HomeMy WebLinkAboutBuilding Permit #Exception - 373 SALEM STREET 5/1/2018 TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT: Applicant must complete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building XOne family
ViAddition ❑Two or more family ❑ Industrial
❑Alteration No. of units: ❑ Commercial
❑ Repair, replacement ❑Assessory Bldg ❑ Others:
❑ Demolition ❑ Other
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DESCRIPTION OF WORK TO BE PERFORMED: .
Identification Please Type or Print Clearly)
OWNER: Name: 0V-^ � 'r L.'Qja== ti Phone:
Address: � �c, n..
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ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ 16.b UC? FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund-
Signature`ofAgent/Ovvre r- ignature of contractor, ..: .._...
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Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑
48'-0"
OFFICE DINING
L)
KITCHEN/LIVING o
M EXISTING
MASTER HOUSE
BEDROOM
BATHROOM BEDROOM BEDROOM
.......... ...... .........................
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PROPOSED �"X 10"s
ROOM
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12'-0" "x 6"s
SLAB
ABERNATHY RESIDENCE
31%3 SALEM STREET
NORTH ANDOVER, MA
ACTION-KING ENTERPRISES,INC.
26 LIVINGSTON STREET
LOWELL,MA 01852 SOARD)RT'H ANDoVI:
TEL:(508)452-7750 GF HATH
FAX:(508)459-0770
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ORIM JUN `3 19%
PART A
CERTIFICATION
PROPERTY ADDRESS: 373 SALEM STREET NO.ANDOVER,MA 01845
DATE OF INSPECTION: 5-23-96 ADDRESS OF OWNER:
NAME OF INSPECTOR: FRANCIS KING III (IF DIFFERENT)
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 INSPECTION. THE INSPECTION WAS PERFORMED BASED ON MY TRAINING
AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL
SYSTEMS. THE SYSTEM.
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
INSPECTOR'S SIGNATURE DATE: 5-23-96
THE SYSTEM INSPECTOR SHALL 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.
INSPECTION SUMMARY:
CHECK A,B,C,OR D.
A) SYSTEM PASSES:
X I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM VIOLATES
ANY OF THE FAILURE CRITERIA AS DEFINED IN 310 CMR 15.303.
ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW.
B) SYSTEM CONDITIONALLY PASSES:
ONE OR MORE SYSTEM COMPONENTS NEED TO BE REPLACED OR REPAIRED. THE
SYSTEM UPON COMPLETION OF THE REPLACEMENT OR REPAIR,PASSES INSPECTION.
INDICATE YES,OR 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,CRACKED,STRUCTURALLY UNSOUND,SHOWS
SUBSTANTIAL INFILTRATION OR EXFILTRATION,OR TANK 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.
PAGE 1
a
II
ACTION-KING ENTERPRISES,INC.
26 LIVINGSTON STREET
LOWELL,MA 01852
TEL:(508)452-7750
FAX:(508)459-0770
PROPERTY ADDRESS:373 SALEM STREET NO.ANDOVER,MA 10845
OWNER:ERIC SANTULLO
DATE OF INSPECTION:5-23-96
ACTION KING ENTERPRISES,INC.HAS BEEN RETAINED BY THE OWNER TO PROVIDE AN INSPECTION
OF THE ON-SITE SEWERAGE DISPOSAL SYSTEM AS DEFINED BY 310 CMR 15303.D.E.P.GUIDANCE
INSTRUCTS THE INSPECTOR TO MAKE AN EVALUATION OF THE SYSTEMS PERFORMANCE ON THE
DAY OF THE INSPECTION. THE TITLE 5INSPECTION IS NOT DESIGNED TO PROVIDE INFORMATION
TO DEMONSTRATE THAT THE SYSTEM WILL ADEQUATELY SERVE THE USE TO BE PLACED UPON IT
BY THE NEW OWNER AS STATED IN 15302. THIS ISPECTION IS NOT A WARRANTEE OR GUARANTEE
OF THE SYSTEM FUTURE PERFORMANCE,AND DOES NOT EITHER EXPRESS OR IMPLY IT.
PAGE 1-A
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
PROPERTY ADDRESS: 373 SALEM STREET NO.ANDOVER,MA 01845
OWNER:ERIC SANTULLO
DATE OF INSPECTION:5-23-96
B) SYSTEM CONDITIONALLY PASSES (CONTINUED)
N/A 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).
BROKEN PIPE(S)ARE REPLACED
OBSTRUCTION IS REMOVED
DISTRIBUTION BOX IS LEVELED 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 REPLACED
OBSTRUCTION IS REMOVED
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
N/A CONDITIONS EXIST WHICH REQUIRE 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 PASS UNLESS BOARD 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 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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF
APPROPRIATE)DETERMINES THAT THE SYSTEM IF FUNCTIONING IN A MANNER THAT
PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND 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 IS WITHIN
A ZONE I OF A PUBLIC WATER SUPPLY WELL.
THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WITHIN
50 FEET OF A PRIVATE WATER SUPPLY WELL.
THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND 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 THE 5PPM.
PAGE 2
e
ACTION-KING ENTERPRISES.INC.
D) SYSTEM FAILS:
N/A 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 FAILUR.
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 BOX ABOVE 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.
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.
ANY PORTION OF A 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 I 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. IF THE WELL HAS BEEN ANALYZED TO BE
ACCEPTABLE, ATTACH COPY OF WELL WATER ANALYSIS FOR COLIFORM
BACTERIA,VOLATILE ORGANIC COMPOUNDS,AMMONIA NITROGEN AND
NITRATE NITROGEN.
E) LARGE SYSTEM FAILS:
THE FOLLOWING CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRITERIA
ABOVE.
_N/A THE DESIGN FLOW OF SYSTEM IS 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:
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 (WPA) OR A MAPPED ZONE II OF A PUBLIC WATER SUPPLY
WELL.
THE OWNER OR OPERATOR OF ANY SUCHSYSTEM 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.
PAGE 3
.t
ACTION-KING ENTERPRISES,INC.
PART B
CHECKLIST
PROPERTY ADDRESS: 373 SALEM STREET NO.ANDOVER,MA 01845
OWNER: ERIC SANTULLO
DATE OF INSPECTION:5-23-96
CHECK IF THE FOLLOWING HAVE BEEN DONE.
X PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF
HEALTH.
X NONE OF THE SYSTEM COMPONENTS HHAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND
THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE
VOLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS
PART OF THIS INSPECTION.
AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT
AVAILABLE WITH N/A.
X THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP.
X THE SYSTEM DOES NOT RECEIVE NON-SANITARY OR INDUSTRIAL WASTE FLOW.
X THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT.
_X ALL SYSTEM COMPONENTS,EXCLUDING THE SOIL ABSORPTION SYSTEM,HAVE BEEN
LOCATED ON THE SITE.
X THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE
SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEE,MATERIAL OF
CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE,DEPRTH OF SCUM.
X THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN
DETERMINED BASED ON EXISTING INFORMATION OR APPROZIMATED BY NON-INTRUSIVE
METHODS.
X THE FACILITY OWNER AND OCCUPANTS,IF DIFFERENT FROM OWNERS WERE PROVIDED
WITH INFORMATION ON THE PROPER MAINTENANCE OF SUB-SURFACE DISPOSAL SYSTEM.
PAGE 4
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C
SYSTEM INFORMATION
PROPERTY ADDRESS:373 SALEM STREET NO.ANDOVER,MA 01845
OWNER:ERIC SANTULLO
DATE OF INSPECTION: 5-23-96
RESIDENTIAL:
DESIGN FLOW:_330 GALLONS.
NUMBER OF BEDROOMS: 3
NUMBER OF,CURRENT RESIDENTS: 2
GARBAGE GRINDER(YES OR NO) NO
SEASONAL USE(YES OR NO) NO
WATER METER READINGS,IF AVAILABLE: 1000 CF PER YEAR
LAST DATE OF OCCUPANCY: OCCUPIED
COMMERCIAL/INDUSTRIAL:
TYPE OF ESTABLISHMENT: N/A-
DESIGN FLOW: GALLONS/DAY
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 DAY OF OCCUPANCY:
OTHER: (DESCRIBE)
LAST DAY OF OCCUPANCY:
GENERAL INFORMATION
PUMPING RECORDS AND SOURCE OF INFORMATION.
11/2 YEARS - HOMEOWNER
SYSTEM PUMPED,AS PART OF INSPECTION(YES OR NO) YES
IF YES,VOLUME PUMPED 1500 GALLONS.
REASON FOR PUMPING INSPECTION
TYPE OF SYSTEM
X SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM
SINGLE CESSPOOL
OVERFLOW CESSPOOL
PRIVY
SHARED SYSTEM (YES OR NO) (IF YES,ATTACH PRVIOUS INSPECTION RECORDS,IF ANY)
OTHER
(EXPLAIN)
APPROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF
INFORMATION.
NEW LEACH AREA INSTALLED 1985 - NEW PUMP 11/2 YEARS AGO
SEWAGE
ODORS DETECTED WHEN ARRIVING AT THE SITE.(YES OR NO)NO
PAGE 5
ACTION-KING ENTERPRISES,INC.
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS:373 SALEM STREET NO.ANDOVER,MA 01845
OWNER:ERIC SANTULLO
DATE OF INSPECTION: 5-23-96
SEPTIC TANK: X
(LOCATE ON SITE PLAN)
DEPTH BELOW GRADE: 5"
MATERIAL OF CONSTRUCTION: X CONCRETE METAL FRP OTHER
(EXPLAIN)
DIMENSIONS: of x 17k
SLUDGE DEPTH: 3"
DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: 2'
SCUM THICKNESS: 2"
DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 6"
DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: 1 V2'
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.)
TANK LOOKED GOOD -LIGHT SOLIDS -LIGHT SLUDGE
GREASE TRAP: NIA
(LOCATE ON SITE PLAN)
DEPTH BELOW GRADE:
MATERIAL OF CONSTRUCTION: CONCRETE METAL FRP 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:
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.)
PAGE 6
,
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS: 373 SALEM STREET NO.ANDOVER,MA 01845
OWNER: ERIC SANTULLO
DATE OF INSPECTION: 5-23-96
TIGHT OR HOLDING TANK_N/A
(LOCATE ON SITE PLAN)
DEPTH BELOW'GRADE:
MATERIAL OF CONSTRUCTION: CONCRETE METAL FRP OTHER
(EXPLAIN)
DIMENSIONS:
CAPACITY: GALLONS
DESIGN FLOW: GALLONS/DAY
ALARM LEVEL
COMMENT:
(CONDITION OF INLET TEE,CONDITION OF ALARM AND FLOAT SWITCHES,ETC.)
DISTRIBUTION BOX'-------X
(LOCATE ON SITE PLAN)
DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: O
COMMENTS:
(NOTE IF LEVEL AND DISTRIBUTION IS EQUAL,EVIDENCE OF SOLIDS CARRY OVER,EVIDENCE OF
LEAKAGE INTO OR OUT OF BOX,
ETC.)
D-BOX E UAL - LOOKED GOOD
PUMP CHAMBER:
(LOCATE ON SITE PLAN)
PUMPS IN WORKING ORDER(YES OR NO) YES
COMMENTS:
(NOTE CONDITION OF PUMP CHAMBER,CONDITION OF PUMPS AND APPURTENANCES,
ETC.)
PUMP IN WORKING ORDER - REPLACED I V2 YEARS AGO
PAGE 7
ACTION-KING ENTERPRISES,INC.
PROPERTY ADDRESS: 373 SALEM STREET NO.ANDOVER,MA 01845
OWNER: ERIC SANTULLO
DATE OF INSPECTION:5-23-96
SOIL ABSORPTION SYSTEM (SAS): X
(LOCATE ON SITE PLAN,IF POSSIBLE,EXCAVATION NOT REQUIRED,BUT MAY BE APPROXIMATED BY
NON-INTURSIVE METHODS).
IF NOT DETERMINED TO BE PRESENT,EXPLAIN:
TYPE:
LEACHING PITS,NUMBER:
LEACHING CHAMBER,NUMBER:
LEACHING GALLERIES,NUMBER:
LEACHING TRENCHES,NUMBER LENGTH: (FOUR) 30'
LEACHING FIELDS,NUMBER,DIMENSIONS:
OVERFLOW CESSPOOL.NUMBER:
COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDIIIAULIC FAILURE,LEVEL OF PONDING,
CONDITION OF VEGETATION,
ETC.)
CESSPOOLS: N/A
(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 (CESSPOOL MUST BE PUMPED AS PART OF U�SPECTION:
COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULICA FAILURE,LEVEL OF PONDING,
CONDITION OF VEGETATION,ETC.)
PRIVY: N/A
(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.),
PAGE 8
ACTION-KING ENTERPRISES,INC.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(CONTINUED)
PROPERTY ADDRESS: 373 SALEM STREET NO.ANDOVER,MA 01845
OWNER:ERIC SANTULLO
DATE OF INSPECTION: 5-23-96
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR BENCHMARKS
COAT ALL WELLS WITHIN 100
SALEM STRIEET
PUMP 22' TANK
CHAMBER
DEPTH TO GROUNDWATER
DEPTH TO GROUNDWATER: >6'
METHOD OF DETERMINATION OR
APPROXIMATION:
BROOK RUNNING APPROXIMATELY 500 FEET AWAY FROM LEACH FIELD AREA
PAGE 9
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DATE OF PUMINQ; -' � ,QU^NT1TY
. = ...._ ._. _. PUMPED:'(43
VtSSPOOL: NO._.. YES
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MAY 0 6 2005
GOOD CONDITION PULL 'T'U (.`OVE;R TOWN Jj- NrlRTH ANDOVER
limyY 011LWE , BAPP>~g3 IN P1,ALE HEALTH LDLPARTMENT �►
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TOWN OF NORTH ANDOVER NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT _ p
400 OSGOOD STREET
NORTH ANDOVER,MASSACHUSETTS 01845 39s''• '"<�
s�cMuse
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 373 Salem Street MAP: LOT:
INSTALLER: Ben Osgood
DESIGNER:
PLAN DATE: February 13, 2006
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
Comments: ❑Topography not appreciably altered
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
❑ Inlet tee installed, centered under access port
Outlet tee (gas baffle or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation—Feb 2006
Page 1 of 6
TOWN OF NORTH ANDOVER f NORTa
Office of COMMUNITY DEVELOPMENT AND SERVICES
• HEALTH DEPARTMENT .
41
400 OSGOOD STREET 14
NORTH ANDOVER MASSACHUSETTS 01845 "" <�
a CMUg�
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ Combo Tank installed. Size:
❑ 1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ 24" inch cover to within 6" of final grade installed over
pump access port
❑ Water tightness of tank has been achieved
Visual testing
❑ Hydraulic cement around inlet & outlet
Comments:
ADVANCED TREATMENT TECHNOLOGY
❑ Type of treatment device:
❑ Installed per manufacturers requirements
❑ All components working in accordance with
Comments: manufacturer's requirements
Wastewater System Documentation—Feb 2006
Page 2 of 6
TOWN OF NORTH ANDOVER f MORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES }?•' a_ -°.° op
HEALTH DEPARTMENT
400 OSGOOD STREET `
NORTH ANDOVER,MASSACHUSETTS 01845 �9SS�CNU9
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
D-BOX
x Installed on stable stone base
x Inlet tee (if pumped or >0.08'/foot)
x Hydraulic cement around inlet & outlets
x Observed even distribution
x Speed levelers provided (not required)
x Schedule 40 Piping (Schedule 20 — Original Pipes)
Comments:
All Schedule — all old pipes.
SOIL ABSORPTION SYSTEM
Bottom of SAS excavated down to soil layer,❑ y , 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:
T was broken in tank. It was replaced. Ben had to cut the pipe to fit it into place. I
asked whether he thought the cut was too deep into the pipe. He said no. Schedule 40
was used out of the tank and coupling was used to connect.
Wastewater System Documentation—Feb 2006
Page 3 of 6
TOWN OF NORTH ANDOVER °F NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
F e 9
HEALTH DEPARTMENT 14
400 OSGOOD STREET
NORTH ANDOVER,MASSACHUSETTS 01845 "Ss;;CHU
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
PRESSURE DISTRIBUTION
❑ -- inch manifold
❑ laterals installed with end sweeps
size:
material:
❑ Squirt test ft in height
F-1. Equal distribution to all laterals
❑ orifice size inch as per plan
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel:
❑ Rated for exterior if placed outside
Comments:
Wastewater System Documentation—Feb 2006
Page 4 of 6
TOWN OF NORTH ANDOVER °t 10R7N
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
400 OSGOOD STREET "►�, . , +'
NORTH ANDOVER, CMU
MASSACHUSETTS 01845 3�Ss eta'
AS
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Tank SAS Sewer
❑ Property line 10 10 --
❑ Cellar wall 10 20 --
❑ Inground pool 10 20 --
❑ Slab foundation 10 10 --
❑ Deck, on footings, etc 5 10 --
❑ Waterline 10 10 10'
❑ Private drinking well 75 1002 50
❑ Irrigation well 75 100
❑ Surface Water 25 50
❑ Bordering Vegetated Wetland ,
Salt Marsh, Inland/Coastal Banka 75 100
❑ Wetlands bordering surface
water supply or trib. (in Watershed) 150 150
❑ Trib.to surface water supply 325 325
❑ Public well 400 400
❑ Interim Wellhead Prot. Area
❑ Reservoirs 400 400
❑ Drains (wat. supply/trib.) 50 100
❑ Drains (intercept g.w.) 25 50
❑ Drains (Other)Foundation 10(5) 20(10)
❑ Drywells 20 25
Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland
bylaws
Wastewater System Documentation—Feb 2006
Page 5 of 6
TOWN OF NORTH ANDOVERof NORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES Map
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 0.1845CN„5<�
Susan Y. Sawyer,REHS/RS 978.688.9546—Phone
Public Health Director 978.688.8476—FAX
SYSTEM ELEVATIONS
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
Wastewater System Documentation—Feb 2006
Page 6 of 6
= Town of North Andover / O/
x;
Health Department Date: ro
Location:
(Indicate Address,if Residential,or Name of Business)
Check#: ffl
Type of Permit or License: (Circle)
➢ Animal $
➢ Dumpster $
➢ Food Service-Type: $
➢ Funeral Directors $
- ➢ Massage Establishment $
➢ Massage Practice $
f. ➢ Offal(Septic)Hauler $
•.: ➢ Recreational Camp $
➢ SEPTIC PERMITS:
❑ Septic-Soil Testing $
❑ Septic.-Design Approval $
La-'!o Septic Disposal Works Construction(DWC)$ �
❑ Septic Disposal Works Installers(DWI) $
L ➢ Sun tanning $
,. ➢ Swimming Pool $
➢ Tobacco $
➢ TrasWSolid Waste Hauler $
r;
Well Construction $
➢ OTHER(Indicate)
Health Agent Initials
1397
t
White-Applicant Yellow-Health Pink-Treasurer
v
07Y41N00-0-0 O-tr00-PQ O
r
1' TOWN OF NOW _ t NORTH
., Office of COMMUNITY DEVE OPMENT'SND SER ICES '�'`'��
• HEALTH DEI AR N p
X100 OSGOO ST R I 2006
NORTH ANDOVER, MA SACHUSETTS 01845, CH„5<�
Susan Y. Sawyer, REHS/RS HEALTh L L;'�-�-, -;41, 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMAWN
ADDRESS: 5-7 3 IrY\ MAP: LOT:
INSTALLER: o�
DESIGNER:
PLAN DATE: -- �� � 1,5 pzop
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
❑Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
❑ Inlet tee installed, centered under access port
❑ Outlet tee (gas baffle or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation—Feb 2006
Page 1 of 6
Olt
d TOWN OF NORTH ANDOVER OOORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT b
t
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 �9SS4CMUS Stg
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ Combo Tank installed. Size:
❑ 1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ 24" inch cover to within 6" of final grade installed over
pump access port
❑ Water tightness of tank has been achieved
Visual testing
❑ Hydraulic cement around inlet & outlet
Comments:
ADVANCED TREATMENT.TECHNOLOGY
❑ Type of treatment device:
❑ Installed per manufacturers requirements
❑ All components working in accordance with
manufacturer's requirements
Comments:
Wastewater System Documentation—Feb 2006
Page 2 of 6
TOWN OF NORTH ANDOVER a NORTH ,
Office of COMMUNITY DEVELOPMENT AND SERVICES or
• HEALTH DEPARTMENT
400 OSGOOD STREET �, . .t"
NORTH ANDOVER, MASSACHUSETTS 01845 "Ss'C U t�9
Susan Y. Sawyer, REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
D-BOX
Installed on stable stone base
;24�7 Inlet tee (if pumped or >0.08'/foot)
d Hydraulic cement around inlet & outlets
on q f�� it Observed-even distribution
,--,/
LSP'� levelers �Wided (not required)
)p
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:
cw
C, fD.1( i9Q 1;&�_
- -
to
V
01a SysteW& tation - -+k,�__ 0o/y r (. e(/
fJ I' Page 3 of 6
TOWN OF NORTH ANDOVER
Office of COMMUNITY DEVELOPMENT AND SERVICES
• HEALTH DEPARTMENT
400 OSGOOD STREET "9 . ,
NORTH ANDOVER, MASSACHUSETTS 01845 39SSACMU5et4g
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
PRESSURE DISTRIBUTION
❑ -- inch manifold
❑ laterals installed with end sweeps
size:
material:
❑ Squirt test ft in height
❑ Equal distribution to all laterals
❑ orifice size inch as per plan
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel:
❑ Rated for exterior if placed outside
Comments:
Wastewater System Documentation—Feb 2006
Page 4 of 6
r
' TOWN OF NORTH ANDOVER AORTkf
+ Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT 4 , v
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Susan Y. Sawyer, REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
Tank SAS Sewer
❑ Property line 10 10 --
❑ Cellar wall 10 20 --
❑ Inground pool 10 20 --
❑ Slab foundation 10 10 --
❑ Deck, on footings, etc 5 10 --
❑ Waterline 10 10 101
❑ Private drinking well 75 1002 50
❑ Irrigation well 75 100
❑ Surface Water 25 50
❑ Bordering Vegetated Wetland ,
Salt Marsh, Inland/Coastal Banka 75 100
❑ Wetlands bordering surface
water supply or trib. (in Watershed) 150 150
❑ Trib.to surface water supply 325 325
❑ Public well 400 400
❑ Interim Wellhead Prot. Area
❑ Reservoirs 400 400
❑ Drains (wat. supply/trib.) 50 100
❑ Drains (intercept g.w.) 25 50
❑ Drains (Other)Foundation 10(5) 20(10)
❑ Drywells 20 25
Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02).
s As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland
bylaws
Wastewater System Documentation—Feb 2006
Page 5 of 6
• A r TOWN OF NORTH ANDOVER cNo oTh q
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT p
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 "Ss';CH„g<`y
Susan Y. Sawyer, REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
SYSTEM ELEVATIONS
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral 3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
Wastewater System Documentation—Feb 2006
Page 6 of 6
I ai'd of Health BF.MC SISTEM f/
orth An ver Have. INSTALLATIC+11 CHECK LIST LCT
pvID
tDATIK
7:1)I;:Pi VIED AVATIC�I Cg FAIL
I
FAIL OK
1. Distance Tot
a. Wetlands
b. gains
' c. Well
i
2. Water Line Location
3. No PVC Pipe
}�. Septic Tank - - '-
a. . -Tees --Length & To Clean Oat Cowers. .
b. Cement Pipe to Tank On Both Sides of Tank
u
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amoimt8
c. No Back Flow
6. - Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped Inds
d. Clean Double Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. splash Pads
d. Tees
e. Cement Pipe to Pit - Both Sides.
f. Clean Double Washed Stone
8. No Garbage Dri.sposal
g.
Final Grading Inspection
lo. Barricading Covered System
ll. As Built Subnitted.. .. ..___ .
"r a. Lot Location ..:
b. Dimensions of System
c. Location with Regard-to Perc Test
z d. Elevations
e. Water Table
i -
--------------------
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DEP hsi provldod'jhl� IGnHvAla��PEpAR['NIENT
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Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASS
System Pumping Record Form47, ,:7
DEP has provided this form for use by local Boards of Healthbtg✓te rd must
be submitted to the local Board of Health or other approving MENT
A. Facility Information
Important:
When filling out 1. System Location,
fors on the
computer,use 313 Ip
only the tab key �1dd`ress
to move your A ) ��1� �1C�r e / t
cursor- et not '/Civvty/T�••City/Town
AL1 State lJ
use the return Zip Code
key. 2. Syst m Owner:
ICI
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ry 2. Quantity Pumped: cano�n�s
3. .Type of system: ❑ Cesspool(s) 0?1eptic Tank ❑ Tight Tank
' ] Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes'was it cleaned? ❑ Yes ❑ No
5. Condition of System: qo()C/
/,rd
6. Sys m Pumped By:
e t Vehicle License Number
Company
7. Location where contents ere disposed:
ignature of HulsDate
http://www.mass.gov/depANater/approv s/t5forms.htm#inspect
t5for4.doc 06/03 System Pumping Record•Page 1 of 1
�L\ Commonwealth of Massachusetts
W City/Town of No.Andover
a W° System Pumping Record
Form 4
M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but,the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days fro Ise limping-date_in
accordance with 310 CMR 15.351.
A. Facility Information
Important: TOWN OF NO Thf
When filling out 1. Sy; em ANC�b1���
forms on the �?m Location: M� t.TH p!*pARTMENT
computer, use ejoien
only the tab key ress
to move your No.Andover Ma 01810
cursor-do not City/Town State Zip Code
use the return
key. 2. System Owner:
tab
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
10 -1141
1. Date of Pumping 2. QuantityPumped:p g Date p Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: c
6. S stem Pumped B
Name Vehicle License Number
Stewart's Septic Service
Company
7. ocation where contents were disposed:
St wart's P -treatrAqntPlant, 20 So. Mill Bradford, Ma 01835
�ag6aturof V Date/C—f
L—Y
Signature o iving Facility Date
t5form4.doc•03106 System Pumping Record•Page 1 of 1