HomeMy WebLinkAboutBuilding Permit #Exception - 7 CARLTON LANE 5/1/2006D. Robert Nicetta,
Building Commissioner
Please Lnnt
TOWN OF NORTH ANDOVER
OFFICE C -F
BUILDING DEPARTMENT
400 Osgood Street
North Andover, Massachusetts 0 1845
HOMEOWNER LICENSE EXEMPTION
DATE: RA q ?Ijb&
JOB LOCATION: CA2
Number Street Address
Telephone (978) 688-95454
Fax (978) 688-9542
HOMEOWNER &&MO f-6&lf-lj #/#6'— 77& 13S)-- 2.?'
Name Home Phone Work Phone
PRESENT MAILING ADDRESS -7 C4ke--ri�n>
City Town State Zip Code
The current exemption for "homeownere' was extended to include owner -occupied dwellings to two units or less
and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the
owner acts as supervisor). State Building (Code Section 108.3.5. 1)
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which helshe resides or intends to reside, on which there is, or is intended
to be, a one or two Family structures. A person who constructs more that one home in a two-year period shall not
be considered a homeowner.
The undersigned "homeowner" assumes responsibility for compliances with the State Building Code and other
Applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department
minimum inspection procedures and requi ts and that heVshe will comply with said procedures and
requirements.
HOMEOWNERS SIGNATURE
J4)
APPROVAL OF BUILDING OFFICIAL
I X )ARD OF APPEALS (;.\8-9541 CONSFRVATION 6XX-,)5,3o I IYAL I'll (AX -9540 IIIANNIV;
TYPE OF SEWARGE DISPOSAL
Tanning!'Nlassage-Yod� Art
S"irnming Pools
PLiblic Sewer
Well
Tobacco Sales
Food Packaging'Sales
Permanent Dumpster on Site
Private (septic tank, etc.
Electric Meter location to
project
NOTE: Persons contracting with unregistered contractors t10 not have access to the guaranj�vfilnd
Signature of Agent/Owner Signature of Contractor
Plans Submitted Plans Waived Certified Plot Plan i 21 Stamped Plans
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED
PLANNING & DEVELOPMENT 11
a]
OWater Shed Special Permit
El Site Plan Special Permit
El Other
COMMENTS
_DATE REJECTED
XCONSERVATIO
COMMENTS �Jj� LZtjaky�,- LL)tt�,— tro / rf— j��
11
DATE APPROVED
DATE APPROVED
,-<IIEALTH
COMMENTS
Zoning Board of Appeals: Variance, Petition No:
Zonina Decision/receipt submitted yes
I I
Planfling Board Decision:
Conscrutien Dccision:
Water & Se"er connection si,ynature & date
1�
DATE REJECTED
10
Cornmen
Commvii
Fernp DLIrnpster on site yes no Fire Department signature date
Building Permit. %pprox ed and fSSLIed by:
P;Ige 2 0'4
DATE APPROVED
D L --5 1 ()-b
APR 2003
4 2003
d,ld
FO
OF
- / . C
PHONE - /?;Y—
AREA CODE
MESSAGE
SIGNED
0 A T E
Z7
NUMBER EXTENSION
il
TIME Aef
RETURNED
YOUR CALL
WILL CALL
AGAIN
CAMETO
SEE YOU
WANTS TO
SEE YOU
48003
FORM U LOT RELEASE FORM
L3 ttas"
TNSTRUCTION& This form is used to*erify that all -necessary approVal /permits from
Boardsand Departrnents having junsdiction ha�e been obtained. 7his does not relieve the
applicant and'or landowner from complianceviith any applicable requirements.
owns on
APPLICANT�), I &qz- f- A-141 17 o* 9 r� e�,, PHONE
C
ASSESSORS MAP NUMBER 101 h LOT NUMBER
SUBDIVISION �__LOTNUMBER
STREET --STREET NUMBER ' '7
. . . . . . . . . . . . . Do a ago am am so a an am a no -a -,,,
OFFICULUSE ONLY
RECOAPOENDATIONS6FT'0"W*"N"gdaG'E"'N'T*'S*'o a 0 0 a a a 0 0 0 a 0 a 0 o".8 ........
0 Vann
. �r - 3 2oko3
DATE APPROVED
CO . NSERVA7.70NADM7TOR DATE RMcTED
CONINIENTS
DATE APPROVED
TOWNPLANNER
DATE REJECTM
CONUVIENTS
W�M �PRO
FOOD INSPECTOR - BEALTH DATE REJECTED
DATE APPROVED
SEPnC INSPECTOR - BEALTH
DATE REJECTED
CONRvENTS 5-611AJ
YUBLIC WORKS - SEWER / WATER CONNECTIONS
DRrVEWAY PERlvffr
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
CONRvENTS
RECEIVED BY BUILDING INSPECTOR DATE
Ai
a
R
CER TIFIED PL 0 T PL A N
0
PREPARED FOR.
S
DIANE & ANDREW O'BRIEN
AT s
lk "NO35773
7 CARL TON LANE K,\-4 V
NORTH ANDOVER. MA.
NORTH ESSEX REGISTRY OF DEEDS: BK. 52 78 pG. 52
ASSESSOR'S MAP.- 107A, LOT 19 ZONING: R-2
SCALE.- 1 `40' DA 7E.-.- APRIL 02, 2003
RALDGH TA VERN
PREPARED B Y-
NOTE: SEPTIC TANK &
D—BOX LOCATION TAKEN
FROM TITLE 5 LOCATION
DATED 07-20-98.
LANE
JOHN ABAGIS & ASSOCIAMS, PROFESSIONAL LAND SURVEYORS
131 PARK VREET, NOR7H READING, MA. (978)-688-4899
JOB NO. 5048
PK.
NAII
SET
Town of North Andover
Office of the Health Department
Community Development and Services Division
William J. Scott, Division Director
27 Charles Street
North Andover Massachusetts MR,19
I
Sandra Starr
Health Director
March 20, 2003
Diane & Andy O'Brien
7 Carleton Lane
North Andover, MA 0 1845
re,
Telephone (978) 688-9540
Fax (978) 688-9542
Re: Application for in -ground swimming pool
Dear Mr. & Mrs. O'Brien:
Your application for a permit for an in -ground pool at 7 Carleton Lane has been reviewed by the Health Department.
The application was denied on March 20, 2003 for the following reasons:
1. X Missing informa tion
2. Passing Title 5 inspection of septic system required
3. Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply:
a. Floor plan of existing and proposed addition — all rooms
b. Certified plot, plan showing house, septic system and proposed pool in scale
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
----- -- --------
CO\4.\io\
. \\-TALTH OF MASSACI41:SETTS
EXECUTIVE OFFICE OF ENvIRONMENTAL AFFAIRS
DEPARTMENT OF EtqvIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTOIN. NIA 02109 617-292-5560
WILLIA1,1 F WELD
GovCmo:
ARGEO PAUL CELLUCCI
Lt. Govcmor' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FbRm
PART A
CERTIFICATION
Property Address: 'I (�'1ZLT-o"' J_ AJ . .1j. A Ad D Address of Owner:
D'ate of Inspection: -71 ZO t9i -5 (If different)
Name of Inspeclor: BERJAMIN C. OSGOOD JR.
I arn a DEP approved system inspector pursuant to Stctlon 15.340 of Title 5 (310 CMR 15.0001
Company Name: NEW ENGLAND ENGINEERING SERVICES, _ INC.
Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 0 184 5
Telephone Number: 508-686-1768
61 C_- q8
TRUDY COXE
Sccrctxn
DAVID B. STRURS
Commissioner
CERTIFICATION STATEAENT I
I certify that I have personally inspected the sewage disposal system 21 this address and that the information reported below is true. accurate
and complete as o(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:
Passes
&nditionalk Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: L,4,cb,
ell ��7
The SN -stem !nspector sh,111 submit a copy oi this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared systern or has a design flow of 10.000 gpd or greater. the inspector and the system owner shall submit
h yst wrier
the report to the appropriate regional off ice of the Department of Environmental Protection. The original should be sent to t e s em o
and copies sent to the byyer. if applicable. and the approving authofiry I
INSPECTION SUMMARY: Check A, B, Q or D:
A] SYST M PASSES:
71 have not iound any information which indicates that the syiterr. viol . zes any of the failure Crite- i2 2s, d=fjnL-d in 3 10 C -MR 15.303.
Any (ailure criteria not evaluated are indicateed below. P L/
COMMENTS: �e,,,_ iepe,,i r -e " "0 cc& --.j %, Coe^ C e d) t;, F- ..<.
81 SYSTEM CONDITIONALLY PASSES:
One or mofe system components as described in the -Conditional Pass- section need to be replaced or repaired- The system, upon
completion o(the replacernent 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 �eptic tank is metal, unless the owner or operator has provided the sys:tem trisp4tclor with a copy of a Certificate Of
Compliance (art2chtd) indicating that the tank was installed within twenty (201 Years Prior to the date of the inspection; of
the septic tank. whether or not metal, is aacked. structurally unsound. shows substantial infiltration or cxfiltr2tion. or tank
failure is imminent. The system will pass inspection i(tt-.e existing septic tank is replaced witha conforming septic Wk.
as approved by the Board of Health.
SUBSURFACE SEWAGE DISPOSAC SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -7 Cc,,-at-Tov t -Ai. A)- Avooj4571z-
Owner: 31J I k CL- M 40 A
Date of Inspection:
-I k Z�-' tct
61 SYSTEM CONDITIONALLY PASSES (continuedi
Sewage Wckup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) o(clue to 2 broken. settled or uneven distribution box. The system will . pass inspeaion if(with approval of he
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
inspegion ff(with approval of (he Board of Health)
broken pipe(s) are replacec
obstruction is removed
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
I
Conditions exist which reaut(e iurther evaluation by the Board o(Health in order to determine i(the system.is failing to protect the
public health. safM and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL FROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or prw�- is within 50 teet oi a surlace water
Cesspool or privy is within 50 feet oi a bordeting vegetated wedand or a salt marsh.
zog
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 PU13LIC HEALTH AND SAFETY AND THE
ENVIRONMENT: I
— The system has a septic tank and soil absorption system (SAS) and the SAS is within ()o feet to a surface water supply or
tributAry to a suriace water supply.
— The system has a septic tank and soil absorption system and the SAS is within 2 Zone I of 2 public water svp,-)Iv 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 wo 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 irom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to Or
less than 5 ppm. method used to determine distance (approximat;on not valid).
3) OTHER
2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: —1 Cct�Zj_jT�A, 0 0— cy--
Owner: JIA"C'_
Date of inspection: -7 t 2,C)
DI SYSTEM FAILS:
You must indicate either -Yes- or -No- as to each of the following:
t have determined that the system violates one or more of the f(Alowing failure criteria as defined in 3 10 CMR 15.303. The basis
(or this determination is identified below. The Board of Health should be contacted to determine what will be necessary to con-ect
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 box above outlet invert due toan ovedoaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6- Wow invert or available volume is less than 1/2 day flo-,%-.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numoer or times pumped
Any portion of the Soil Absorption System. cesspool or privy is below the high groundwater elevation
Anv ponion 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.
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 writh no
acceptable water quality analysis. if the well has been analyzed to be acceptable. attach copy oi well water analysis for
coltiorm bacipria. volatile organic compounds, ammonia nitrogen and nitrate nitropen.
El LARGE SYSTEM FAILS: I I
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 (a6lity with a design (low of 10,000 go 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) of a M,2LPPed Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compl iance with the groundwater treatment progr�arn
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
Crovipod 04/25/1-J) Pago 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECtION FORM
PART 8
CHECKLIST
Property Address: I t—,j.
Owner: J'OL t L_ 9 -AA o A.�
Date of Inspection:
I t
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 thesystern components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period- Large volumes of water have not been introduced into the system recently of
as pan of this inspection
As built plans have been obtairied and examined. Note ii they are not available with N/A.
AM
The iacilitv or dwelling was inspected for signs of sewage back-up.
The syste m does not receive non -sanitary or industrial waste flow.
The site was inspected for signs of breakout
A([ systern components. excluding the Soil Absorption System. have been located on the site.
The septic tank manholq were uncovered. opened. and the interior of the septic tank was in1pected (or condition of
baffles or tees. material of consiruciion. 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 tand occupants, if different from owneo were provided with information on the proper maintenance of
Sub -Surface Disposal System.
Existing information. Ex.iPlan at B.O.H.
Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation o(distance is
unacceptable) (15.302(31(b)) I
(r-vi..d 04/25/97) P.7. 4 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM
PART C
SYSTEM INFORMATION
PropeTty Address: AJ -
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: p.dJbedroom (or S.A-S
Number o(bedrooms: -
Number of current residents:
Garbage ge.r.der (yes or no!: q
Laundry connected to system (yes or no):
Seasonal use (yes or no): 0
Water meter readings. if available (last two (2) vear usa&e (gpd):
Sump Pump (yes or no):
H c,
Last date of occupancy:_eA2,nCf,,.,T ITI-7 Mye- 1qW7
COMMERCIAIJINDUSTRIAL:
Type of establishment:
Design flow:----__pIlons/day
Creare trap present: (yes or no!
Industrial Waste Holding Tank present: ives or nol_
Non -sanitary waste discharged to the Title 3 syslem (yes or no)_
Water meter readings. if available
Last Cate 01 O�Cupanc\ -
OTHER: (Describe!
Last date of occupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of information
System PuMjXd as part of inspection: (ye�
If Yes, volume Pumped: _gallo�s
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: Ice 1- -5
Sewage odors detected when arriving at the site: (yes or no) zV
(revised 04/2S/s7)
raly. 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (20al-TZA-1 �-AJ, �J. AAIOC�, C/Z.
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
material of construction: V'�c;ist iron 40 PVC — other (explain)
Distance (rom private water supply wellor suction lirt- -LV- ft—
Diameter Y
Comments: (condition o(joints. venting. evidence of leakage. etc.)
SEPTIC TANK:—
(locate on site plani
Depth below grade:
material of construction: Zconcrete —metal —Ffberglas� _Polyethylene _other(explain)
if tank is metal. list age _ is age confirmed by (-eniltcale 01 i_ompiiance
Dimensions: /oco
Sludge depth- �/ z
Distance from top of slud
,je to bonom of outlet tee or baff�e:.
Scum thickness 4. i I .'
Distance from top of scum to top of outlet tee or baffle:. &
Distance (rom bonom of scum to bonom of outlet tee or baffle: J i3
How dimensions were determined: W,'-ots u,<, -c, ae A
Comments:
(recommendation for pumping. condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert. stru�lural
integrity. evidence of leakage. etc.) -"rAAIA A,' KN 7 0.,V 1-e
bAJ.
GREASE TRAP: AIA -
(locate on site p(anj
Depth below grade:
material of construction: —concrete —metal —Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance (rom top o(scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom ol'outlet tee of 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-4 04/7s/17) P.9. 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -7 C --
Owner:
Date of Inspection -
I I t,'--> 1-7
TIGHT OR HOLDING TANK: /t* iTank must be pumped prior to. or at time. o(inspection)
(locate on site plan)
Depth below grade:
material o(construction: —Concrete —metal —Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacitx,- gallons i
Design i!ov, g�llon-Jda%
Alarm level Alarm in working order Yes. — NO
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches. etc.)
DISTRIBUTION BOX:—
(locate on site planj
Depth of liquid level above outlet inven:
Comments:
(note if level and distribution is equal. evidence of solids carryo+er,
014,
XaQ -!�-toce-
PUMP CHAMBER: A)A
(locate on site plan)
of leakage into or out of bOX, etc.)
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.)
(r-viv-d 04/25/97) P.V. 7 of 10
0
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: z"D C:�
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:
leaching trenches. numbef.length:
leaching fields . number. dimensions:—Z
overflow cesspool. number:
Alternative system:
Name of Technology:
Co'mments:
(note condition of soil.' s of hydraulic failure. level of ponding, condition of vegetation. etc.)
.,::� C <:b Cia
IS I U,
CESSPOOLS: /Uf+
(locate on site plani
Number and configuration
Depth4op of liquid to inlet inven:
Diepth.of solids layer:
Depth of scum laver:—
Dimensions of cesspoo!:
Materials of construction:
Indication of groundwatec
inflow (cesspool must be pumped as part oi inspection)
Comments:
(note condition of soil. signs of hydraulic failure. level of ponding, condition of vegetation, etc.)
PRIVY: _42111�
(locate on site plan)
materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition o(soil. signs of hvd(aulic failure. level of ponding. condition of vegetation, etc.)
a of 10
0
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 CC, a.L- j-0 A"-Qoa�e—
Owner: 0^
Date of Inspection:
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)
a
0
,I,
9 A �, e- I &,I-� T 0-0,5 PA.)
(r-viv.d 04/25/971 P.q. 9 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: —7 CC( rtl_ T-4) ,.i
Owner: V+ L e- /vt� 0 A-�'
Date of Inspection:
Depth to Groundwater j Feet
Please indicate 211 the n-.e(h(>ds used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abuning property. observation hole. basement sump etc.)
Determine it irom local conditions
Check ,th !oca! *Board oi health
Che6 FEMA Maps
Check pumping records
Check local excavators. installers
V"Use USGS Data
Describe in vour o�n words ho,,N- you established the High Groundwater Hevat,on.: (Must be Completed)
0.
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5
FORM 4 - SYSTEM PL-.\Wr�G RECORD
Commonwealth of Massachusetts
, Massachusetts
S
ystem Pumping Record
N'stem Owner
ystem-Location
ja 2 1 iqq,�
�-j f, I -�o n L a&\p
�j I "Uex-
Date of Pumping: Quantity Pumped: gallons
Cesspool: No 2- Yes [I Septic Tank: No El Yes
System Pumped by- . &Joezv� E��j License
Contents transferred to: (0 , L , <��, � 0 -
Date Inspector
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F"
Address of property Lovv\e I Aj"-Vk
owner's name
Date of Inspection
PART A
CHECKLIST
7
Check 1 the following have been done:
::� �i__
Pumping information was requested of the owner, occupant, and Board of
� H th.
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. Largo volumes of water have not been introduced into the
system recently or as part of this inspection.
NLA As built plans have been obtained and examined. Note if they are not
vailable with N/A.
eThe facility or dwelling was inspected for.signs of sewage back-up.
>'he ite was inspe'cted.for signs 'of breakout.
/All system components, excluding the SAS, have been located on the
site.
The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
ludge, depth of scum.
The size and location of the SAS on the site has been determined based
n existing information or approximated by non -intrusive methods.
The facility owner (and occupants, if differeft from owner) were
provided with information on the proper maintenance of SSDS.
q
I t
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
�&number of current residents
garbage grinder, yes or no
s laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
C)o TIS
Water meter readings, if available: :�-3?-95' lea C6.Qs
Last date of occupancy c*
GENERAL INFORMATION
Pumping records and source of information: (" ()y)j-V\ (:5;(e-
, j —
\Ij
I System
pumped as part of
cti�u,
yes or no
if yes,
volume pumped
Reason
for pumping:
A ba-,k�)
Type_;e system
__L,t:f-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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: 3 1 V oW- —nujrve-.,�
No Sewage odors detected when arriving at the site, yes or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SEPTIC TANK: SYSTEM INFORMATION continued
(locate on site plan)
depth below grade: Id
material of construction: concrete metal FRP other(explain)
V1 t I =
dimensions: )KEA (4
" S sludge depth
distance from top of sludge to bottom of outlet tee or baffle
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
depth of liquid
R-vidence.of-lea
for pumping, condition of inlet and outlet tees or baffles,
level in relation to outlet invert, structural integrity,
age reco e d f
Rla�iops or r p
k�� T I A ie --k-- -,6 &IT yvo --Ives
W\k�tA oil
DISTRIBUTION BOX: ilof"
(locate on site plan)
— D depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
7 e i of leakqge int) or out of box, recommendation for rej�jirs, etc
r un. k� A Q ;��' CU�� Tj ( I '" r -�� 0e5A ( )0 1 � 'T -:1--f J) tep C
,C),
PUMP CHAMBER:JAIMNO
(locate on siti p-I-aii-)
pumps in workiqn:6 �e , yes or no
We
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
4
9
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS): L1�
(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 and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
T%T.�d
leaching fields, number, dimensions
V V
overflow cesspool, number
Comments:
(note condition of soil, signs of hydraulic
failure, level of ponding,
cor i t , . a
ton of ve
V t q , recommnda ion for maint no* r a ir *to
VC.,
-X *4cv\ Ala,
5) 9
I tj Ge_ - �j All) 15)!?4 jA_1R c4-- /Vj v
,g�o
yk
CESSPOOLS (locate on site plan)
L/
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 inspection)
Comments:
(note condition of soil, signs of hydraulic
failure, level of ponding,
condition of vegetation, recommendations for
maintenance or repairs,etc.)
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 1001
=LOt7 1 8 r/ I I'
—00,)c :- �� / 0
DEPTH TO GROUNDWATER
M60wV\ depth to groundwater
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indichte yes, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances. If "not determined", explain why not)
iv Backup of sewage into facility?
IV Discharge or ponding of effluent to the surface of the ground or
surface waters?
/V Static liquid level in the distribution box above outlet invert?
AlLiquid depth in cesspool <611 below invert or available volume< 1/2 day
flow?
/V Required pumping 4 times or more in the last year?
number of times pumped
IVSeptic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
IVIs any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
/V within 50 feet of a surface water?
/V within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
/V_ within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS)?
within 50 feet. of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysi
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK
PART D
CERTIFICATION
Name of Inspector N6 I �S_. Bali'le-Cc�n
Company Name
Company Address
c(ac)
Certification Statement
I certify that T have personally inspeQt*4 the sewage diapomal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance f on-site sewage disposal systems.
C L �
hec ne:
L , T ave
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined
the environment a
determination is
form.
Inspector's Signature
Date
that the system fails to protect public health and
s defined in 310 CMR 15.303. The basis for this
id d i
provi e 1 the FAILURE CRITERIA section of this
n 4 4 '1 or I — I �.Iof
A. .j " a to system owner
Copies to:
Buyer (if applicable)
Approving authority
Tou-vN
rOU)n 04C�
LOLO
uoc��
SUBSURFACE SEWAGE DIS SAL SYSTEM INSPECTION FORM
Address of property I 0-0-fl-tcon o r1or-\ tNt
Owner's name Ren�)m (�
Date of Inspection
(0 PART A
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
'e-00'None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
N_�A_ As built plans have been obtained and examined. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
1_0" .
The site was inspected for signs of breakout.
system components, excluding the SAS, have been located on the
site.
.,�The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
.'._�The size and location of the SAS on the site has been determined based
on existing information or approximated by non -intrusive methods.
11100"The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
C_ "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS):
�locate on site plan, if possible; excavation not required, but may be
approximated by non -intrusive methods)
If not det.ermined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Is
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
conqition of vege�ation
,, recommWations for m�ip�epance or repairs,etc.)
CESSPOOLS (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 inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
PRIVY:
(locate on site plan)
materials 'of construction
dimensions
depth of solids
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
I
SKETCH OF SEWAGE DISPOSAL SYSTEM:
I
include ties to at ileast two permanent references landmarks or benchmarks
locate all wells within 1001
DEPTH TO GROUNDWATER
>(O depth to groundwater
method of.determination or approximation:
S
>o%L
OSDA
P...
SUBSURFACE SEWAGE DISPOSAL SYSTEM IXSPEC7IOW FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
number of current residen
no
garbage grinder, yes or &
laundry connected to system,.--�s r no
seasonal use, yes o Aww-�
K2-0)
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping reAords and_sWrce qf information:
System pumped as part of inspectiont,,�s r no
if yes, volume pumped
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)
Other (explain) 0 ear— �N ra.
Approximate age of all components. Date installed, if known. Source of
information -
IJ Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade: I
material of construction: '_-_�concrete —metal FRP other(explain)
"'dimensions: 9-0)( 'M-3)( b
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
all scum thickness
�jb -Tc--t-distance from top of scum to top of outlet tee or baffle
06 =—ke-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,
evidenc?
Al __ ?f 1jakage, recommendations for repairs, etc.)
DISTRIBUTION BOX:
(locate on site plan)
— depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
ev' of leakage into or out of box, recommendation for repairs, etc.)
iA?Q 1 '0 n e-- G% ( I VN e ('\on k -N — I Z
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc.)
- - . 1 .1 . 4 . I I - – , , 4 , , — - - - , , Ic --, - . . "I" ,M -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOX FORM
PART C
FAILURE CRITERIA
Indicate.yes,, no, or not determined (Y, N, or ND). Describe basis of
determination in all instances. If "not determined", explain why not)
0— Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters'?
N W Static liquid level in the distribution box above outlet invert?
NOLiquid depth in cesspool <611 below invert or available volume< 1/2 day
flow?
A/_ Required pumping 4 times or more in the last year?
number of times pumped
0j. Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
O/DIs any portion of the SAS, cesspool or privy:
. below the high groundwater elevation?
VV- within 50 feet of a surface water?
V1 within 100 feet of a surface water supply or tributary to a surface
water supply?
Uwithin a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS)?
within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analyr
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORK
PART D
CERTIFICATION
Name of Inspector
Company Name AN rtzb Ln r tQ.
Company AddressT, ?.q9 Lowck NA V�si
Cer ification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the,environment as defined in 310 CMR 15.303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date
Original to system owner
Copies to: a 0
Buyer (if applicable)
Approving authority
I
11
Town of North Andover, MR
watershed Septic System
Servicing ReRort
Date: � -;L I h&
Homeowner:
Street :---7 CC--(-J-Je4,1 L,-arU—
Phone
Nature of Service:
Observations:
0
Description of Work:
,--DLL Vh T)e/( ) 5 -co
Comments:
Routine 7y—
Emergency
Pumper :
Address:
WN OF NORTH ANDOVEI
BOARD OF HEAJH_
SEP 13 19M
Phone : Sln;i� -3 Cqq //0 Q�,
Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
FAI74
77777,777,777
q NN g
J,
A Ni, r) rl)
N Q R T
y P-
P U N c o,
�YSTEM L o
(VX4 m P It: IQrl fro,n(
v, Y. --------
...........
QUANTITY:'
PUMPC, D
�.S'EPTIC'
TANK: NO
T U R E. 0 F..� S E R.Y.I. C E:" R 0 UT I N E�
V-"'
EMERCENCY
R Y:;\
WV
L L 'T COY C, j�.
.0 A FFL ES I ['A C
R'Q OT
LEACHFIELD
RUNUACr<...
ULM:
RR M�
-... ,, - A YO Y
777
M p Q M. p c �o
A*-�
-vp
. ...................
cl 1� R S
�7
Town of North Andover
Office of the Health Department
Community Development and Services Division
William J. Scott, Division Director
27 Charles Street
Sandra Starr North Andover, Massachusetts 01845
Health Director
March 20, 2003
Diane & Andy O'Brien
7 Carleton Lane
North Andover, MA 01845
Re: Application for in -ground swimming pool
Dear Mr. & Mrs. O'Brien:
Telephone (978) 688-9540
Fax (978) 688-9542
Your application for a permit for an in -ground pool at 7 Carleton Lane has been reviewed by the Health Department.
The application was denied on March 20, 2003 for the following reasons:
1. X Missing information
2. Passing Title 5 inspection of septic system required
3. Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply:
a. Floor plan of existing and proposed addition — all rooms
b. Certified plot plan showing house, septic system and proposed pool in scale
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
FORM U LOT RELEASE FORM.
Roof I" I'sZe,
-INSTRUCTIONS- This form is used to -�'erifythat all -necessary approval /permits from
Boards.and Departments having jurisdiction h�'�
a I e been obtained. This does not relieve the - .3' "DV- 103
downer from comp, 1, -
applicant and'or lan liance with any applicable requirements.
a 8 a a a 0 a 0 0 a =.a a x a 0 0 a a a a 9 0 0 a 0 0 a 0 a a a a a a a a 0 a 0 a 0 a a a a a a 0 0 a a a a a 0 0 0 a 0 a a a a m m 0 a a 0 m a
APPLICANT -7 PHONE
4C6 .. q L ocr-
ASSESSORS MAP NUMBER 101 , A —LOT NUMBER
SUBDMSION LOTNUMBER
STREET C OL r(tta ttA STREET NUMBER �7
. . . . . . . . . . . a a am A a a a am m a w -W. -m.
0MC11AL.USE ONLY
.............
WZENDAnONS OF TOWN AGENTS
om� go
DATE APPR
Aa
C.0 . NSERVATIONAD147TOR DATE . REJECTM
CONMENTS
DATE APPROVED
TOWNPLANNER
CONMEN'TS
FOOD INSPECTOR - BEALTH
SEPnC INSPECTOR - BEALTH
CON*&NTS-
PUBLIC WORKS - SEWER / WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTNIENT
CONRvffNTS
RECEIVED BY BUILDING INSPECTOR.
DATE PE)ECTED
DATE ArPR
DATE REJECTED
DATE APPROVED
DATEREJECTED <31IR6
DATE APPROVED
DATE REJECTED
Town of North Andover
Office of the Health Department
Community Development and Services Division
William J. Scott, Division Director
27 Charles Street
Sandra Starr North Andover, Massachusetts 01845
Health Director
March 20, 2003
Diane & Andy O'Brien
7 Carleton Lane
North Andover, MA 0 1845
Re: Application for in -ground swimming pool
Dear Mr. & Mrs. O'Brien:
Telephone (978) 688-9540
Fax (978) 688-9542
Your application for a permit for an in -ground pool at 7 Carleton Lane has been reviewed by the Health Department.
The application was denied on March 20, 2003 for the following reasons:
1. X Missing information
2. Passing Title 5 inspection of septic system required
3. Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply:
a. Floor plan of existing and proposed addition — all rooms
b. Certified plot plan showing house, septic system and proposed pool in scale
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Cc: Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535