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Home My WebLink AboutCertificate of Compliance - 333 RALEIGH TAVERN LANE 1/13/1999 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 1/13/99 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by John Soucy a North Andover Licensed Installler at 333 Raleigh Tavern Lane,No. Andover, MA 01845 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit # 986.5 dated 7/23/98. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector )VO4 OF NOfil H A, BOARD OF HUAL, imuu I 1 min ol k r r TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( constructed; ( ) repaired; by �t � located at "' !i c was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # dated with an approved design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. p Bed inspection date: , ' e . . resen "t A - En gi �er Re p e ... Final inspection d te: Enginggr Represent i e Installer: + ' ..,._- Lc.#: Date: rry w. Design Engin ..,. _,.. Date: cal, s � f MIX-- 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 14, 3S3 QA�.C7t6[4 L��t� , R10.A�cDOV �, Hf)•otBuS Owner's name Date of Inspection PART A CHECKLIST Check if the following have been done: �/ Pumping information was requested of the owner, occupant, and Board of Health. V/ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. V/ The facility or dwelling was inspected for signs of sewage back-up. 1/ The site was inspected for signs of breakout. V All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of / sludge, depth of scum. The size and location of the SAS on the site has been determined based / on existing information or approximated by non-intrusive methods. V/ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. S 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential ' L number of bedrooms e_ number of current residents 10 _ garbage grinder, yes or no laundry connected to system, yes or no C) seasonal use, yes or no If nonresidential, calculated flow: Water meter readin s, if available: 19Z 6 'p-b' AV6 , 7� 4)r't Lt-21 ,gy) CyQQr1sT Last date of occupancy GENERAL INFORMATION Pumping records and source of information: \ System pumped as part of inspection, yes or no if yes, volume pumped 1000 6AL _ Reason for pumping: TLS I W �PEc C��L 1 110 ( O1F Tla 1 1►�_ . �d�Ft�l S l y 1/.r 3 pee--- Type of system Septic tank/distribution box/soil absorption system Single cesspool- overflow cesspool Privy 1 � Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Col_r S i(,u c -F—D �10 Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:z (locate on site plan) depth below grade: 2 Z. material of construction: V---'Concrete metal FRP other(explain) dimensions: L= 0' hJ 6' sludge depth '06" distance from top of sludge to bottom of outlet tee or baffle 4,, scum thickness Z" distance from top of scum to top of outlet tee or baffle JZ" distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) CI Q(."'io lwvrL (::?- ou-Fu l (L4V6"2T , S(20C-TU"L P'4rF-6P1T-\'j IS o0b , co Evfcfijc� o LuL HA Pt c,�s i �✓�F � i�cs��aTro�r (DE SON• LIU PALL lVa S IS DISTRIBUTION BOX: >/ (30" gE6)� GSA lam) locate on site plan) ( p ) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) (q 'Z, " X 2LI" ,llo f-7vc Sof-+6 ScC-�pS Cg Rat ova o55 Zva54Q CcG. SvTTS t--N // PUMP CHAMBER: W( A (locate on site plan) pumps in working order, yes or no Comments: . (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: -,i A•,�, l�jFo, oGTA)KjG1] Faotn "PLeAkI SHowI�(C A2cPaSFL� Sv'l�Sc (ZF�}cj 4 G t�i SPoSAL SVS-gf t AwQ) Pt?,PofrQ G�i CxRs�oiuCa" p� fF_� 2-17-7� �/ T��P►-E s. ��>rc��c.o 2•�, ou �� win-+ n-+F tir�2Tr-+- � �.��0��2 f3o8 R3 o F H f!!:A L 1 Type leaching pits and number 3 S H(ALL.oLJ te-,4 c H i KA6y P TS leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) Mo Popp (005. o-j fl-�Ox , ,L1cy Si C,uS DE K-'fbMULt G ,F✓ 1 LUk2� o p_S, Rr--- Apr 0v057dZ 0.A•s ARv:A 1,jo - v��T PIPE- F4L 9QLY'45,t1 CESSPOOLS (locate on site plan) : number and configuration U/8 -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 (cesspool must be pumped as part of inspection) Comments: (note condition 'of soil, signs of hydraulic, failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of constructionl�A dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent referendes landmarks or benchmarks locate all wells within 100 ' N �po0 GqL. N o � Ss✓�r�c,-rt�u� I��- °"ED'S .D-- &-)X DEPTH TO GROUNDWATER depth to groundwater(moo wAT2� method of determination or approximation: S� Soil S(Ili! „ 1�- (Z t-?i�Tlo�_I F r�1 l Z--7 L1 &�► of l - P)i Pe P El : 1 SS y 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) N 0 Backup of 'sewage into facility? No Discharge or ponding of effluent to the surface of the ground or surface waters? ID Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? N 0 within 100 feet of a surface water supply or tributary to a surface water supply? N,O within a Zone I of a public well? 0_ within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analy: for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART U CERTIFICATION Name of Inspector Lf�F!Lb P, �'_10 p I h Company Name P l 'IEGSZII`�RG ��Ca1�1d21 lCa S2V/C = ° Company Address PAQK Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Ch ck one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature Date Original to system owner Copies to: �J0 -I-H A)- f� C)V(52— Buyer (if applicable) Approving authority