the proposed system area. Please let me know if you have any questions. Thank you, Isaac Isaac M. Rowe,R.S. Project Manager Mill River Consulting 6 Sargent Street 1 + t �yDJY, y� �lir cc� p Ss us t� Health Department May 14, 2010 Thad D. Berry Howard/Stein-Hudson Associates, Inc. 363 Boston Street Topsfield, MA 01983 Re: 470 Lacy Street(Map 105A, Lot 6) Dear Mr. Berry: The proposed wastewater system design plan for the above site dated April 28, 2010 and received on May 9, 2010 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. 1. There is only one test pit in the area of the proposed leaching facility. A Local Upgrade Approval request is required(3 10 CMR 15.102). ,/2. Please provide the Local Upgrade Approval request as a note or chart on the design plan (NA 3.2). ,/'3. Please provide a statement identifying if the property is within or not within the / watershed of Lake Cochichewick(NA 3.2). v/ 4. The D-box is required to be H-20 loading(NA 3.2). 5. Please indicate by notation that all the D-box outlets shall be at the same elevation and �_/ laid level for the first two feet(3 10 CMR 15.232(3)(b-c)). 6. Please provide the designer certification statement on the design plan(NA 3.2). c_/7. A note indicating the proper abandonment of the existing system is required(3 10 CMR 15.354) (NA 3.2). 8. In accordance with the Enviro-Septic Massachusetts Design and Installation Manual, it appears that the breakout elevation for systems on a 0-10% slope is at the bottom of the system sand bed. This elevation is 6"below the invert of the Enviro-Septic pipe. The design plan indicates the high and low breakout elevations at 129.50' and 127.75'. The invert elevations of the high and low end pipes are indicated at 129.94' and 128.32'. Please explain why the invert elevations of the high and low end pipes are not 6"above the breakout elevations or bottom of system sand bed elevations (130.00' and 128.25'). J 9. Please indicate the required maintenance for the Enviro-Septic leaching facility on the design plan. 1600 Osgood Street HEALTH DEPARTMENT Page 1 of 1 Building 20;Suite 2-36 E-Mail: healthdept@townofnorthandover.com North Andover,MA 01845 Phone: 978.688.9540 Fax:978.688.8476 t � 10. Please provide the most recent DEP approval letter for the Enviro-Septic leaching facility +`_K that is proposed. 11. Two wells are shown on the property. It appears the well that is 10' from the dwelling is the potable water source. Please indicate the intended or existing use of the well shown approximately 35' southeast of the potable well. 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, ---Su Y. Sawyer, REHS/R Public Health Director cc: Windrush Farm Therapeutic File Jam, 10. Please provide the most recent DEP approval letter for the Enviro-Septic leaching facility that is proposed. 11. Two wells are shown on the property. It appears the well that is 10' from the dwelling is the potable water source. Please indicate the intended or existing use of the well shown approximately 35' southeast of the potable well. 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, Z Y. Sawyer,REHS/R�. Public Health Director cc: Windrush Farm Therapeutic File COPY North Andover Health Department Community Development Division August 10, 2010 Windrush Farm Therapeutic Attn: Marjorie V. Kittredge 30 Brookview Road Boxford,MA 01921 RE: Septic System Design, 470 Lacy Street; Man 105A lot 6 Dear Property Owners, The North Andover Board of Health has completed the review of the septic system design plans, for the above referenced property, submitted on your behalf by ASB design group, dated, April 28, 2010. This approval includes the Health Department approval of a local upgrade for allowing the use of one deep hole test within the area of the proposed system instead of the required two deep holes. Please keep a copy of the attached document for your records. This design plan has been approved for use in the construction of an onsite septic system for a 5- bedroom house (maximum 11-room) and is valid for a period of two years from the date of this letter or from the date that the system failed a documented Title V inspection. 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 of an imminent health problem, such as sewage backup into the dwelling, the North Andover Board of Health may reduce the time period for which this plan is valid. This approval is subject to the following conditions: 1. 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 or imply compliance with any of the aforementioned requirement. 2. 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. 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com Your effort to provide a properly functioning septic system for your dwelling is greatly appreciated. The Health Department may be reached at 978-688-9540 with any questions you may have. Sincef&y, Susan Y�ae RE ILIA/RS Public Health Director Encl: list of licensed septic system installers Cc: Thad Berry, ASB Design Group 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com f ,&ORTH 10 BOARD OF HEALTH 120 MAIN STREET TEL. 682-6483 SSACMUSNORTH ANDOVER, MASS. 01845 Ext. 32 1 - Minutes: October 22, 1992 Lacy Street - Windrush Farm: Mrs. Starr stated that the owner, Marge Kittredge wants to put on a small addition which will require a septic system. Mrs. Starr needs the Board approval to accept the water tests done out of season on August 26, 1992 . Mrs. Starr explained that Mrs. Kittredge put in an indoor riding arena and now wants to put a small addition for an office. Mrs. Starr believes there is no potential problem. On a motion by Mr. Osgood, seconded by Dr. Rizza, the Board voted unanimously to accept the soil tests and deep holes done out of season on August 26, 1992. � 1� �s r , �r K£ � �/ �/`'1�G5 HAYES ENGINEERING, INC. 603 SALEM STREET 3 1 WAKEFIELD, MA. 01880 Tel: (781) 246-2800 Fax: (781) 246-7596 June 13, 2011 Ms. Susan Y. Sawyer, REHS/R.S. Health Department 1600 Osgood Street No. Andover, Ma. 01845 Re: Septic system design plan 470 Lucy Street North Andover, Ma. 01845 Dear Ms. Sawyer; It was a pleasure speaking with you at your office. As you requested, I am addressing the changes to the approved septic system design-repair plan by ASB design group that I feel that will not affect the workings of the septic system. 1) That a sweep be installed out of the septic tank to eliminate the use of the cleanout #1. 2) That the distribution box be rotated 90 degrees to except the 4" pvc pipe directly into the distribution box. 3) That the high vent be eliminated from the plan because it is not required. The system is a gravity flow and not a pumped system. Hayes Engineering, Inc. and W. Gordon Rogerson will now be responsible for supplying inspections and as built septic system design. Thank you for your attention to these changes. W. Gordon Rogerson SE2074 Sanitary Design Engineer Certified Soil Evaluator Certified Wetland Scientist wgr DelleChiaie, Pamela From: Sawyer, Susan Sent: Monday, June 13, 20114:34 PM To: 'W. Gordon Rogerson' Cc: 'Isaac Rowe'; DelleChiaie, Pamela; Grant, Michele Subject: 470 Lacy Street SAS repair Thank you, Your requests have been approved as written for 470 Lacy Street. I will attach your note to the approved plan. 1) That a sweep be installed out of the septic tank to eliminate the use of the cleanout#1. 2) That the distribution box be rotated 90 degrees to except the 4" pvc pipe directly into the distribution box. 3) That the high vent be eliminated from the plan because it is not required.The system is a gravity flow and not a pumped system. Thank you, Susan Sawyer Health Director Stoaa SCrLUyu .I u6&W xaPtRl.Diwd" 1600(Uogood Stwd 93F.4 2U,una 2-36 ✓Vat&Qndoaen,ma 01845 office 978 688-9540 fax 978 6884476 All email messages and attached content sent from and to this email account are public records unless qualified as an exemption under the [ http://www.sec.state.ma.us/pre/preidx.htm ]Massachusetts Public Records Law. Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 1 Sawyer, Susan From: Sawyer, Susan Sent: Wednesday, June 15, 20112:05 PM To: 'W. Gordon Rogerson' Subject: RE: 470 Lacy St Also, Bob stated that he may be able to eliminate the sweep depending on how he places the tank. From: Sawyer, Susan Sent: Wednesday, June 15, 20112:02 PM To: W. Gordon Rogerson' Subject: 470 Lacy St I spoke to the installer, Bob, He told me that there is not a 1500 gallon tank rather a 1000 gallon "new"tank in place and that it is in good condition. 1) If it indeed is a 1000 gal ledge tank, I would concur that a 500 second tank would be acceptable. 2) Our local regulation requires all fields greater than 50 feet from the permanent structure be staked by the engineer.See attached 4.7 of the new regulations. Thank you Susan From: W. Gordon Rogerson [mailto:GRoaersonCcbhayeseng.coml Sent: Monday, June 13, 20113:31 PM To: Sawyer, Susan Subject: RE: 470 Lacy St Here is the revised letter. Gordie From: Sawyer, Susan jmailto:ssaMer@townofnorthandover.coml Sent: Monday, June 13, 20112:54 PM To: W. Gordon Rogerson Subject: RE: 470 Lacy St I am looking at the changes your requested, but while I do, can you add an email that says you are now the responsible engineer on the job? Thx Susan From: W. Gordon Rogerson [mailto:GRogerson hayeseng.coml Sent: Monday, June 13, 2011 1:02 PM To: Sawyer, Susan Cc: DelleChiaie, Pamela Subject: 470 Lacy St Attached is the request letter that you requested for your files 1 �1 DelleChiaie, Pamela From: Sawyer, Susan Sent: Tuesday, June 28, 2011 2:08 PM To: W. Gordon Rogerson' Cc: DelleChiaie, Pamela; Grant, Michele Subject: Windrush Farm -470 Lacy Street Ok,now I understand.You were telling us you are going Wed. What we need from you is after you verify the elevations,location etc.,to call our office and tell Pam. She only contacts our consultant after you call,because we want to be sure it is ready for our inspection. Then the consultant will call Bob Amore and set up the final inspection with the installer.Once approved by the consultant,the installer can cover the system. After loam and seeding Bob will call us and ask for a final grade.Note that our as-built requires that you place a statement saying you find the final grade meets the out break etc. Lastly,you did not answer one part of my initial question.How was the c-33 sand issues resolved?I have not seen any documentation yet. Thank you Susan -----Original Message----- From:W.Gordon Rogerson rmailto:GRogerson@hayesen .cg oml Sent:Tuesday,June 28,20111:30 PM To: Sawyer,Susan Subject:RE:Hi Hi Susan, I am not sure what the meaning of"the final has been approved".I am going to the site for the final grades of the pipes and piping to the disposal field Wed.morning about 10am.to make sure that the inverts meet the proposed grades. I called this morning and talked with Michele to let her know that that I was going to the site on Wed.morning.They(your office)was going to contack Dan Otten.To set up a final on their part. Gordie -----Original Message----- From: Sawyer,Susan(mailto:ssawyer@townofnorthandover.coml Sent:Tuesday,June 28,201111:16 AM To:W.Gordon Rogerson Subject:RE:Hi What was the outcome with this?I understand the final has been approved. Susan -----Original Message----- From:W.Gordon Rogerson jmailto:GRogerson@hayesen .cg oml Sent:Monday,June 27,20116:39 AM To:Sawyer,Susan Subject:RE:Hi If the slip says Presby Sand than it would have to meet the standard for 1 ,rC-33'test. Gordie -----Original Message----- From: Sawyer,Susan fmailto:ssawyer@tovvnofnorthandover.coml Sent:Friday,June 24,20112:15 PM To:Grant,Michele;W.Gordon Rogerson Subject:Re:Hi I say it is Ok with me if it doesn't say c-33 as long as he submits a sieve analysis showing it meets the requirements.As long as that is ok with you Gordy? ------Original Message------ From:Michele Grant To: Susan Subject:RE:Hi Sent:Jun 24,201112:06 PM Bob Amor called,the slip for sand will say Presby sand Not c-33 sand. Is that OK? Hope you get this -----Original Message----- From:Sawyer,Susan Sent:Friday,June 24,20118:35 AM To:Grant,Michele Subject:Re:Hi Tom says tell him to get out to Fisco's house and get to work:)------Original Message------ From:Michele Grant To: Susan Subject:RE:Hi Sent:Jun 24,20118:27 AM I'm getting beaten up by Dougie -----Original Message----- From: Sawyer,Susan Sent:Friday,June 24,20117:32 AM To:Grant,Michele;DelleChiaie,Pamela;Rillahan,Deb Subject:Hi I am not taking my town phone to CO but you can reach out by email if need be. Have a good weekend.Susan Sent on the Sprint(r)Now Network from my BlackBerry(r) Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. Sent on the Sprint(r)Now Network from my B1ackBerry(r) 2 i DovruQ 40 Property Exclusion from Pesticides Date: Please exclude the following property from mosquito control activities this year: Resident name: In d.)( c A Fwr rn Address: 4r? + q rl ) �--C)LC I S Town: K. and 0 v-e� WLA Telephone number: 97� (6 9-a. 7 8 5 5 Property owner(if different): Address of owner: Town: Types of mosquito control applications to be excluded: V Adulticiding Larviciding This form must be submitted by certified letter dated between January 1 and March 1,of the year the exclusion is requested,to the Municipal Clerk in the town in which the property exists. The exclusion will run from April 1 of that year to March 31 of the following year. 2b 2015 TU.. K • SETTLio COPY • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division FI(AqtE OF C09WPLLWCE As of .duly 1 S, 2011 This is to cert that the individuafsu6surface disposaCsystem received a SATISTACTO1RT lYST EMON of the: Complete System (pair of an On Site Sewage �DisposaCSystem �y� Wp6ert,Amor At. 470 .lacy Street 9Wap-105.A~Parcef-0010 5Vorth A.ndover, 9W q 0184.5 'The Issuance of is certificate shaffnot 6e construedas a guarantee that the system wifffunction satisfactorily. Aianft.Sawy , (Pu6 gfeafth Direc 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandaver.com AS-BUILT CHECKLIST All changes to the design plan have been reflected on the as-built ✓ Is of suitable scale;(one inch=40 feet or fewer for plot plans and one inch=20 or fewer or details of syste components) Lot number, Street Name,Assessors Map and Parcel Number ERECEWDLot Lines and Location of Dwellings served by the system 14 Z011 Locations&Dimensions of system,including reserve(if applicable) NORTHANDOM DERARTMW Ties to dwelling or Permanent Structure&Wells V a.From Septic Tank !/ b.From Leach Area ✓ Ties to Lot Lines from leach area Locations of Deep Holes&Peres Elevations of Disposal System Top of Foundation Elevation Locations of Wells,Drains,Watercourses within 150 feet of system Location of water,gas,electric lines,cable Distances from Corners of House to Center of Tank&D-Box Location of Structures within 6 Inches of Finished Grade c/ Original Stamp&Signature Location and holder of any easements which could impact the system Impervious Areas;Driveways,etc North Arrow Location&Elevations of Benchmark used / STATEMENT ON PLAN(NA 5.3) C/ "I certify the locations, elevations, ties, cover material; exposed component covers etc. shown on this as-built substantially agree with the approved plan and have determined that the break out elevations, if applicable, have been met." Signature of Designer Date or, if a STUCTUR,4L WALL IS PRESENT(NA 4.9)Letter or statement on the as-built indicating the wall was, or was not, constructed in accordance with the intended design and any manufacturer's specifications Signature of Designer Date As of:Wednesday,April 27,2011 MORTIS F ! i Y Y � S:.a • �CHU�+ PUBLIC HEALTH DEPARTMENT Community Development Division TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM—INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System( constructed;( )repaired; UY By: t-t I/1/f,C7 47 SO o 9 (Print Name) U_1 Located at: 7 I"�770 LACV S'– Ealy ' TOWN OF NORTH DOVER (Installation Address) HEALTH DEPARTMENT Was ''installed in conformance with the North Andover Board of Health approved plan,originally dated "T-2$—t and last revised on 8–os–to ,with a design flow of 55 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. Bottom of Bed Inspection Date: t0 n-'74 J44104 Engineer Representative(Signature) And–Print Name Final Construction Inspection Date: Engineer Representat a(Signature) �.101�DitJ & D AJ And–Print Name Installer:o � (Signature) Date: f And–Print Name Enginer• z,8 u� Date: OGRENI CIVIL '^ ^ No.27145 E� 1 L•��.�IL� O�Q� �.�F9FG/STEA �� And—Print Name AL E��G 1600 Osgood Street, North Andover,Massachusetts 0184S Phone 978.688.9S40 Fax 978.688.8476 Web http://www.townofnorthandover.com 06/08/2011 13:48 781-438-6316 DTS PAGE 01 Particle Size Distributio�nftport TO CE Z 50 uJ Ix LLI 40 CL 30 20 IT 0 500 100 (3RAiN SIZE-mm SILT %SAND 23 %Ccwl a==�!97�7 420 84.5 Uraft #200 2.3 0-5 Coefficlemft Rernaft 2.9%BY WEIGHT OF THE SAMME RETAINED 014 THE SAMPLE MEETS GRADATION. Sample No.: I source of Sample: ROWLEY,MA PIT 2 Date: 6/08/2011 Location: Elev./Depth: -UTS OF MASSACHUSETTS, INC. client: R.T.AMOR&SON EXCAVATING 5 Richardson Lane Project Stoneham, MA 02180 Project No: Figure ' 06/30/2011 09:19 781-438-6216 UTS PAGE 01 Particle Size Distribution Report < 5 100 -- �bn•AGSM C -bene 90 � 70— UJ 0 W 60 1 1 0. 1 30 1 20 � 0 500 100 10 1 0.1 0.01 0.001 GRAIN SIZE-mm %COBBLES °/.GRAVEL %SAND e/.SILT %C 0.0 1 0.4 97.8 SIEVE PERCENT SPEC." PASS? Material Des_Criotion SIZE FINER PERCENT (X-NO) F-M-C SAND,TRACE SILT,TRACE GRAVEL 3/8 in. 100.0 100- 100 #4 99.6 95- 100 48 86.9 80-100 416 66.6 50-85 A_tterbeM Limits #30 42.5 25-60 PL= LL= PI= #50 18.7 10-30 #200 5.5 2-10 Coefficients #200 I.8 D85= 2.18 DgO= 0.974 D50= 0.736 030= 0.426 D15= 0.260 Dir 0.206 Cu= 4.74 Cc= 0-91 Classification USCS= SP AASHTO= Remarks ASTM C 33-Sand Sample NO.: 2 Source of Sample: 13ENTLEY WARREN,C33 SAND Date: 6/30/2011 Location: Elev-(Depth: UTS OF MASSACHUSETTS, INC. Client R.T_AMOR A SON EXCAVATING 5 Richardson Lane Project: Stoneham, MA 02180 Project No: Fi ure 2 G L SOIL ABSORPTION SYST M (General) Bottom of SAS excavated down to 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 ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = n. D a 1-4 1 �. O a d 1^i�"L'C ►�c D -�- P�tl._j e, { ,•oR4y Commonwealth of Massachusetts Map-Block-Lot 105.A0035 •. o0 ----------------------- ILBOARD OF HEALTH Permit No a, • North Andover BHP-2011-0728 ----------------------- P.I. FEE ,S34CHust� F.I. $250.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted RobertT. Amor to(Construct)an Individual Sewage Disposal System. at No 470 LACK STREET as shown on the application for Disposal Works Construction Permit No. B141?-2011-072 Dated June 13,`2011 ---- y ----------------- Issued .Issued On:Jun-14-2011 U1ETH k } °RTM Application for Septic Disposal System 3r Ott ' `' ' °< TODAY'S DATE Construction Permit - TOWN OF ORTH ANDOVER, MA 01845 $250.00—Full Repair '�;s�•*.. � - omponent a�cNuse Important: Application is hereby made for a permit to: /17 When filling out forms on the El disposal y p Construct a new on-site sewagedis system* computer,use Pillepair or replace an existing on-site sewage disposal system* only the tab key • to move your ❑ Repair or replace an existing system component—What? cursor-do not use the return key. A. Facility Information Xx q ILMI Address or Lot# Cityfrown 2.-*TYPE OF EPTIC SYSTEM*: ❑ Pump ZGravity(choose one) J� ***If pump system,attach copy of electrical permit to applicat n*** ❑ Conventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to i system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D Box Present)S.A.S. 2. Owner information 1'iv,v A1011 ,eef Name 6,?p W't'&'0A'V/'A".0 Address(if different from above) CitylTown State � Zip Code Telephone Number 3. Installer Information Name /f Name of Company Address City/Town State Zip Code Telephone Number Cell Phone#if possible please) 4. Designer Informationa� S� Name Name ot'Company Address ,! City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 oApplication for Septic Disposal System ••~+ `•• `p Construction Permit — TOWN OF TODAY'S DATE '''•' - •`'K ORTH ANDOVER, MA 01845 $250.00-Full Repair '•�... $125.00-Component 1as�cNus�t PAGE 2OF2 A. Facility Information continued.... S. Type of Building: 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 issued by�this sBBoard ,of Health. / Name Date Application Appr Ved (Board of Health Representative) Name Date � Ap cation Disapprov for the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump System? Ifso,Attach copv of Electrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(hew construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 y ,,, SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic syst ) For plans by (E n1n eer) Relative to the application of nstaller's name) And dated xigina ate Dated `,/' ��o ay s ate With revisions dated s (Last revised date) 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 plansrp for 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 manager,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 Tide 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally,this is the first(V5 inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built of verbal OK(or e-mail to: healthdelt(@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a 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. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done 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 a=pproved plans No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) (Name—Print) e— igne r HAYES ENGINEERING, INC. 603 SALEM STREET WAKEFIELD, MA. 01880 Tel: (781) 246-2800 Fax: (781) 246-7596 June 13, 2011 Ms. Susan Y. Sawyer, REHS/R.S. Health Department 1600 Osgood Street No. Andover, Ma. 01845 Re: Septic system design plan 470 Lucy Street North Andover, Ma. 01845 Dear Ms. Sawyer; It was a pleasure speaking with you at your office. As you requested, I am addressing the changes to the approved septic system design-repair plan by ASB design group that I feel that will not affect the workings of the septic system. 1) That a sweep be installed out of the septic tank to eliminate the use of the cleanout #1. 2) That the distribution box be rotated 90 degrees to except the 4" pvc pipe directly into the distribution box. 3) That the high vent be eliminated from the plan because it is not required. The system is a gravity flow and not a pumped system. Thank you for your attention to these changes. W. Gordon Rogerson SE2074 Sanitary Design Engineer Certified Soil Evaluator Certified Wetland Scientist wgr TOWN OF NORTH ANDOVER Permit Number NORTH ANDOVER,MASSACHUSETTS 01845 �yOR*H , Date Issued } Expiration Date x � sS{C}Wg6 Jackie's Law — Permit Application Pursuant to G.L. e. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant Gv�i✓ ,,�` // ,,*e „ PhoneQ Cell Street Address -Pd City/Town MA ZIP Name of Excavator(if different from applicant) Phone Cell Street Address City/Town MA ZIP Name of Owner(s)of Property Phone Street Address City/Town MA ZIP A ©,97 Other Contact Permit Fee Received No Yes Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trenchh((e°g;pipes/cable�li+nes etc..)Please use reverse side if additional space is needed, Insurance Certificate 1 Q D Name and Contact Information of Insurer: r l Policy Expiration Date: -'v.X0 /.P- Dig Safe#: Name of Competent Person(as defined by 520 CMR 7.02): Massachusetts Hoisting License# License Grade: Expiration Date: BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L.c. $2A,520 CMR 7.00 et seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW. THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNYCIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE DATE EXCA ATOR SIGNATURE(IF DIFFERENT) DATE OWNER'S SIGNATURE(IF DIFFERENT) DATE: 2 1 P a g e ,,1 R .c:�s<;�r1-':fir. ^anb�al>-- '-'^r�� ".^c-.'•- r��"�'�r-.�:�.'�.r"1 � ��:� .r-serf-.. ..�+F.- -l...Y-..>...e� ..�>.c."� _ : .,- -�+--��xaY.. °D`2 r ,� �ii.=•-x „. �"-",� r� :�'=�z��-:.� :v,'�C-r _�-��' H:�;:,. .,.�� i7 r��,{;`,..,,?!.�c..�.,��;�.��^w-i v'"'J,-"_'"v�^';�:�r,-✓.r�t,,C'r "`-,. _ ,�T~^s�•' ��a"��-s�..ci�.�t �b^-•' v°��"cr'_`�"�-`="�'�.�aa.'r�--'.-"-�^>s .....G-:?-0-ft2:�'7�,r¢'.-�e.��=:,r-�;,`�,3- �".�.;`M'=Fy�.-3`(',.'__m-''"".'fey- r ,!_ 1",:='��"�-�=cam"." - fcrs ^.,vs".:'�,, ,.'G;-�_ r'x":�.<,-.c--_^'�.--�`_"A'-r-_�`','".�.*".l�`;.� �`•�"-%�.`�,"._''��`..,��1��`°r:,:..r,-`e��..�,-- c;:s:�.r�� ,-..s'�„''"F,,^'. �c� T�. ��.. ..tiy''}.a .,��%^- `.:Y:=�.L��,�F ;..��ru�T..'�.,-3,�:��c-C.�''-�-'• ..-c r:�`Sr� c.:,rr:�><�3' r=;-��. .�. - C -.r�..^' :.�/r.n;.._rr.-,+^.y-. 2v<lSc;. ..�F.`:: _...•,✓.i�rrFi^�r%fi1 .r,.'-".'..: ._..d>.;-Mi,>::_..� CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the application,the applicant understands and agrees to comply with the following: i No trench may.be excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including,but not limited to,the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164(DIG SAFE); Trenches may pose a significant health and safety hazard. Pursuant to Section 1 of Chapter 82 of the General Laws,an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR 1926.650 et.seq.,entitled Subpart P"Excavations". iv. Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety; (2)that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CMR 1926.650 et.seq.,entitled Subpart P"Excavations"as well as any other excavation requirements established by this municipality;and(3)that he is aware of and has,with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www,mass.gov/dns 3 1 P a g e 1 • s ✓lie Vr antnzan�uec�� a�✓ULaaducrriic6e�7b DEPARTMENT OF PUBLIC SAFETY Hoisting Engineer License ENumber: HE 009587 Expires:08/11/2012 Tr.no: 1789.0 Restricted: 2A ROBERT T AMOR 290 MIDDLETON ROAD c, BOXFORD, MA 01921 Commissioner J Far_HUb tdernabonal Mm EngbRdT&Cg0k2ft-Taem Of RaWiey(147 11:840402211G NF-G5 Pg 83-03 .Ci?Ient9:X23 RTA ORSWE ACORD- CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATEWCASAMNii9iOFMF0MRUMO :YAW SUDIUSMilP 7111ECERTMA3EEWLDEP-THIS CERnFICATEDQESNDTAF TMELYORlIIEGATmaypAmmEmmaitALimim BYTmP=.2tmS BELOW YMCERiWATEOFNMWJWMD08SNDTCONSW MACONTRWtBE1VAEEiYMMMMMUMBMM EK>RIZED JtATtvE OR PRODUCER,AND TTE CERIVHCATEHOLZM OWORTANT_Wthe cute holderlSaR AMBFISUNWifSt ltm ttwponcypeo �-beendorm&WSUBVJWATWNISWArAD.SubjectiD the terms and conditions st lm POft.e8rtate pokes uWreg0lm as�AsbNRUMtentIft owe does net ocafer rights to the carObcabhailerinBmefsuch . PRWUCHt HU8 hftm3#onW 1iew ErLgUW owe 978�-6Ip0 299 Bdbrdvale St S18988t1036 ExAe_ vwfm rmjwL MA 81887 978 65 -MOD N1SUR9=AFFGRD=C0VERRGE KAWN aw: BtlyioeCes R T Amor a Sen EK=Mft Irtc M M M M a-TrdVSWS�►Ca AIn dr Bats Amor tC-fir hrsarartoe 8275 Turnpike Rd MSUMMD: Rowley,MA 0196.9 e: flit F- GFS CERTWATE N-LVAMR REVOWi I RAS THIS IS TO CERTIFY THAT 7W POlCEM OF IZ1R414CE LISTED BB.OiAf HAVEtiEMis TOME IOtJREO rrlMt®AHOVE FoRTtIE POM PERM N...,,A mD7tlltmwAHW4G Am moi,780 OR NOF ANY comm ACTOR unim OOCW91wr YI m RESPWI TO WHICH THIS ATE MY L- OR MAY FEWAK THE rI K2:A BY 7HE POUCH DMCRMW FIS S!MEXT, TO ALL THE 71ENW O CLUMOM AAD CONMTMM OF SLJCi POUCM L.IY9iS SHMM VKY HAVE BEEN FMDUMD BY PAD CLAM LTR TYMOFit r Ym A aLtmeerrY . =211411 81121MM12 EKNOCu M em PPiD3 l n.GENEML kusarrY S1,600,600 Ctmomm 0 omot ane ) $18.000 Befi5b0 PegortALaAa ppm s1, 000 6@a3t11LAGGRMkM szookm GMAGGAEC,ATEtN T'APPIMSFER PtiOMICiS-C10W /t6� S OOO POmr PR6 LOC S C MMUMB"UAB 39000e7820e801190ASM4 09=20tl SR4MEUW AgYAUTOAUGWNM YbipIRYLPcp�q�) S AUTOS R mom RRED 80D�YROAAtYkPe►amdenQ S MWAUTOS x t�Rrm owrAc s s Y�tera LU9 CKXM EAMO s O(CMLrAB mmzm E AGGREME S _aar rt£Temams s B A� ��Yre 4:190PS72 /2iMI04101 1IMCSTAT[L Oirt O EMUMM I NI NIA E.LEAMAOCMBir eee gy �urdw ELk -&FEMPL SZ tri OF VFEMTWMbd,w E1 .POLICYLHe(r QQQ ilOtr OF OP6tATICkIS I LACI1TrONSI (Aeah/tCOii!10f,Alf d Raoats pie space is j CER7tF7CATE HOLDER CANCELLATION - SHOULD ANYOFTWASOVEDESCRM3ED mIBG CANcE.L.ED REPOW THt: EOlRMt M OWE THOMF, rrof= WILL W DARiERED W Town of No.Andover PANUMMANCE YM THE POLICY PRDyjwAM Board of Health 120 Main Street AVFH0RMEDR8MES8MTW Andover,MA 01845 IV — 0198�tBACORD L30RP�ATt(�Aki reserved. ACORD 2512if9=5) 1 aft TbeACORD name and 10MOmnuffishmed aim aFACO W I@ITilOt NUMBER 00Rxy COMMONWEALTH OF MASSACHUSETTS BHP-2011-0729 rOy Q �,l�eo •+��86� North Andover FEE $100.00 • r = � BOARD OF HEALTH 'Ss =wins WINDRUSH FARM THERAPEUTIC EQUITATION, . --------------------------------------------------------------------------------INC -------- NAME 470 LACY STREET ------------------------------------------ ------------------- ----------------------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Trench Permit This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires -----------September 13, 2011-----------unless sooner suspended or revoked. ----------------------------------------------------------------- June 14, 2011 BOARD OF ----------------------------- ----------- HEALTH ---------- Public Health Director TeCop------------------ pORTy COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2011-0729 Q °: North Andover FEE $100.00 = • BOARD OF HEALTH 'SSAtNUsti WINDRUSH FARM THERAPEUTIC EQUITATION, INC. ----------------------------------- NAME 470 LACY STREET -------------------------------------------------- --------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Trench Permit This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ...........September 13, 2011-----------unless sooner suspended or revoked. ----------- ----------------- BOARD OF June 14, 2011 _ "' HEALTH " / '' ---- ------- ------------------------------------------- Public Health Director f- a Agriculture and LanRsCape$rogcam UMas s Soil and Plant Nutrient Testing Laboratory West Experiment Station Extension 682 North Pleasant Street University of Massachusetts CENTER F O R AGRICULTURE Amherst,MA 01003-9302 Phone:413.545.2311 Fax:413.545.1931 www.umass.edu/soiltest/ TEXTURAL ANALYSIS RESULTS REC 1 Customer Name: North Andover Health Dept - Susan Sawyer Jul 2 5 2011 1600 Osgood St, Bldg 20, Suite 2-36 North Andover, MA 01845 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Sample ID: 102183 Customer Designation: 470 Lacy St USDA SIZE FRACTIONS PERCENT OF WHOLE SAMPLE PASSING Main Fractions Size (mm) Percent Size (mm) Sieve # Sand 0.05-2.0 97.0 Silt 0.002-0.05 2 .8 Clay < 0.002 0.2 4.75 #4 99.6 Total < 2.0 100.0 2.00 #10 78.9 Sand Fractions Size (mm) Percent 1.00 #18 61.7 0.50 #35 35.8 Very Coarse 1.0-2.0 21.8 0.300 #50 19.6 Coarse 0.5-1.0 32.9 0.25 #60 14.9 Medium 0.25-0.5 26.4 0.15 #100 6.2 Fine 0.10-0.25 14 .1 0.10 #140 3.8 Very Fine 0.05-0.10 1.8 0.075 #200 2.7 0.05 #270 2.4 97.0 0.02 20 um 1.1 0.005 5 um 0.3 Silt Fractions Size (mm) Percent 0.002 2 um 0.2 Coarse 0.02-0.05 1.6 Medium 0.005-0.02 1.0 Fine 0.002-0.005 0.2 2.8 USDA Textural Class = an coarse `V sand Gravel Content = 21.1% COMMENTS: ssawyer@townofnorthandover.com, pdellechial UMass Extension is an equal opportunity provider and employer,United States Department of Agriculn on disability accommodations.Contact the State Extension Director's Office if you have cc www.extension.umass.edu/civilright! ' Agriculture&Landscape Program UNIVERSITY OF Soil and Plant Nutrient Testing Lab 07/15/11 West Experiment Station yy MASSACHUSETTS University of Massachusetts 1 Amherst,MA 01003 413.545.2311 UMass Extension 413.545.1931 HT7P://www.umass.edu/plsoils/soiltest RECEIVED ? 25 Z011 TOWN OF NORTH ANDOVER TEXTURAL ANALYSIS RESULTS HEALTH DEPARTMENT Customer Name: North Andover Health Dept - Susan Sawyer 1600 Osgood St, Bldg 20, Suite 2-36 North Andover, MA 01845 Sample ID: 102183 Customer Designation: 470 Lacy St USDA SIZE FRACTIONS PERCENT OF WHOLE SAMPLE PASSING Main Fractions Size (mm) Percent Size (mm) Sieve # °s Sand 0.05-2 .0 97.0 Silt 0.002-0.05 2 .8 Clay < 0.002 0.2 4 .75 #4 99.6 Total < 2 .0 100.0 2 .00 #10 78.9 Sand Fractions Size (mm) Percent 1.00 #18 61.7 0.50 #35 35.8 Very Coarse 1.0-2.0 21.8 Coarse 0.5-1.0 32.9 0.25 #60 14.9 Medium 0.25-0.5 26.4 Fine 0.10-0.25 14.1 0.10 #140 3 .8 Very Fine 0.05-0.10 1.8 0.05 #270 2.4 97.0 0.02 20 um 1.1 0.005 5 um 0.3 Silt Fractions Size (mm) Percent 0.002 2 um 0.2 Coarse 0.02-0.05 1.6 Medium 0.005-0.02 1.0 Fine 0.002-0.005 0.2 2 .8 USDA Textural Class = coarse sand Gravel Content = 21.1% COMMENTS: ssawyer@townofnorthandover.com, pdellechiale@townofnorthandover.com TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSG G 20; SUITE 2-36 NORT pry@//� jEjV( AN � AC SETTS 01845 ;'ss"•'°' �/ �1CM1M1 Susan Y.Sawyer,REHS,RS DEC 7 Z�Q9 978.688.9540—Phone Public Health Director D � �D 978.688.8476—FAX healthdept@townoftiorthandover.com TOWN OF NORTH ANDOVER www. HEALTH DEPARTMENT townofnorthandover.com APPLICATION FOR SOIL TESTS DATE: CP/i ,T7,C)Qq MAP &PARCEL: MoI/DURA �1' lo D "i LOCATION OF SOIL TESTS: �P.G 4 o L-Gt c q 5-�- OWNER: M(]i�QY �t� lrl�P� Contact#: q7 g3LJ247 APPLICANT: wth 6r jZ� 'JCi Contact#: g7e3 - 7665 _ ADDRESS: ?,p e!mokVlC►\/ kend Cl.)r-/l� ENGINEER: AM Gr r-/ Contact#: 97t-6 C -gy.Iq JGZIJ� &Q -487-- 76Bo 66Fr) CERTIFIED SOIL EVALUATOR: And P3..-,rt1/ Intended Use of Land: Residential Subdivision �Famnily Commercial Is This: Repair Testing:_ Undeveloped Lot Testing: Upgrade for Addition: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM ➢ Proof of land ownership(Tax bill,or letter from owner permitting test) ➢ 8.5"x]]"Plot plan&Location of Testing(please indicate test nit 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 proval Date: ! — V t7 Signature of Conservation Agent: i Date back to Health Department: t mp in): Q s Q �� =,ry z: L(-77 CSS soo QZ 1 a+' 1 9 v \ s•a t� CII as - t o u r DelleChiaie, Pamela From: Isaac Rowe[irowe@milldverconsulting.com] Sent: Tuesday, January 05, 2010 3:19 PM To: 'Daniel Ottenheimer; Grant, Michele; irowe@milldverconsulting.com; 'Marianne Peters; DelleChiaie, Pamela; 'Randy Burley'; Sawyer, Susan Subject: 470 Lacy Street Attachments: 470 Lacy Street-Soil Testing Results 1-5-10.pdf Susan, Please find attached the soil testing results for the above referenced property. The testing was for the existing fame house on the property. It is a horse farm (Windrush Farm). As you will see the perc rate was a little slow due to the compacted glacial till. Please let me know if you have any questions. Thank you, Isaac M. Rowe,R.S. Project Manager Mill River Consulting 6 Sargent Street 1 PCr _ ... .__. _..`..............._....... .. 12 _..............; _ - 1 411 i y z oq� t�. ..z-� .5,•� ..., f 4-K y i... s rte. . 7 j _ - ;/it/ 77.5 _ r 7-1t-b FILE# Ancef I Z 307 A e TITLE V INSPECTIONS �CEIt/ED Dean G. Luscomb II& Sons DEC 0 S 2009 P.O.Box 135 TOWN of Noh:i, ri;gjuvER Middleton,MA 01949 kiALThi bEf�ARTIUIENT 978-774-4065 Licensed Plumber#20285 �1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PROPERTY OWNERS NAME Mkr10 ry Kr'#rl 46� PROPERTY ADDRESS -4/70 y Y� 184`Aq rdov er- Mr, , o194`3- ADDRESS DDRESS OF OWNER(if different) DATE OF INSPECTION ©U NAME OF INSPECTOR -be0.v,, G . Z,141CJ^6 QUALITY IS NUMBER ONE TO US. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector use the return key. Dean G. Luscomb II & Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 Cityrrown State Zip Code 978-774-4065 S 1848 Telephone Number License Number B. Certification 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes VFails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's tignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Foran:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts N . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 470 Lacey Street - Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) �� Inspection Summary: Check A,B,C(DJor E/always complete all of Section D A) System Passes: // ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): l d ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 „ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: !� You must indicate "Yes” or"No"to each of the following for all inspections: t Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ �l Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 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 1/day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 commonwealth of Massachusetts = Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 470 Lacey Street - Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a -desig„n flow of 10,000 gpd to 15,000 gpd. For large systems, u must indicate either"yes" or"no"to each of the following, in ad n to the questions in Section D. Yes No ❑ ❑ the system is within 400 o urface drinking water supply ❑ ❑ the system is w 1 00 feet of a tribu atq ,o a surface drinking water supply ❑ ❑ the s m is located in a nitrogen sensitive area*terim Wellhead Protection ea—IWPA) or a mapped Zone II of a public waters y well If you hav swered"yes"to any question in Section E the system is considered a sl nificant threat, or a_ ered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No LJ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Q/ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) LJ ❑ Was the facility or dwelling inspected for signs of sewage back up? 2 ❑ Was the site inspected for signs of break out? R" ❑ Were all systemcomponents, excluding the SAS, located on site? E ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? E!1- ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has y/ been determined based on: I� ❑ Existing information. For example, a plan at the Board of Health. d ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ] No Is laundry on a separate sewage system? [if yes separate inspection required] ® Yes No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage (gpd)): Detail: � 4:�d ��► s I i7e Sump pump? ❑ Yes X No Last date of occupancy: j�2Urreiy Date Commercial/Industrial Flow Conditions: Type of Establishm Design flow(based on 310 CM 203): Gallons per gpd) Basis of design flow(seats/persons/sq.ft., etc. . Grease trap present? ❑ Yes ❑ No Industrial waste holding tan sent? ❑ Yes ❑ No Non-sanita ste discharged to the Title 5 system? El No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is MA December 3, 2009 required for N. Andover every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of oancy/use: Date Other(describe below): General Information Pumping Records: Source of information: r Was system pumped as part of the inspection? ❑ Yes [v'No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 9? Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is N. Andover MA December 3, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: last iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): T •, �� raVp d s7 �-�'DUIX S tn.C' Septic Tank(locate on site plan): Depth below grade: feet 40 Material of construction: Voncrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) ZZ-20 sfy�� m Le �y 7 .1-nIf tank i years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate No Dimensions: DC�y'a WOO /D ,Cons Y�11 Sludge depth: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments H , 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffleg" Scum thickness -n Distance from top of scum to top of outlet tee or baffle S " Distance from bottom of scum to bottom of outlet tee or baffle /3 How were dimensions determined? R4 4iC. 5 AVA Js Kmeau re- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I�IC. "(t- r,-,d 60>_Xe s Gi;r r-1 Lie-rl f 94y T� L11g t4►14 En . ��IL. I's runninq � - r - ��e�4 �orkit/W Grease Trap (locate on site plan): Depth below grade:'--- feet t Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene,,.,- ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee affle Distance from bottom of scum to button of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 470 Lacey Street Property Address Marjorie Kittridge Owner Owners Name information is N. Andover MA December 3, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): v Depth below grade: Material of construction: ❑ concrete _-❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explai \� Dimensions.- Capacity: imensions:Capacity: \``� gallons Design Flow: gallons per days Alarm present: Yes' J ❑ No Alarm level: ,Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 Lacey Street Property Address Marjorie Kittridge Owner Owners Name information is required for N. Andover MA December 3, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): j Depth of liquid level above outlet invert �`��' �° ' �� . �I / Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Dox- tS (Z` Uoo qe'J-4, (?o5C C5 17"X(7 "Xge.GGLzt llV4 Du '1, —a CVL(5tYLc lam' 1 V! Is rp rile o I '^�- l 4 lit t l o 9C !* 4-"u n s € Pump,Chamber(locate on site plan): D Pumps in workin der: ❑ Ye ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump cha con n of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: L� leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 6ru lt�� ra I' 1 Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 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 ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):-- Privy (locate on site plan): l7 Materials of constrrection: Dimensions Depth of solids Comments (note condition of soil, signs of hydraU'li ailure, level of ponding, condition of vegetation, etc.): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �--- Subsurface Sewage Di. posal System Form -Not for Voluntary Assessments 470 Lacey Street f� Property Address (l�G Marjorie Kittrid e Owner Owner's Name ' information is required for N. Andover MA December 3, 2009 eve pa-e._ City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal S rovide a view of the sewage disposal system, including ties to at least two permanent ence landmarks or benchmarks. Locate all wells within 100 feet. Locate where public wa upply enters the building. Check one of the boxes below: [�hand-sketch in the area below D Gives W e. ❑ drawing attached separately t,)+-.T'= 79 hl�0 LAY �t A). � a /wet, a P �k \P /r O J PILO f'o`r= �� D ✓ P,t j�-►D - � t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is required for N. Andover MA December 3, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope 4&-rczd6ta./ Surface water IUOA-P-, ® Check cellar /pry A-b 5�"^ ' Foc,�io ® Shallow wells S Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of 1Health -explain: ❑ Checked with local excavators, installers-(attach documentation) [� Accessed USGS database-explain: You must describe how you established the high ground water elevation: t�- ba,S�w..-�-•.� i5 t�� .ow c�'�c�x,e. �� e1.3� ,st. H-�,� pc�.�.V� Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 470 Lacey Street Property Address Marjorie Kittridge Owner Owner's Name information is N. Andover MA December 3, 2009 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i �� -�_ J �,�' � � -� �� a' �� ;.,� �� r � � �� `�,� _ � � ��; � �� LO C S ^� _ 710 rX Z1p 134 ' jN �?bC pi to/AJ - N ELEV S — .Bag /d 90r Z 5 �` ave- - 90. e91-5 /4141 �v DoT 9;3 - . ADD1 " 10 N Lo ( Z� 4 'xg ' F-;WvJ•usa s �1j- ' S�ot�y i FOR ' W I NDRUSH FARM �� 0 LACY ST DATE *. 4 JAN 93 THIS PLAN SUBSTANTIALLY CONFORMS SCALE : 1�=2 O� TO THE PLANS PREVIOUSLY APPROVED �A��NOf ASc�'�ti STEVEN J . D ' URSO R . S . gtaw ENVIROMENTAL DESIGNS 22 LILLY POND RD. BOXFORD, MA . 01921 .�; �lST �;' �.•' L. 5 08- 3 5 2 -987 2 •....�„�r�„;�,