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HomeMy WebLinkAboutBuilding Permit #BHP-2010-0560 - 224 CARLTON LANE 6/28/2013 poRTN r BUILDING PERMIT TOWN OF NORTH ANDOVER ° t APPLICATION FOR PLAN EXAMINATI h Permit N0: Date Received ^0 Argo Date Issued: ACHU IMPORTANT:Applicant must complete all items on this page LOCATION �-Z.-1" U d h-Y) �4 ilf,, 4 �3 01{1 "A,4ff ( HA /� Print PROPERTY OWNER !.�fl M UN Lh)(r10cC , J Print MAP NO: Zq PARCEL: 10 �� �ZONING DISTRICT: �P� S IG�?�Ii rie District yes no 1k N-03 Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building N4ne family ❑Addition ❑ Two or more family ❑ Industrial ❑AI eration No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer "1124, I�•.� Identification Please Type or Print Clearly) OWNER: Name: W ake's Phon4-- wo-043 Address: Z car LI ,�- / t 0oah /-Kn d ovff I HA 0 10 4-6 CONTRACTOR Name: i„lr✓tiei ��������Phone: � i����{- 316 Address: L4Z- Supervisor's Construction License: M�Kc i 12-12-0 Exp. Date: ' ! j Hike 6-, f Home Improvement License: 1 CIJAC( k, i ( Exp. Date: fa 2.7[2-0 1 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 1 FEE: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have ac ces o he guaranty fund Signature of Agent/Owner Signature of contractor 1C u -TT9 E t h P- 1 5Fn� V►��A U 6�,13'S � , o .� 10 Soo 5r- Gy 5FGy S t wq��h Commonwealth of Massachusetts Map-Block-Lot 107.A0203 3;p�l�, to .s,�yoot _ Board of Health Permit No ' -20 North Andover BHP10-0560 ----P-20------------- 40 -' P.I. FEE �, ,.•.�� $125.00 ass;cNuSt� F.I. DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John DiVincenzo - - - - - ----------------------------------------------------------------------------------------- to(H-20 D-BOX REPLACEMENT)an Individual Sewage Disposal System. at No 224 CARLTON LANE ----------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2010-056 Dated --April-28,_2010---____ Issued On:Apr-28-2010 Board of Health e ' •r r 10 Application for Septic Disposal System 3�•`•' •`' ` °c Construction Permit - TOWN OF TODAYDATE $250.00—Full Repair ;,s.,,,•,.s� ORTH ANDOVER, MA 01845 125.0 Iii ' C Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal Sys only the tab key (� _ �� to move your ZI Repair or replace an existing system component—What. J cursor-do not use the return A. Facility Information key. 1LI Address or Lot or City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑Gravity(choose one) ***If pump system,attach copy of electrical permit to application*** ❑Conventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information -#o f !-c Name t /(� Address(if different from ab ;r' r^,, . ' City/Town State Zip Code �� Telephone Number 3. Installer Information a ill AJ CCM Name Name of Company /4/K d✓L�S'S �>�� Addres City/Town State ip Cod 3 ;� Telephone Number(Cell Phone#if possible please 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 r r� of MORto, Application for Septic Disposal System 3�•�' '•`' ' °< TODAY'S DATE , Construction Permit - TOWN OF °• -=���,�' ORTH ANDOVER, MA 01845 $250.00-Full Repair „••" $125.00-Component ••Sswswus,< PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: A 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 Board of Health. A p L. I- o1 V i m Name Date Applicf-n Approved (Board of Health Representati; Z71 e) #� 2D1v Date Application Disapproved for the following reasons: �Di S GtvSS C d 1-/, t?-0 For Office Use Only: L Fee Attached. Yes P� No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Svstem? If so,Attach coR,y ofElectrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 � � v SEPTIC SYSfE'M INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Engineer) Relative to the application of tJ �) y I Ai eeAU And dated (Installer's name) ngma ate Dated J ? o� ` o ay s ate With revisions dated (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 plans prior to performing any work on a site. I must have the appror ved 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 Title 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 (15� 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: healthdeptgtownofnorthandover.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 ofHealth 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 approved plans. No instructions by the homeowner,,general contractor, or any other persons shall absolve me of this obligation. Undersi ed Licensed Septic Installer: (Today's Dat _ S ame— rtnt —7— Signed) TOWN OF NORTTi'ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES o HEALTH DEPARTMENT 1600 OSGOOD STREET;Building 2-36 41 NORTH ANDOVER,MASSACHUSETTS 018 !� SALHUS Susan Y.Sawyer, S / X Public Health Directorctor 978.688.9540—Phone978.6881.847;6/F D-BOX 6 Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to _ soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel-less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: Wastewater System Documentation—Feb 2006 Page 3 of 6 I Commonwealth of Massachusetts -- Title 5 Official Inspection Formqqpp,� Subsurface Sewage Disposal System Form - Not for Voluntary Assess ntst t1 224 Carlton Ln. OFNOW" Property Address LA.��� WhalleyJ� Owner Owner's Name y 1231-2010 information is North Andover MA 01845 -1=204— required for every State Zip Code Date of Inspection J page City/Town .1G jt7 Inspection results must be submitted on this form. Inspection forms may not be altered in anyI� L way. Please see completeness checklist at the end of the form. ��� Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Jablonski use the return Name of Inspector key. Jablonski &Sons Inc. r� Company Name 167 Willow Ave Company Address Haverhill MA 01835 City/Town State Zip Code 978-360-9358 4574 Telephone Number License Number B. Certification t 1 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: �- j (-CP 6r-4 y, 10 ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Fu er Evaluation by the Local Approving Authority `'1�/�(,h.,o Inspector's Signat Date The syst ector shall submit a copy of this inspection report to the Approving Authority (Board of Heal r 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 Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is required for every North Andover MA 01845 3/23/2010 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or 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 Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is required for every North Andover MA 01845 3/23/2010 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): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Distribution box is cracked and needs to be replaced ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I i' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is North Andover MA 01845 3/23/2010 required for every page Cityrrown 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. F1The 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: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 1/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts _ -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is North Andover MA 01845 3/23/2010 required for 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 design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IW PA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "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 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 �l I Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments «N 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is North Andover MA 01845 3/23/2010 required for 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 ® ❑ 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? ❑ ® 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) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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? Was the facility owner(and occupants if different from owner) provided with ® ElWas on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 t5ins•09108 Tale 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 ..° 224 Carlton Ln. Property Address Whalley - Owner Owner's Name information is North Andover MA 01845 3/23/2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 2 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 ® No Water meter readings, if available (last 2 years usage (gpd)): 121 gpd Detail: Sump pump? ❑ Yes ® No Occupied Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ 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 _ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is North Andover MA 01845 3/23/2010 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Last pumped 5/16/2008 by Barleson Enterprises. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: na gallons How was quantity pumped determined? na Reason for pumping: na Type of System: ® 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•09108 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 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is required for every North Andover MA 01845 3/23/2010 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: Certificate of Compliance signed 9/23/1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2411eet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: na feet Comments(on condition of joints, venting, evidence of leakage, etc.): Watertight at foundation Septic Tank(locate on site plan): 8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: na years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6x65x68 Sludge depth: 3" 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 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is North Andover MA 01845 3/23/2010 required for 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 baffle 31" less than 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is structurally sound Inlet and outlet tee's in good working order. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/09 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 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is required for every North Andover MA 01845 3/23/2010 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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ 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 �M 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is North Andover MA 01845 3/23/2010 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): Box is corroded and needs to be replaced Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition 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 _ -_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is required for every North Andover MA 01845 3/23/2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2- 70' ❑ 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.): No sign of hydraulic failure or ponding 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 224 Carlton Ln. Property Address Whalley Owner Owners Name information is North Andover required for every MA 01845 3/23/2010 page. City/Town 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): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments H 224 Carlton Ln. Property Address Whalley Owner Owner's Name information is North Andover MA 01845 3/23/2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ZZH tot 0 a 13 C t I CZE 7 ZL t 1 t5ins•o9/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 224 Carlton Ln. Property Address Whalley Owner Owners Name information is required for every North Andover MA 01845 page. Cityrrown 3/23/2010 State Zip Code Date of Inspection D. system Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 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: 1/17/1985 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: E� E-b z acsr5 w,sZ�, (o ,8 ,8Z I-14yES E.✓G �,, t >wc5� I3 i G�o��N `�. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5in5•09/08 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 w� 224 Carlton Ln. Property Address Whalley Owner Owner's Name information isMA 01845 3/23/2010 North Andover required for every page City/TownState 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 Town of North Andover Licensed Septic System Installers (Disposal Works Installer's) Please note that the se tic installer is licensed onl -- not the com an Five or more Installations within the last Name 18 months #of Affiliated Company Phone# 1 Amor,Robert 0 JR.T.Amor 978-887-5468 2 Bateson,Todd djI 20 113ateson Enterprises, Inc. 978-475-1474 3 Beaulieu,Serge R. 0 1 Roadway Excavators 603.893.9189 4 Breen,Peter 0 Peter Breen Excavating,Inc. 978-682-7774 5 Briscoe,Daniel R. 1 Daniel R.Briscoe 7 978-372-2200 6 Busby,Philip A.Jr. 0 Busby Construction Co.,Inc. 603-362-6015 7 Carr,John 0 Ramey Construction 978-633-6791 8 Colosi,Philip A. 0 Colosi Construction LLC 978-777-5679 9 Coyle,Kevin 0 Kevin Coyle 1 603-944-8501 10 Currier,James H. 1 James H.Currier Construction Co,Inc978-774-6685 11 jDalgle,Robert K. 1 Robert K.Daigle,Jr. 978-887-3703 12 DeLucia,Rocci Jr. 0 Frank DeLucia&Son,Inc. 978-686-8200 13 DiVincenzo,John L. 2 Andover Septic/J&S Dev.Corp. 978-372-7471 14 Giard,Daniel 0 jDanial A.Giard Septic Service 978-686-7653 15 Hall,Bill,Inc. 0 Bill Hall,Inc. 1 978-689-3711 16 Hartigan,James 0 James Hartigan 978-766-0087 17 Hoehn,Bruce 0 Bruce Hoehn 1 978-372-8274 18 Hutton,Arthur 0 Hutton's General Construction,Inc. 978-685-2667 19 Innis,Robert L. 0 R.L.I.Corp. 1 978-663-6006 20 Jablonski,Chad 0 Jablonski&Sons 978-360-9358 21 Kellett,James 3 Kellett Excavating 781.953.7146 22 Marsh,Steve 0 The Westchester Co. 978-742-9778 23 Maynard,Dave 0 Maynard Construction 978-375-7228 24 Murray,David 1 Ranger Development Corp. 978-360-8506 25 Osgood,Ben 1 New England Engineering 978-686-1768 26 Pearce,Warren 0 Pearce Construction 978-664-5264 27 Petrosino,Angelo 0 Angelo Petrosino 978-664-2030 28 Quinlan,Timothy 0 Quinlan&Rand Builders 978-457-0528 29 Reilly,Mike 0 F.P.Reilly&Sons 978-475-1237 30 Sawyer,William T. 1 Arco Excavators,Inc. 603-642-8910 31 Shaw,John 111 0 Wildwood Excavation,Inc. 978-474-8088 32 Soucy,John J. qW 8 Soucy's Sewer Service 800.541.9379 33 Sullivan,Jack 0 Jack Sullivan 1 978-352-7871 34 Surianello,Joseph 0 Ralph Surianeilo,Inc. 617-799-3900 35 Todd,Charles R. 0 Charles R.Todd Contractor,Inc. 978-667-4270 36 Waelty,Craig Skip 0 Craig Waelty 978-664-2126 37 Watson,Joseph 0 lJW Watson,Jr.Inc. 978-475-8581 38 Zaher,Charles 0 IChades Zaher 978-804-7786 39 Zaloga,Dave 0 Dave Zaloga 603-765-9296 Total Installations 1/1107.717108 39 Note: The Septic Installer Exam is held in January.March,May.July and September of each year. You must call the Health Department to sign up for the exam at 978.688.9540. The testing fee is$25. Last Updated:7/7/08 Last Updated: 7/7/2008 T COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y�y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION R�,CEIVED Property Address: c2 aZ4 'Z' /{t / G-� ---bl o n1my Owner's Name: Owner's Address: 7H Ah* TOS DF NOR H�,p.LTH DEPAf2Th Date of Inspection: 5= U- 0 5- g Name of Inspector: (please print);lm 1 a Company Name: Mailing Address: 12 , �� � Telephone Number: _ CERTIFICATION STATEMENT 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 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. Notes and Comments ****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. ti Title 5 Inspection Form 6/15/2000 page 1 ti ' • -Page'2 of I I " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A n CERTIFICATION (continued) `L '} Property Address: Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D + A. System Passes: ! S r /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: s� 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 -Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l j t-/ 7i Owner: Date of Inspection: _ 5-- V- p -5, C. Further Evaluation is Required by the Board of Health: A/ 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 A 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. r 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 and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3 t Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _ //7,) /Z LTz 1 1 L N Owner:—1,u/-//=i t- o. Al Date of Inspection: D. System Failure Criteria applicable to all systems: ' You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ ✓$ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool "bischarge 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 '/,day flow L- 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. ��ny 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] (Yes/No)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 design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: —2 �/ ('d4-/10 Owner Vic//yG i N Date of Inspection: r Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ✓_ Pumping information was provided by the owner,occupant, or Board of Health t--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? /Have large volumes of water been introduced to the system recently or as part of this inspection? L." _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? 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? _✓_ 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 been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] g 1 5 Page 6 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION Property Address: Owner: f/il/C//3-rr Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): Hu [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): /-/u Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): /-A Last date of occupancy: 6 Cc b(b e d COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_ gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 7/ Was system pumped as part of the inspection(yes or no):&'5 If yes, volume pumped:/1-00 gallons-- How was quantity pumped determined? Reason for pumping: �'� n i1 7A H/1_ S7 R o c Tc.2 C TYPE OF SYSTEM _✓Septic tank,distribution box,soil absorptian 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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):H-0 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 ?. �� C1v�tp�, �,n✓ /'0 e a,e r2 Owner: , l- Date of Inspection: `- BUILDING SEWER(locate on site plan) Depth below grade: ZZ Materials of construction: o"cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): JOWT S GdaO SEPTIC TANK:1�9(locate on site plan) Depth below grade: rf Material of construction:_-Concrete_metal_fiberglass_polyethylene —other(explain) r If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /0 (, " l 5 Sludge depth: 5 , Distance from top of sludge to bottom of outlet tee or baffle: '34 Scum thickness: /" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 4 Al S/ IX Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 1�i¢FfGFl 7-4NK 6dur) 04 -t/)/ Tiozr GREASE TRAP: locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: ` Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 • Page 8 of I 1 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z ( ,1kkrwl G,y /'/ H On Ut✓ Owner: Date of Inspection: I!r-- TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: lob J/ 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.): e v IO ' PUMP CHAMBER: /(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Wage 9 of 11 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,2.� '/ 1.1.17'iji GN 14 Owner: Lu/1-r de Date of Inspection: /—a ►� SOIL ABSORPTION SYSTEM(SAS):y (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: zleaching trenches,number, length: 0 f Pl 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.): Y0124uu - jCW11,412K — So/cS y�y 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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): ? 9 ,Page 10 of 11 ` r " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: ,,2 2 / d�� �,�a i Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. d C r /3- - a 19 G ' ' r �o V I y j I 1 1}Fix- 10 Page' 11 of 11 s ^ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / PART C SYSTEM INFORMATION(continued) Property Address: ,l v/ n,,y Z-r/ Owner: Date of Inspection: g= y—o 1� SITE EXAM Slope _ `L ►' Surface water Check cellar Shallow wells M•A Estimated depth to ground water t, feet Please indicate(check)all methods used to determine the high ground water elevation: V'' Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked.with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: t - 11 CO/MONWTALTH OF MASSACI412SETTS ( EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. AIA 02106 617-292-5560 All, TRUDYW1LUA%!F WELD C0� Govcrno: Scactan ARGEO PAUL CELLUCCI DAVID B.STRUHS U.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address O�oTT v �` `ti��n'� 16d AtZ6ve(<- Address of Owner: Date of Inspection: /o1�d AF (if different) Name of Inspector: BENJAMIN C. OSGOOD JR. ` 1 am a DEP approved system inspector pwrsuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SARVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1768 CERTIFICATION STATEMENT I cenify 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(nspeciron. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: !� Passes _ CondRtonalk Passes l Needs Further Evaluation By the Local Approving Authority _ fails Inspector's Signature: Date: The Svstem inspector shat ubmit a copy of this inspection report to the Approving Authority twithin thirty(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 repon to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority, I INSPECTION SUMMARY: Check A, 8, C, or D- t AI SYSTEM PASSES: V/', TEt have not found any information which indicates that the system violates any of the failure :te::a as dafined in 310 ChiR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pus- 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. Indicate yes, no, or not determined (Y. N.or NO). Describe basis of determination in all instances. If-not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(201 years prior to the date of the inspection: or the sic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltnor tion, ta septic nk failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (r-i-d Ol/7S/f71 P.O. , ,,, 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 0Q,P CERTIFICATION (continued) a /f ; Property Address: 5 ���`fvK �i,�/ 1� , {,t-c>�Ovee Owner: -�b&Q 1, #0"6 ¢q OT Date of Inspection: /O BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health;. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 replaces I cbstruction is removed t C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reourre iurther evaluation by the Board of Health in order to determine if the system.is failing to protect the public health. safety and the environment: 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE �YSTEM IS NOT FUNCTIONING IN A MANNER t WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: i Cesspool or pri„• is within 50 ieet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: , The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a suriace water supply. I The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supn'y well. ` _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but SO feet or more from a private water supply well. unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free irom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. method used to determine distance (approximation not valid). 3) OTHER s.y. 3 Of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a�� �l�Q I v'ti 1 � j IVO ei" 4-1, Date of Inspection: B(3 * c�G k Sa7J D) SYSTEM FAILS: You must indicate either `Yes"or"No-as to each of the following: I have determined that the system violates one or more of the f6llowing failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. 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 boa above outle inverts due to an overloaded or clogged SAS or cesspool. liquid depth ,n cesspool is less than 6' below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of Mmes pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation Am portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. l Any portion of a cesspool or privy is within a Zone 1 of a public well. I An% portion of a cesspool or privy is within 50 feet of a private water supply well Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no T acceptable Nater quality analysis. If the well has been analyzed to be acceptable. aaach copy of well water analysis for cohiorm baagria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: Ypu must indicate either 'Yes- or -No-as to each of the following: tThe following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (interim Wellhead Protection Area- IWPAI or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/1S/17) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: q Caine t1 6,- art.e- , (Vl)&P L Owner: rt- Date of Inspection: Check if the following have been done: You must indicate either -Yes`or'No'as to each-of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ 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(he system recently or as pan of this inspection As built plans have been obttamed and examined. Note of then are not available with N/A. _ The iacility or dwelling was inspected for signs of sewage back-up. ( _ The system does not receive non-sanitary or industrial waste now. The site was inspected io( signs of breakout _ All system components. excluding the Soil Absorption System, have been located on the site. !! The septic tank manholets were uncovered, opened. and the ititerior of the septic tank was in{peded for condition of baffles or tees. material of constructwn. dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: The iacility owner (and occupants, if different irom owners were provided with information on the proper maintenance of Sub-Surface Disposal System, Existing information. Ex.(Plan at B.O.H. _ Determined in the field (d anv of the failure criteria (elated to Part C is at issue, approximation of distance is unacceptable) (13.302(3)(b)) (r.vi..d 04/2S/271 T.y. 4 or 10 r . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C I SYSTEM INFORMATION Property Address: a� t�(!�e Q0 KJ Prfu V N ��0 d Pve_ Owner: Date of Inspection: / FLOW CONDITIONS RESIDENTIAL: Design (low: ft.P.dJbedroom for S.A.S Number of bedrooms:, Number of current residents: Garbage gr-r.der(yes or no!:_,qD Laundry connected to system lyes or no):AL Seasonal use (yes or no):_.d4 Water meter readings. if available (last two (2) vear usage (gpd): /lbs PV/0" Sump Pump (yes or.no): Last date of Occupancy: our i I I COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: 'Rallons/da% ' Grease trap present: (yes or nof_ , Industrial Waste Holding Tank present: Ives or no)_ Non-sanitary waste discharged to the Title 5 system: lyes or not_ Water meter readings, if available Last date of occupanq- � f f OTHER: (Describe! Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information 1 ' ^T*�,k P) ,PC 0 3 y Q_-l-tes C&,,, I tm System pumped as part of inspection: lye or not lel j 1(yes, volume pumped: Rallohs Reason for pumping TYPE OF SYSTEM `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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: /C� Va*-es Sewage odors detected when arriving at the site: (yes or no) Q� (revised 04/2S/j7) Page 5 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C = 11 SYSTEM �, INFORMATION (continued) Property Address: d� (26 e�r0 U kt, 6z i 1V V Q K Owner. R u�a Q� o Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron ✓0 PVC _other (explain) Distance from private water supply well or suction hr-. Diameter Comments: (condition of joints, venting, evident of leakage, etc.) 1 C =Oc�n 6+ �5 �Qi P i`n cr ��C 4S V� (A l^A � �GG w L tlr Old r � I SEPTIC TANK:_ I I (locate on site plant Depth below grade: Material of construction: dconcrete _metal _Fiberglas§ _Polyethylene _other(explain) If tank is metal, list age _ Is age conitrmed by Cendicate of Compliance —(Yes/NO) / Dimensions: ,� X( 0 1 �Q— P�II{GGZ 19 �S Sludge depth: to Distance from top of sludge to bottom of outlet tee or bait :96 Scum thickness: /H _ I A F/ 'e't. Distance from top of scum to top of outlet tee or banle c7© Infe4-s&17e,"u.1' s /T _ Distance from bottom of scum to bottom of outlet tee or baffle: c9.1 /e e' icy sf�-GG � How dimensions were determined: Meeb,;ea Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, stru4tural integrity, evidence of leakage, etc.) v f/-c Tec /�e iv AC w• /L� SG%�� V,) PUG /p I ' GREASE TRAP: (locale on site plans Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _othertexplain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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, etc.) (r.vi..d 04/)5/97) T.q. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: c9py �9QL 'u /' Qj Paje A eiL' Owner: fbeee )oGllT Date of Inspection: TIGHT OR HOLDING TANK: tTank must be pumped prior to. or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal_Fiberglass _Polyethylene —other(explain) Dimensions: Capaaty: gallons Design f!ow gallonlda% Alarm level Alarm in working drder _Yes. _ No I Date of previous pumping: Comments: (condition of inlet tee. condition of alarm arta float switches. etc.) ` i i • t DISTRIBUTION BOX:_ Q (locate on site plan) b 0 K //119'SB,�7L'A-' ['" ��` 071 �/a+2 k D fL ThS Z,s:Arc o�ti s Ut-e L�i Depth of liquid level above outlet inven: _ 45 p,`P41 Tp o 7-,-) k ax . Comments: (note if level and distribution is equal, evidence of solids carryoLer, evidence of leakage into or out of box, etc.) beu. -b P,OX ,,( o r el Z, ,;A /ICU /z040--k-C✓ 01/c%Z I I � t PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (rtvia.d 04/25/97) rag. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n J J SYSTEM INFORMATION (continued) Property Address: a 5 t{ 0'#'Q 1 V 0 n h 4, d Q �4 kL e.4, Owner: Pei 4gaer & c)L'S d f Date of Inspection: in/-v+ " '?'7 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: Type. leaching pits, number:_ leaching chambers. number:_ leaching galleries, number: _ / t leaching trenches. number,length: �' J&-tckv,=, 10 otiC—1-7*c`l leaching fields, number, dimensions:_ overflow cesspool, number: Alternative system: Name of technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, co dition of vegetation, etc.) may/ e2 CESSPOOLS: _ (locate on site plan) Number and configuration Depth-top of liquid to inlet invert: Dr-pth of solids layer: Depth of scum layer: Dimensions of cesspoo!: &Jaterials of construction: I I Indication of groundwater: inflow (cesspool must be pumped as pan of inspectibn) ' Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of'construction: Dimensions: Dep(h of solids: Comments: (mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r.vi4.4 01/]5/17) P.q. S of 20 c17- %17 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) h��vtZ�, 1'VI /J- Property Address: �a y Owner: pt-oC Date of Inspection: .16 4/(J/5�7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I I � ✓) D cK o Q cl- rtv T i tj tc' \ 8� P' N ort To S C 4 t-�7. _. ._. ..,�. P... 9 of In l � I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: as t_( C e , v `� 10Je&A I Owner: _ Date of Inspection: oQ13 t2l G k S( f40T 7 /O/J-- Depth to Groundwater Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Aborting property obsen•ation hole. basement sump etc.) Determine it irom local conditions Check %wth !o--a! Board of health t Checi, FEMA Maps Check1 i pumping records Check local excavators, Installers Use USGS Data Describe in your own words ho..• you established the High Groundwater Elevation. (Must be completed) 1 ) 17t�s`ic�-�v ���� �y -Tom S 1�{�r��� V�sso� • 'bAAQ0 fietI� GTit Say L ��( � oTkcze 3011 0 Ofz T CeC (-i..d 04/71/971 P.9. 10 or 10 NEW ENGLAND ENGINEERING SERVICES INC f6ANiel&.�e1Fn�•er a S` • 21997 September 9, 1997 North Andover Board of Health Town Hall Annex School Street North Andover,MA 01845 RE: TITLE V REPORT 224 Carlton Lane Enclosed is the Title V report for 224 Carlton Lane,North Andover, MA. The system passes our inspection,there are however some noted repairs that should be made. If there are any questions please call me at my office, 686-1768. Yours truly, e 'aurin C. Osgood ,E.I.T. esident 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 CO'v MONWEALTH OF MASSACHUSETTS : EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ r� DEPARTMENT OF ENVIRONMENTAL.P—ROTECfT6.N 0E WINTER STREET. BOSTON. NIA*02.�08'�6LT,:92�t500 WILLIAM!F WELD yl TRUDY CO)M Govcmo: y Secretin ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP�E T4 FORM Commissioner PART A / CERTIFICATION Property Address:,V'/��,e//O/u h 4yOi 4U0. A4 00`101ddress of Owner:' Dale of Inspection: g/�/.97 1 (If different) Name of Inspector: BENJAMIN C. OSGOOD JR. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: NEW ENGLAND ENGIrNEERING SERVICES, INC. i Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reponed below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal sysiems The system: Passes _ Condrtronalh Passes ►seeds Further Evaluation By the Local Approving Authority Fails Inspector's Signatu . Date: 9 `u/y t r The System !nspector All'submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable.-and the approving authority. t INSPECTION SUMMARY: Check B, C, or D: AI SYSTEM PASSES: r' I have not found any information which indicates that the system violates any of the failure trite:ia as defined in 310 C-MR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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. Indicate yes. no. or not determined (Y. N. or ND). Describe basis of determination in all instances. If'not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(201 years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection i(the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. .. . ......... ........ ..... . _. u - 9?-Y7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:x2,/L4-ee l/d a ��v , Ali )4-,14Ve(C,ol — Owner: Wcqlge�- //O 10 Date of Inspection: BI SYSTEM CONDITIONALLY PASSES Icontinuedi Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if'(with approval of the Board of Health,. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approvals of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire further evaluation by the Board of Health in order to determine if the system is failing to protect the public health. safety and the environment 1) SYSTEM WILL PASSUNLESSBOARD OF HEALTH DETERMINES THAT THE SYSTEM IS`NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or pri.1• is within 50 ieet of a surface water Cesspool or prwy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIE4, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: I I The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water'supply. ' The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 54 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well. unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determine distance (approximation not valid). 3) OTHER (rovio•d 04/75/47) pa9• 2 of 20 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / ,C/ERTIFICATION (continued) 1 Property Address:�a����f H / #4 01 /V v '41 d,4vt se, m tx- Owner: �o g��f V C,k.<"Nor Date of Inspection: DI SYSTEM FAILS: You must Indicate either "Yes"or -No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool I I _ Static liquid level in the distribution box above outlet (nven due to an overloaded or clogged SAS or cesspool. Liquid depth ,n cesspool is less than 6"below invert or available volume ,s less than 1/2 day flow. � 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Ahv pon,on of a cesspool or privy is w,ih,n 100 feet of a surface watet supply or tributary to a surface water'supply. Any portion of a cesspool or privy is within a Zone I of a public well. Am portion of a cesspool or privy is within 50 feet of a private water supply well. Anv 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 Nater quality analysis. If the well has been analyzed to be'acceptable, attach copv'of well water analysis for colnorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. I EI LARGE SYSTEM FAILS: S You must indicate either "Yes- or "No- as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (r.via.d 04/25/!7) pay. 3 of 10 17 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST /J ,B lion �tiQ1 /(Jo l �vvee/ �? , Property Address: p�p?•lj� 9• I� Owner: eoB�?Q �- ,oJoG l�`STi�O7� Date of Inspection: 74-9 I'9T y Check if the following have been done: You must indicate either "Yes'or'No' as to each-of the foflowing: Yes/ No Pumping information was provided by the owner, occupant, or Board of Health. 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 bgen introduced into the system recently or as pan of this inspection. As built plans have been obtained and examined. Note ii they ere not available with N/A. The facility or dwelling was inspected for signs of slwage back-up. t v _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout -4-/ _ All system components. excluding the Soil Absorption System, have been located on the site. Y _ 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 Soil Absorption System on the site has been determined based on: _ The facility owner(and occupants, if different from pwner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is r unacceptable) (15.302(3)(b)) (revia•d 04/25/97) PAy 4 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:.2'� Iv., � nt � �Ud jl�Qdee, Flo' Owner: ?O6eift Date of Inspection: 97/,�-519-7 FLOW CONDITIONS RESIDENTIAL: Design flow:_ t.P.dJbedroom for S.A.S Number of bedrooms: Number of current residents: Garbage gr.r.der (yes or no):-" Laundry connected to system (yes or no): t Seasonal use (yes or no):—C/0 Water meter readings, if available (last two (2) year usage (gpd): /(/J /Ov,th V"Irz- Sump Pump (yes or no): Last date of occupancy: 6U�K y COMMERCLAUINQUSTRIAL• i Type of establishment: Design flow:_ t?allons/dav ' Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: tees or no)_ Non-sanitary waste discharged to the Title 5 system (yes or no)_ Water meter readings, if available Last date o) o cupancy: OTHER: (Describe) Last date of occupancy. i GENERAL INFORMATION t PUMPING RECORDS and source of informati n T� u,.#s i A-*D y0w#g4ej System pumped as part of inspection: (yes or(0— If yes, volume pumped: eallons Reason for pumping TYPE O�SYSTEM r/ 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: (✓b dmf Sewage odors detected when arriving at the site: (yes or no) A _ (revised 04/25/)7) page 5 of 10 ��-Y7 Q - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /I / SYSTEM INd) FORMATION (continued) Properly Address: as y e' eR A 4 F"Ol X00 #',djO"'eA wo- Owner: /Zpg/li2 f `�oG St9 D T Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:L Material of construction: _cast iron "'40 PVC _other (explain) Distance from private water supply well or suction Itre /110L ' Diameter _Sl„ Comments: (condition of joints, venting, evidence of leakage, etc.) A(�'� 43 l�i d trr D/G �S LG�l� T &h. a !-' 0/U. I SEPTIC TANK:_ (locate on site plant t t Depth below grade: f Material of construction: -concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, lost age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: SaC /0 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle &-0 40;:'4/Z- Scum thickness:_ Distance from top of scum to top of outlet tee or banle:N'OFLrZ- Distance from bottom of scum to bottom of outlet tee or baffle:PD How dimensions were detetrmtned: MI,74sve/2ot-1 S&C le– Comments: eComments: t (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, etc.) �.�aGPe'f/l �i3F�. S /�Q/1 B2�/C/l A, ©,elz eo•'D)�`°rt D/� 7;4w ' eil el��f� d O I ,ik r�CD.�n2h0 Q�3PlnG�Mea f- u/w raer5 u - h Sc e o� iT�Ps1 41 doeey o /et 7-,, 7b Dgox L& c it 7,'-m4 w , `C. alfeOcf Sysfd?� GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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, etc.) (r—i—d 04/25/97) p&9a 6 of 10 5�- 37. v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:p73 ,Yi�,l )o9.i�Z, Owner: P06 d 2 t o G k St6vT Date of Inspection: /l g/ 9 7 TIGHT OR HOLDING TANK: +Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) .s Dimensions: Capacity: gallons Design floe gallon/da% I I Alarm level. Alarm in working order _ Yes: _ No Date of previous pumping: Comments: + + (condition of rule) tee. condition of alarm and float switches, etc.) i ) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet rnven ® .41 Comments: + + (note if level and distribution is equal. evidence of solids carryover, evidence of leakage into or out of box, etc.) 5{� b- I3ox Zs Bentey DeTe�e,`O,gA--o , w:,Ah -1 ouL leo Aahx� oPz>.v *p b:e,ac .tGd�l T 4?e 1.4,e I o x , PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 0{/35/97) Paye 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:�a`f c�R Q°c �U 4ou g i 'vD ✓�� a Owner: �p 6(jQ t /1D G T- Date of Inspection: 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: Type: leaching pits. number:_ leaching chambers, number:_ leaching galleries, number: t leaching trenches, number,length: T�rJG�lrs 7 4 fOti G /ZIP h I leaching fields, number, dimensions:_ overflow cesspool, number: Alternative system:, Name of.Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition.of vegetation, etc) Tha,ey is /Lv S-� o,• /fy02�1v�,�G 9y LaQg. rarce M Ts �/.�� Fu,¢�. /VO /iU,`G�t3�t�r� Oi•— PonO"oe- >3 fC, i CESSPOOLS: _ (locate on site plan) Number and configuration: + + Depth-top of liquid to inlet invert: i Depth of solids layer: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater: ' inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: = (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r.vi..d 04/25/97) p.g. E of 10 1 9�-y7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a a y C e N , O �,� �tl ere I Vl I&- Owner: f Date of Inspection: oQ►3 QT G k S fi4�T g l � � l �-7 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record s Observation of Site (Abuning property, observation hole, basement sump etc.) Deterrnine .t from local conditions Check %v!th !oca! Board of health ! Cheri. FEMA Wraps I t I Check pumping records Check local excavators, Installers Use USGS Data Describe in .our o-A words how you established the High Groundwater Elevation. (Must`be completed) �') LIzS`I c,-�,v �t LtAw �y �"IOWL�S �I�LV� ►�SSOG � t��� A�6� '� ��IE�` ��iCtA-�S ' (� ��U-� lA�a�e�e 't'a 3 l-(� w : -�4�� H •rtk � Sy s�`"` �ei�to ©►z '? Say ��I�P �+a OIv .►-.KS Q12 C 'to lb �4 S ��wt PSL lr� �- oTtiae PKoPI�e�Y w �-k ; " 3dor 3r) USG- +�t �,`cr��t�s Soy � s Ps CQn CeC, 4el-��N , � o�-►, (r—i..d 04/75/97) p.q. 10 of 10 i , NEW ENGLAND ENGINEERING SERVICES INC 157 5 i October 30, 1997 North Andover Board of Health Town Hall Annex School Street North Andover,MA 01845 RE: TITLE V REPORT 224 Carlton Lane,North Andover, MA. Enclosed is the Title V report for 224 Carlton Lane,North Andover, MA. The system passes our inspection. This is a revised inspection from our inspection dated 8/29/97. The d-box and pipe from tank to d-boX and the outlet tee has been replaced. If there are any questions please call me at my office, 686-1768. Yours truly, t* * Osgo d Jr.,E.I.T. 33 WALKER RD. - SUITE 22 - NORTH - - O H A NDOVER MA 01845 508 686 1768 Grant, Michele To: amyhughes14@gmail.com Cc: Sawyer, Susan; Blackburn, Lisa; Gaffney, Heidi Subject: FW: Message from "ComDev-Health-Ricoh" Attachments: 201308271033.pdf Hi Amy, 1. Page 1, A note from HD indicating system may be different than the As-Built. 2. Page 2, is the most recent T-5, done in 2010. We assume this is correct. It's different from the As-Built. It looks like the T-5 inspector made some changes regarding distances. 3. Page 3, Table 1, Setback distances. 4. Page 4 & 5, Local Regulation information: CMR 310:15.228 (3) CMR 310:15.240 (7)&(10) 5. Page 6, State Regulation information. CMR 310.15.211 At any point you may need to access any one of these components. Ie: Pipes, Tank, D-box, Field. Its never in ones best interest to place a permanent structure on top of components. Here's some good information to review, Please call with any questions. If I'm not available, please speak to Sue Sawyer. Best Regards, Michele E. Grant Public Health Agent Town of North Andover 1600 Osgood St I Suite 2035 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email mgrant0townofnorthandover.com Web www.TownofNorthAndover.com -----Original Message----- From: noreply(atownofnorthandover.com [mailto:noreply(@townofnorthandover.com] Sent: Tuesday, August 27, 2013 10:33 AM To: Grant, Michele Subject: Message from "ComDev-Health-Ricoh" This E-mail was sent from "ComDev-Health-Ricoh" (Aficio MP C3002). Scan Date: 08.27.2013 10:33:25 (-0400) Queries to: noreplyptownofnorthandover.com i 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. 2 Z�Z `SIL Pen, r � s .b '11' l � . _-;�YsL) b 1.4- b e.-/� V T) rJ Q a I F P a 1 Gommonwealth of Massachusetts f , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' r 224 Carlton Ln. Property Address Whalley ger Owner's Name ormation is North Andover MA 01845 3/23/2010 equired for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately l- ZZN o r A 13 G t I 2�.� Zc ' 1 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 3.4 Design plans for a tight tank shall require approval of the Board of Health at a public hearing. 3.5 All drilled or dug wells shall meet all setbacks and be considered potable water supply wells. 3.6 Wetlands resource area setbacks as described in these regulations and in Title 5 are to be measured from the resource as may be jurisdictional under federal, state or North Andover requirements. 3.7 No well shall be constructed or placed within the distance specified in Table 1 from the component of an existing onsite wastewater system. 3.8 If a variance to the North Andover Board of Health regulations,Title 5 Local Upgrade Approval and/or Title 5 variance can be met with the incorporation of a Massachusetts Department of Environmental Protection(DEP)-approved device which reduces wastewater to levels below 30 mg/L BOD and 30 mg/L TSS,then the design plan can be approved by the Health Department and does not require a hearing before the Board of Health unless otherwise required. 3.9 Per the current fee schedule,the fee for the onsite wastewater system plan review shall be paid upon initial submission and will cover the first revision if applicable. Each subsequent revision will require a separate fee. TABLE 1 -SETBACK DISTANCE TABLE Resource Build Septic Tanks,Pump Tanks, Soil ing Treatment Units,Tight Absorption Sewer Tanks,Grease Traps(feet) System(feet) Deck on footings 5 10 Tributaries to Surface - Water Supply 325 325 Watercourses or Wetland - Resource Areas 75 100 Wetlands Bordering - ' Surface 150 150 Water Supply or Tributary (in.watershed district Private Well 50 - (setbacks are supplemental to MADEP 310CMR 15) Page 6 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION 15.227: continued (2) The minimum separation between inlet and outlet tees shall be no less than the liquid depth of the septic tank and shall be the longest direction (which shall not include the diagonal distance)across the tank in plan view. (3) Inlet and outlet tees to rectangular tanks shall be set in the end walls or into a side wall within 12 inches of the end wall.For circular tanks, the inlet and outlet tees shall be set and stabilized on opposite ends of a diameter of the tank. (4) There shall be an air space of at least three inches between the tops of the tees and the inside of the tank cover. The tops of the tees shall be left open to provide ventilation or separate ventilation shall be provided. All outlet tees shall be equipped with a gas baffle or a Department -approved effluent tee filter. (5) The inlet pipe elevation shall be no less than two inches nor more than three inches above the invert elevation of the outlet pipe. The inlet and outlet invert elevations shall be at least 12 inches above the high groundwater elevation. If high groundwater(redoximorphic features)is determined by soil evaluation in accordance with 310 CMR 15.100 through 15.107 at the proposed location of the septic tank,the Approving Authority may reduce the 12 inch required separation,but in no cases shall it be reduced to less than one inch above high groundwater as determined by redoximorphic features. (6) The inlet tee shall extend a minimum of ten inches below the flow line. The outlet shall be provided with a tee extending below the flow line in accordance with the following table: Liquid Depth in Septic Tank Depth of Outlet Tee below Flow Line 4 feet 14 inches 5 feet 19 inches 6 feet 24 inches 7 feet 29 inches 8 feet 34 inches (7) Effluent tee filters maybe installed in lieu of outlet tees provided that,they are installed in accordance with the manufacturer's specifications,include an appropriate outlet cover at grade, a�Placeent d aistd and cleaned at least on an annual basis. ssibilit of Septic Tank (1) Septic tanks shall be installed level and true to grade on a level stable base that has been mechanically.compacted and on to which six inches of crushed stone has been placed to minimize uneven settling.If the septic tank is placed in fill,proper compaction is required to ensure stability and to prevent settling. Septic tanks shall have a minimum cover of nine inches. Systems buried greater than nine inches below grade must be equipped with risers on all tank top openings and the distribution box. (2) At least three manholes with readily removable impermeable covers of durable material shall be provided. The manholes over the inlet and outlet tees shall have a minimum opening of 20 inches and the center manhole shall have a minimum opening of eight inches. By July 1,2007,manufacturers of fiberglass and polyethylene tanks shall comply with the center hole requirement.Access ports shall be placed at the center and over each inlet and outlet tee. For compartmental tanks, the center manhole shall be placed as access to the compartment connection. Inlet and outlet tees shall be made accessible for inspection and maintenance by providing precast concrete or equivalent watertight risers(with steps where appropriate)with covers over the access ports to within six inches of finish grade for system designs in excess of 1,000 gpd. For system designs of 1,000 gpd or less,at least one access port shall be accessible within six inches of final grade, Manholes brought to final grade shall be secured to prevent unauthorized access. (3) Septic tanks shall be accessible for inspection and maintenance.No structures shall be located directly upon or above the septic tank access locations which interfere with performance, access,inspection,pumping,or repair. 9/22/06 (Effective 4/21/06)-corrected 310 CMR-522 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION 15.240: continued (2) Effluent from any component of an on-site sewage disposal system shall not be disposed of by direct discharge to any waters of the Commonwealth,unless in compliance with a permit issued pursuant to 314 CMR 3.00(surface water permitting)or 314 CMR 5.00(groundwater permitting). (3) Soil absorption systems shall be designed as an integral part of the system. Septic tank effluent is to be distributed throughout the soil absorption system by means of effluent distribution Iines so that the effluent can migrate through the underlying soil column under unsaturated flow conditions.All soil absorption systems shall achieve the following objectives of the soil treatment process: (a) maximum stabilization of organic wastes in the effluent; (b) removal of pathogenic organisms,nutrients,and particulates; (c) recharge of the ground-water table with adequately treated effluent with minimal attendant pollution of the groundwater;and (d) disposal of the effluent without discharge to the ground surface or the creation of any nuisance. (4) The minimum area for the design of a soil absorption system shall be determined by the results of the site evaluation set forth in 310 CMR 15,100 through 15.107 and in accordance with the appropriate long-term acceptance rate criteria specified in 310 CMR 15.242(effluent loading rates). Area requirements increase by 50%when garbage grinders are installed and the system shall be upgraded to meet such requirements prior to the installation of a garbage grinder. (5) All soil absorption systems designed to serve single family dwellings,including but not limited to single family condominiums and cooperatives,shall be designed to serve a minimum of three bedrooms,unless a deed restriction limiting use to two bedrooms is granted to the local Approving Authority. (6) Absorption trenches should be used whenever possible. (7) No driveway,parking or turning area or other impervious area shall be located above a soil absorption systein,except where restrictions on the use of the land make it unavoidable.in such cases,the soil absorption system shall be vented to the atmosphere in accordance with 310 CMR 15.241. e (8) The bottom of each soil absorption system shall be excavated to a level grade.If the removal ; of stones or boulders is required, creating localized depressions, filling to grade with the excavated naturally occurring pervious soil or material in compliance with 310 CMR 15.255 is acceptable. (9) The soil placed as backfill over the soil absorption system shall be a minimum of nine inches,excluding topsoil,placed in lifts and sufficiently compacted to prevent depressions due to settling which may-intercept or collect surface water runoff above the system. Backfill must s be clean and free of stones and boulders greater than six inches in size. Tailings,clay or similar materials are prohibited. (10) Final cover above the system shall be stabilized and graded to rdduce infiltration of surface water and minimize erosion. Finish grade shall have a minimum slope of 0,02 feet per foot. (11) Surface drainage shall be directed away from the soil absorption system. (12) For systems with a design flow of 2,000 gpd or greater,the separation distance to the high groundwater elevation required by 310 CMR 15.212 shall be determined by adding the effect of groundwater mounding to the high groundwater elevation as determined pursuant to 310 CMR 15.103(3), I 4/21/06 310 CMR-526 L T 310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION 15.204: Increases in Design Flow to System No person shall increase the actual or design flow to any cesspool or to any other system above the existing approved capacity,or change the type of establishment of a facility served by a cesspool, unless the cesspool or system is upgraded first. Upgrades to accept increased design flow shall be performed in full compliance with the requirements applicable to new construction unless a variance is allowed pursuant to 310 CMR 15.414. For purposes of 310 CMR 15.204,the approved design flow shall be the flow listed in the most recent Disposal Works Construction Permit. 15.211: Minimum Setback Distances (1) All systems must conform to the minimum setback distance for septic tanks,holding tanks,pump chambers,treatment units and soil absorption systems,including reserve area,measured in feet and as set forth below. Where more than one setback applies,all setback requirements shall be satisfied. Septic Tank Soil Absorption System Holding Tank Pump Chamber Treatment Unit Grease Traps Property Line 10[5] 10[5] Cellar or Crawl Space Wall, Swir uning Pool(inground),foundation drain 10 20 Slab Foundation 10 10 Water Supply Line(pressure) 10[1] 10[1] Surface Waters(except wetlands) 25 50 Bordering Vegetated Wetland(BVW), Salt Marshes,Inland and Coastal Banks 25 50 Surface Water Supply- Reservoirs and Impoundments 400 400 Tributaries to Surface Water Supplies 200 200 Wetlands bordering Surface Water Supply or Tributary thereto 100 100 Certified Vernal Pools 50 100[2] Private Water Supply Well or Suction Line 50 100 Public Water Supply Well (2) (2) Irrigation Well 10 25 Open,Surface or Subsurface Drains which discharge to Surface Water Supplies or tributaries thereto 50 100 Other Open,Surface or Subsurface Drains (excludingfoundation drains)which intercept seasonal high groundwater table[3] 25 50 Other Open,Surface or Subsurface Drains (excluding foundation drains) 5 10 Leaching Catch Basins& Dry Wells 10 25 Downhill Slope not applicable 15[4] [1] Disposal facilities shall be at least 18 inches below water supply lines. Wherever sewer lines must cross water supply lines,both pipes shall be constructed of class 150 pressure pipe and shall be pressure tested to assure watertightness. [2] The required setback shall be 50 feet where the applicant has provided hydrogeologic data acceptable to the Approving Authority demonstrating that the location of the soil absorption system is hydraulically downgradient of the vernal pool.Surface topography alone is not determinative. 4/21/06 310 CMR-512 ZONING DISTRICT Rl DATE: SEPT. 14, 2004 SCOTT L. GILES FRANK S. GILES u I/V REVISIONS: FRANKS. GILES SURVEYING SCALE: 1 INCH = 40 FEET 50 DEERMEADOW ROAD NO. ANDOVER, MA 01845 TEL: (978) 683-2645 CARLETON o 4o so FrankGilesSurvey@comcast.net 44N SEPT. 15, 2004 „�1 L,= 173.92' S l lOCJ6o R =245.941 POT PLAN OF LAND L = 31.42' 41 LOCATION R= 20.0' 30' SETBACKN6�o FOREST STREET 224 9., NORTH ANDOVER, MA tp w 13 96' DRAWN FOR o = ERIC & ANN WHALLEY w � .o � o a� MA P107A, PARCEL 203 LOT 45 49,772 S.F. Cs o SUBJECT PROPERTY ko MAP 107A, PARCEL 203 tan l; ® ^, ERIC T & ANN WHALLEY d. bo. w 224 CARLTON LANE M NORTH ANDOVER MA 01845 S 73o081 � M AREA= 1.14 4g"E .30,�,S�' 3 T'oA pvo DEED BK. 4892, PAGE 268 a� I CERTIFY THAT THE OFFSETS SHOWN COMPLY WITH THE ZONING BY LAWS OF NORTH ANDOVER, MA. AT THE TIME OF CONSTRUCTION. THE OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY AND SUCH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON-CONFORMITY WHEN CONSTRUCTED. C:\CLIENTS\WHALLEY ANNE\PLOT PLAN.DRG I Town of North Andover '11 b TF, OE4,�a61�C Community Development and Services Division 02 Office of the Health Departmentp x • i .^ +F 400 OSGOOD STREET >' North Andover,Massachusetts 01845 ss"T'° 1 ACNUS� Susan Y.Sawyer,RENS/RS (978)688-9540-Phone Public Health Director (978)688-8476-Fax Date: April 22,2005 Address:224 Carleton Lane,North Andover,MA 01845 Re: Application for: Addition Dear- Mr.Whalley Your application for an addition at 224 Carlton Lane has been reviewed by the Health Department. The application was denied on,April 22,2005 for the following reasons: 1. X Missing information 2. X Passing Tule S inspection of septic system required With an As-Built 3. 0! Location of structure not acceptablepyo Qi t l 2`�s v 0,&O 4. O Undersized septic system ��7�/lil� 7`l� � To address the problem(s): If#1 is checked, please supply: a. Floor plan of existing and proposed addition—a1J rooms VVV1� If#2 is checked: a. Have the septic system inspected by a certifted Tule S inspector to dd ine the size of the system and whdher it is operating properly. If#f3 is checked: a. Relocate the project. If#4 is checked: a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, L lillrj Mictele E.Grant Cc: Budding Department / ) File '4/7 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 TO: NORTH ANDOVER, MASS AC� - 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at �0 7- �fS �`% �Z-- )`-0AJ �G�—%yam North Andover, Mass. SITE LOCATION The grades and construction are as specified in moy plans and specifications dated C) C1 J oda cohf4f 6 CU ®r cg. n erlye ni ian F a l' FOM U. TOWN OF NORTH ANDOVER LOT RELEASE FORM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDR"S GNED BY D.P.W. STREET ' 93 APPLICANT PHONE DATE OF APPLICATION TOWN USE BELOW THIS LINE PLANNING BOARD I — DATE APPROVED TOWN AMER DATE REJECTED CONSERVATION . COr ISSION Cut �o l ` ��i�� DATE APPROVED - �.' q I CONSERVATION ADMI . DATE REJECTED BOARD OF HEALTH DATE APPROVED 7 125-111 HEAL11r6ANITARIAN DATE REJECTED DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT SEWER/WATER CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. � ,• � li Ijjl ---- --I--- - -- - :?-v C ol jQr i j d o S E,�4 /OCL y��o�� coMMoy�� 7 c W S p 9��F0 p 5a S113S� so Ll- o X a u