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HomeMy WebLinkAboutMiscellaneous - 10 CHERISE CIRCLE 4/30/2018I N All MAP PARCEL # STRUCTI.ON_APPR�v!pLpjA A... NU coN.._._..... W EEE BEEN PAID? App, BY - . S PLAN REV IE , HA DATE Dn F E PLAN - App ROV AL n --- ' ITIONS -- --�- WELL TOW_. _......_......._. SUPPLY'. DRIi-LER.`-....__._.- WATER WELL PERMIT \ CHEMICAL (11I�FIUVEU VAIE WELL TESTS BAG T 1A I DAj.E AF-'PItUVEll BACTERIA COMMENTS: APF U APPROVAL% --By DATE ISSUED APPROVAL AID YES NU EI�,At-ALL PERM tu TIO�STRUCOION APPRUVAt- Y WELL SEPTIC SYSTEM CONS / NO YES OTHER DY .:. . DA E• ANY VARIANCE NEEDED APPROVAL: F HEAL F INIAL BOARD OTH A E .S THE INSTALLER LICENSED? : , n �� YES NO YPE.OF CONSTRUCTION: t NE 'REPAIR 1: • NEW CONSTRUCTIDN: CERTIFIED PLOT PLAN REVIEW YES NO • r CONDITIONS OF..APPROVAL NO (FROM FORM U) f , ISSUANCE OF `DWC PERMIT � YES NO DWC" PERMIT ND. INSTALLER: 7/AA Mtn- U�� ' BEGIN INSPECTION ES N0 EXCAVATION. INSPECTION: :NEEDED: PASSED r BY . :'-.:CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YESs ♦' APPROVAL. TO BACKFILL: DATE: X711 BY fINAL.GRADING APPROVAL: DATE BY .',FINAL CONSTRUCTION APPROVAL- DATE- MAP # LOT.. # 3: PARCEL # STREET._ �ONSTRUCTI.ON APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE APP. BY_ DESIGNER: 6/W/6%// -/SSC- A, PLAN DA-I'E: CONDITIONS WATER SUPPLY: OWN WELL WELL PERMI WELL TESTS: CHEMICAL DAT E APPROVED-- . .......... B ERIA I VA1E f1PPRUVED BACTERIA DA 1'E APPROVED COMMENTS: FORM'U APPROVAL: APPROVAL TO ISSUE ES—D NO e DATE ISSUED %7' BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO YES NO YES NO YES NO YES NO DATE:...........__..._ ...DY:._.. . IS THE INSTALLER LICENSED?� YES TYPE. OF- CONSTRUCTION•• NEW REPAIR' �;. .-:.,NEW CONSTRUCTION: ,.CERTIFIED PLOT PLAN ,REVIEW YES NO CONDITIONS OF..APPROVAL YES NO tFROM FORM U) . .J •_`.,ISSUANCE •OF DWC PERMIT" YES NO •DWC • PERMIT N0. —INSTALLER: BEGIN INSPECTION YES N0: ' :-.:EXCAVATION . INSPECTION: :NEEDED: -; PASSED BY :.:CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YESs ` APPROVAL TO BACKFILL: '` DATE:- BY FINAL.GRADING APPROVAL: DATE BY FINAL CONSTRUCTION APPROVAL: DATE: BY Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab tetum Commonwealth of Massachusetts RECEI', Title 5 Official Inspection Form APR - 5 2007 Subsurface Sewage Disposal System Form -Not for Voluntary Asses ents(F TOWN OF NORl 10 Cherise Circle HEALTH DEPAR:, _ qT �� fr'4 / Property Address ✓ Denise Mitchell Owner's Name No. Andover MA 01845 04/04/07 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Benjamin C. Osgood Jr. Name of Inspector New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover City/Town 978-686-1768 Telephone Number B. Certification MA State License Number 01845 Zip Code 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: JXL Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Insp or'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. ""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. TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner's Name No. Andover MA 01845 04/04/07 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. 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 TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner's Name No. Andover MA 01845 04/04/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 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. TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner's Name No. Andover MA City/Town State B. Certification (cont.) 01845 04/04/07 Zip Code Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 ❑ ® 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 ❑ I Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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 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. TITLE 5 FORM 2007.DOC • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner's Name No. Andover MA 01845 04/04/07 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ [R Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 14 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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 ❑ Q the system is within 400 feet of a surface drinking water supply ❑ Q the system is within 200 feet of a tributary to a surface drinking water supply ❑ �i 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. TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner's Name No. Andover MA 01845 City/Town State Zip Code C. Checklist 04/04/07 Date of Inspection 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? X ❑ 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? R] ❑ Was the site inspected for signs of break out? J2 ❑ Were all system components, excluding the SAS, located on site? Z ❑ 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: ❑ 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)] TITLE 5 FORM 2007. DOC - 08106 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System - Page 6 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner's Name No. Andover City/Town D. System Information Residential Flow Conditions: MA 01845 04/04/07 State Zip Code Date of Inspection Number of bedrooms (design): --y Number of bedrooms (actual): ` DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): GG d Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): ❑ Yes IQ No ❑ Yes J0 No ❑ Yes No ❑ Yes f No ❑ Yes Eld No Fav Date Date TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15 Gallons per day (gpd) ❑ ❑ ❑ Yes ❑ No Yes ❑ No Yes ❑ No Date TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner's Name No. Andover MA 01845 04/04/07 City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: gallons �euRs C;,,ti a PF[Z OIJA1(F (L RL Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes [2 No ❑ 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: 7-1-� I --, � 9 ct.s PE'a. ft:5> - OO' c.T ?L A &J Were sewage odors detected when arriving at the site? ❑ Yes CKL No TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.N 10 Cherise Circle Property Address Denise Mitchell Owner information is required for every page. Owner's Name No. Andover City/Town D. System Information (cont.) State 01845 Zip Code Building Sewer (locate on site plan): Depth below grade: Material of construction: F-1 cast iron ® 40 PVC ❑ th I feet 04/04/07 Date of Inspection U 1U1 (exp C3 "In Distance from private water supply well or suction line: /�%�l� feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: [,concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 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 How were dimensions determined? TITLE 5 FORM 2007.DO.0 • 08/06 / J 0 C-li c. L J iV S Z ,Me- }5u2 6- .sTZcK Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner Owner's Name information is required for No. Andover MA every page. City/Town State 01845 04/04/07 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.): ,TANK tAJ &-00P 60Qat-rj6Y- SCK do FU C. TTWm w GooS Al JA Grease Trap (locate on site plan): /u114 Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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 feet ❑ polyethylene ❑ other (explain): Date of last pumping: Date 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): TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts ,MP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 10 Cherise Circle Owner information is required for every page. Property Address Denise Mitchell Owner's Name No. Andover MA 01845 04/04/07 City/Town State Zip Code Date of Inspection D. System Information (cont.) A f l#4Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert b 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.): 13 C19 C=-oo C1 AJ.>,1-)OA, it/o Peg of 1..erfA46- I V OR 007, aVT)0NJ 45-QyAK-, W lam` Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments H 10 Cherise Circle Owner information is required for every page. Property Address Denise Mitchell Owner's Name No. Andover City/Town D. System Information (cont.) State 01845 Zip Code 04/04/07 Date of Inspection 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: Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: number: number: number: number, length: number, dimensions: number: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Alze-A DI= 1=1 O -Z- 0 t-6 O K.$ N 2 ^4 str- A,) 0 a,) 4 o e h E 4F TITLE 5 FORM 2007.DOC - 08/06 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15 Owner information is required for every page. -Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner's Name No. Andover MA 01845 04/04/07 City/Town State Zip Code Date of Inspection D. System Information (cont.) NjFr 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ,A/Ierivy (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.): TITLE 5 FORM 200TDOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Cherise Circle Property Address Denise Mitchell Owner Owner's Name information is required for every page. City/Town MA 01845 04/04/07 State Zip Code Date of Inspection D. System Information (cont.) 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 i 5,r'A -j GES t -T 3o.-7 Z- T k�•3 C K ZtsE Cl?- TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary � Y Y Assessments p 10 Cherise Circle H Property Address Denise Mitchell Owner Owner's Name information is required for No. Andover MA 01845 04/04/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ['Check Slope E Surface water B- Check cellar ['Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: Q Obtained from system design plans on record If checked, date of design plan reviewed: Svd Te-,rl-7f2 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: sy�rc.�-, �S rn`�.,.�S ( -4., + cjz, DJC. Surro$,., Diyy A -2F,9 7 7a 3 'L L-Jc 11",_ TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 • t3VpnU Vr r'rwr a v. COMMONWEALTH OF MASSACHUSETTS - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR [-- DEPARTMENT OF ENVIRONMENTAL PROTEC 5 ON ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAU? CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: jo C6 e f ;i c C t`1 f C Name of Owner S•f. t -C i�► f T�fr M u f 1 h AA4t0 Q ✓r- Address of Owner: / u C A e r ji t C e r cr a Date of Inspection: k V rT% /1 N n V v e- fr J -a . Name of Inspector: (Please Print) V I'Accn r 1hool l3cjv^ib I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000) Company Name: Srt,!tir '/hAw/ R6 ;—.f I - AA^, Mailing Address: f� C Rt r. 4.90 N- Q. 'Oen'' 9 C hr (1- Telephone Number: G) r . e 6 > V/ H Ii 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: V Passes — Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority \ Fails Inspector's Signature: ' I&Vf,&*- 09;l ae Date: C` The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 ofYEnvironmental Protection. The original should *be sent torvw system owner and copies sent to -the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1of11 0 Printed on Recycled Paper 3� t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) �1 Property Address: / C C AV c 1--tc C Owner: SG it ; C h4 f 7-!e r Date of Inspection: J-)- / 9 1 INSPECTION SUMMARY: Check A, B, C, or A A. SYSTEM PASSES: V I have not found any information which indicates that any of the failure conditions described in 310 CMR 1.5.303 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. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. lei 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 (20) 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 if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 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 levelled or replaced - The system required pumping -more than fourtimes-a Yeardue to broken or obstructed pipe(s). The,systern willpass- inspection if (with approval of the Board of Health): - broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: % 0 C% e r J -e C's' rc f c N• A v /O dv P - Owner: SC -c,,,,- C b i"r'` t t Date of Inspection: 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 the public health, safety and 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.PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEN.Tz 13 Cesspool or privy is within 50 feet -of 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 ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - c 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 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 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 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 5 ppm. Method used to determine distance - (approximation not valid). 3) OTHER s revised 9/2/98 Page 3 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: j() C h e c ;s c C i cc 1 c N' A ro Pov c,, Owner: S'C vr-T C iq Date of Inspection: /44- 9T D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: tV D 1 have determined that one or more of the following failure conditions exist as described 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 4aciBtyFor••systemcomponent�due tte an overloaded orclegged-S:AS 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. _ V00'_ 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. _ LZ_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. t 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. v 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: 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: The system serves a facility with a design flow of 10,000 gpd or grgfater (Large System) and the system is a significant threat to public health and safety and the environm4kt because o4 or more of the oliowing conditions exist: Yes No _ the system is within 4lia feet f a sur ace drinking ater suppl the system -is -2,0 - feet -of arty-to•a rfaoe•d the system is located nitrogen ensitive are (Interimwater supply well) The owner or operator of any such systehall upgrade the system in accordance office of the Department for further information. revised 9/2/98 Page 4of11 Area - IWPA) or a mapped Zone II of a public 310 CMR 15.304(2). Please consult the local regional 0 Property Address: ) CI Owner: Sc' Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST c[rctt. N. /�iNI�tlVe e- C14(•T; of 1)-/-9f Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes Pumping information was provided by the owner, occupant, or Board of Health. A/U A ( %4 VA •f/ 14 10 None of the system components haus been pwnped+toratJeast two weeks andrthe-vystem hasrbeea+receiai+g#r+aal -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 NIA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, 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 Soil Absorption System orrthe site has been determined based on: - Existing information. For example, 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 unacceptable) [15.302131(bl) The facility owner land.occupants.if differegt from-owwnerLwera.provided.with infounation.on t ha ernpon-maintena�+:.f SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: j o C h C f" j C C i' fY f c A/, 441 i7 (1VC — owner: S c ` rT Date of Ins C 14 I ries pec6on:. fa- /-9f FLOW CONDITIONS RESIDENTIAL: Design flow:to A Qg.p.d./bedroom. Number of bedrooms (design):_ Number of bedrooms (actual): Total DESIGN flow Number of current residents: Garbage grinder (yes or&: Ato Laundry (separate system) (yes or :iVI� nr I ;. If yes, separate.inspection,required Laundry system inspecd (yes oro Seasonal use (yes or o /r0 Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or o) Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 syste : \Ys Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: KC Abl AW vC' uM e. System pumped as part of inspection: as or no)_ If yes, volume pumped: /s OO gallons Reason for pumping: C1►fck Strur-rvo/ whir -e( Y> �f��f lev � TYPE O�STEM �/ 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date instalied4if-known►•and source: of•iRformation: #moi -b - � /F t•, — ,�Crf A /0.! d br • i i- Pl b 9 -re-4 A77 -,0--.4-e0 Sewage odors detected when arriving at the site: (yes or o) AID revised 9/2/98 Page 6 of 11 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / o C A e C I J C C1 rC/ c Owner: Date of Inspection: 'SC. vt r 9iA r �� t• ✓ BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction: _ cast iron _ 40 PVC_ r ( plain) I / Distance from private water supply well or suction li Diameter Comments: (condition of joints, venting; evidence iea e, -etc. SEPTIC TANK: Pj (locate on site p an) Depth below grade: Material of construction: I"concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is Fnetal, list age _ 1s.age_confirmed by Certificate of Compliance _ (Yes/No) Dimensions: Sludge depth: /, Distance from top of sludge to bottom of outlet tee or baffle: .3 -- Scum thickness: Z 11 r Distance from top of scum to top of outlet tee or baffle: tr Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: f h e4i vrrg Comments: (recommendation for pumping, condition of inlet andoutlettees or -baffles, depth of liquid level in relation to outlet invert, structural4ntegrity, evidence of leakage, etc.) Xy, OTIc Jg011, fh(,vlh 1)e— 10VADeg Vegarl y_ 2W If - Pvra _,I, - Alb _ ot /fgoig, _ I - GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _ her(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or e:_ Distance from bottom of scum to bottom of outl t or Date of last pumping: Comments: (recommendation for pumping, condition of in/It andoVtt tees or evidence of leakage, etc.) revised 9/2/98 Page 7of11 level in relation to outlet invert, structural integrity, 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 Cj C I ✓ C Cr r71 t /01 • /-)tvOo L e— Owner: S c tor- C v9 rn 't e Date of Inspection: 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 lgther(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working Date of previous pumping: Comments: (condition of inlet tee, condition of alarm Yes float svjtches, etc.) 6 DISTRIBUTION BOX:�a (locate on site plan) Depth of liquid level above outlet invert: Comments: (note,if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - - - — LeVet rA Dfit rrrilkzr�.41 1iv r�1 eq /W .rClr'G► cwc>v,lN /Vi M rrlea�r� Gyp /C io I J ?hrin U0- 0 1f 04 0V>-' � 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, conditi f pu ps and revised ,9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) .` Property Address: 14 G�rCt✓c �l'�/� Af- 19ovoevrj �/ Owner: ,SC v� a4 fTr P,� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS)- %v e-1 (locate on site plan, if possible; excalation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: ' , S k S(, overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) so4&#2) ..Cd/i An S. %111 ff - J4%,br /,'; Z.,# e, AAn rt.iwnf. CESSPOOLS: _ (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: 1 Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pa I of n: 0 Comments: (note condition of soil, signs of hydraulic failur ,_level of PRIVY: (locate on site plan) Materjals of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level revised 9/2/98 of,degetation, etc.) Page 9 of 11 etc.) Dimensions: �1 C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / G Ci _ r. �J C i, rC I C lV' ANi�cr✓� Owner: , f C vy- r C V9 Date of Inspection: 1a -/-9F SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) revised 9/2/98 Page 10 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: A CkCr'j e c%,rcJL At- Avioc Vc,- ���/// Owner:SC C --T r Date of Inspection:Pr NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater' Feet Please indicate all the methods used to determine High Groundwater Elevation: g v Obtained from Design Plans on record `- Observed.Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ccjp� 01- rel Ai % Ap'» S'c,I'I n r3 rC T•% /�n..> f «r fST revised 9/2/98 Page 11 of 11 CHRISTIANSEN & SERGI, INC. PROFESSIONAL ENGINEERS AND LAND SURVEYORS 160 SUMMER STREET HAVERHILL, MASSACHUSETTS 01830 July 27, 1995 Ms. Sandra Starr North Andover Board of Health 120 Main Street North Andover, MA 01845 Re: Lot 3, White Birch II Dear Ms. Starr: (508) 373-0310 FAX: (508) 372-3960 In response to your letter of disapproval dated July 17, 1995, please find the enclosed revised plans for your review. A response to your reason for disapproval is as follows: 1) Primary area must be S feet to groundwater. As indicated on the enclosed revised plan, the primary leaching area has been relocated such that the 16 minutes per inch percolation test now lies in the primary area and the 2 minutes per inch percolation test now lies in the reserve area. For this reason, the 4 foot separation from groundwater is now sufficient. I trust that this information sufficiently addresses the issues raised in your letter of disapproval. Please call me if you have any questions. Ve Truly Your mtdj Daniel J. O'Connell Encl. c.c. Dan Betty No................_....... THE COMMON Appliration for Dispan1 Workii Cgumitrurtiurt Vamit Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal System at: ................ __. !;;J ra.................. _........... .... L©r3 _..., W HI69 611eCH Location • Address or Lot No. . 01.T_ c -o l�4. � ��l � i�.t� l.. co.: .N :...... ....KO. s.. :...N.r�.l��- !u...:4111 :..._........ Owner Address ............................................. ---•--............................................................................... .... InstallerAddress Type of Building Size Lot.... . ...Sq. feet Dwelling — No. of Bedrooms ........... 4 .............................Expansion Attic ( ) Garbage Grinder ( ) Other —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other Ir. -...res Design Flow ............... . .......81_-.!? ..gallons per person per day. Total daily flow ................ �C.� ................gallons. r �� L �► I Septic Tank – Liquid capacrt j�..........gallons Length.%P...- Viz... Width. �ci..-..... Diameter........... D th...-. ? . ( ... Width.....Z.5.1...... Total Len �:0().'..... Total leaching area ..� �_..... ft Disposal gth.....g , O sq, . Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total. leaching area .................. sq. ft. Other Distribution box (X ) Dosing tank ( ) Percolation Test Results Performed by... CA AEA_ ?)4421&.:._...... Date .4/1l/`9.l, .s. f 93„,..7/*? 5 9 P -S Test Pit No. 1 .... /.�P....... minutes per inch Depth of Test Pit ......10......... Depth to ground water...... 3.Z,............ EYP 3A) y P- G Test Pit No. 2 ..... L ....... minutes per inch Depth of Test Pit.......” ....... Depth to ground water..... 3.Z.`............(TP 74-6) Description of Soil...... MQULf6 ......................................................................................................... ......................................................................................................... Nature of Repairs or Alterations — Answer when applicable Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLTL.E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... .......................... Date Application Approved By..................................................................... .. ................................................................... Date Application Disapproved for the following reasons: ................................................................................................................ .........-•---•....................................•...........---....................................._........................-••-•................---.................................---••-•----•-- Date PermitNo ................................•--................ --- Issued ................................................. Town of North Andover, Massachusetts Form No. 2 NORr►, BOARD OF HEALTH �yy y 1 5 Io w 41 F DESIGN APPROVAL FOR SS�CMUSOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant_Test No. Site Location-( Reference Plans and Spec ENGINEER Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee I I z j � JA �� i C AIRM)VN, BOARD OF HEALTH Site System Permit No. NUS.ETTS. P[VYIQea Ptt form for uao by local Boards jn, &jj h'H�Tho System Pumping bo eubmlrjad to tJ Q local Board of oallh or other a i , H t"horlty, A;. Facility lnfofftatlon�ngQ_ �,•„wr, 4 9`ovt 1. System lOCBUon �� the 1cOY Address �j�,� '.;r mcro you C �(.� • C���� --- rrowm<Y;.: CltY�fown 'r" ••��".7,'1.i'' � Vlale ... � �oVe •�'•, ,;.. � CJI }•y;,,(I/i,.,; 1.?!i It:. Q l •� ,�,' .: r.l i,. ,, ' p ,�;�. •, 7., ,,;,.,t:,,},,2,J.,.V.Ys em Own'a�r .t ,�' . r� . , ,.. r, '" ��:�%� �, � �';:.�,�iy. k'YY�I tI' .l. }` •1i'.,'"�;.'�l i' �f .��1✓I u11.01 1 .,, *,'vr,• `). y%. N•une ,•,/�:� iy ly �l��'h l,lrl.� .': .�. t../,. •; •;' ','„tor!, 7r r i•,; r•L : •.i;,.,,a'. - V r l / � IC.� A4dreu W d(NerOnl (M locaUon) ... CEq'fTown Stale --- r /, {,.y:,11 1, , �, r i(n,,v A'I!•`!�'{r,�i !'� � �Dg '' �;'. ,, �. �; , 1, Da,h of Pumping” nate 2, Quandry Pumped: -- Type pl;ayalem; , ❑ Cdsspool(s) apcic 'Tan x ❑ T9ht Tanx . ...,:, •.t�,•,•�1.,Olher (descrlbe�; �.� -- , r ' Y ,•/I,r I 4 Effluent Tea Fllla Y'..y• r•' (.�f,esant? ,❑as Il cleaned? [] Ye No I f Yes, w yes r ... 1 `',1`(r... �%•6.1,COndl�Jo.n'Q,(,,.•SY;�ni.;''t�.�; � • •i . ti , .fir.; •.1 /� (1' ., ,,. ��r�•r\ C1 iJ�'��J'?j `•�'flt�/('rind, ;.l';, )�;�,;, Yyy•; �':. / �T�..�f "`./ , r , tG ;•... '�. '1.'!y'a,'t,a%�ir�N r, �J�r I � r•I���t '(,'� 'r.JrJ .if1�J�`��:��•„1�'V� r.�..',.�,ti ly �r •��,;.; . . on.where corlfenls yrere d4ow ro mass' �• � 9 � alar/apprOvaJs/lb(orms,hlm#Inspect ,J'' VehlcJe lJcenfe NNutftor J� J rrza Syt10M P(. pM Rec e 05/11/2000 15:57 5083736611 STEWART/ANDOVER PAGE 02 A1,6(4h Alvtiwer C -in. 4. Na r4h A W,aul Lee- IS/ -�14 e- MMMT'S SEPTIC ThM SERVICE 47 RAILROAt) STREET BRADFORD, MA 01835 978-372-7471 Mom% OF MOMMY REPORT FOR TUM OF "I LL") DATE 47ADDRESS /4,17 4� -7 9,0 3L 3c drL,, JLIM e FORM 4 - SYSTEM PUMPING RECORD Commonwe th of Massachusetts r , , , Massachusetts System Pumpin Recce System Owner (a r+i f- r �& Date of 9 Pum in /J ��- P Cespool No Yes Condition of System: k System Pumped by: Sewer-Man/Rooter-Man Contents Transferred to: io INofNOP'��=4 BOARD OF HL:r, ! 13 1999 System Location C���s-e10ce -& tel- 76�b Quanity Pumped: &2) 0 gallons Septic Tank: No Ye (-f AM License No.: / ) U (_6 w.x,1 Date. Inspector: FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: CC�"l Co tN J �f� �- Phone _ �%y 0 0? y LOCATION: Assessor's Map Number Parcel Subdivision 1"J;Tc Lot (s) 3 Street (T -x (T-xewI-I -e C St. Number _ ************************Official Use Only************************ RECOMMENDATIO S OF TOWN AGENTS: ` Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector -Health Date Rejected _,4 J��— ,L) Date Approved Septic Inspector -Health Date Rejected Comments 96Az 5; Public Works - sewer/water connizaro ion-% - driveway permit � Fire Department Received by Building Inspector Date D J O F=4 CD o �4 o��� w ti Cd a o z w wW4 G 0 o �c CO L O _ Ria. :mom as g� m 0- d� -AP\ =,7Z v� 12 w° cQj n U. w a ° LT. wcn cz v C E cG � w cz ° c w w v o c4 cn cn D J O F=4 CD d O mCL� N N C N G O cm CD 'O m 0 Q1 _G .G O N o t 0 Z O I;Z�� A*' o a� G w ti Cd Q Oo G 0 o �c CO L O _ Ria. :mom as g� m 0- d N ago N — CD cir•+ CD CZ N C d O mCL� N N C N G O cm CD 'O m 0 Q1 _G .G O N o t 0 Z O I;Z�� A*' o a� G w o Q Oo �c CO L O O v :mom Z 0- 0 O y O N — Z o Cui o m ccG ca N co m G0 L •� CD 1: CL i. C l i O O O � i G Q cc O d v M cm Q �Z C* C .O C O. p QCD = G7 ► L m G CA. m =43 H 0 j- CQ co W LL --LD •N�C �, G CC c N C'L G W E v � r C.) 6i pm ig G -a m O- m 'j O = Cp .0 N c, 16- d O mCL� N N C N G O cm CD 'O m 0 Q1 _G .G O N o t 0 Z O I;Z�� A*' P cr LL a } cc H z LL Q LL cc • J o z l� CO L O O v '— Z 0- 0 O y O — Z o Cui o P cr LL a } cc H z LL Q LL cc J o z l� CO L O O v '— Z 0- 0 O y O — Z o Cui o U) m G0 z v O i O O � i cc O d M cm Q C* C .O o Cc Cc c Z 0� z c CL CO) z � z z P cr LL a } cc H z LL Q LL cc WHITE BIRCH LANE �5.2'� 5 i EASEMENT BUFFER LINE 1B.51 nor 3 � AREA=21780 S.F. N N 37.7' 36.7 93.5' FOUNDATION LOCATION PLAN CLIENT. JPD DEVELOPMENT THIS CERTIFICATION 15 MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: NORTH ANDOVER,MA. SCALE: 1" = 40' DATE: SEPT.21, 1995 CHRISTIANSEN & SERGI PR LANDOFESSIONAL SURVENGI EYORS ERS 160 SUMMER ST. HAVERHILL.MA. 01830 TEL 508-373-0310 © 1995 BY CHRISTIANSEN & SERGI INC. 29.9' 41 pF HAN- j EALTH SEP 2 7 1995 I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REOUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTSWETLANDS,EASEMENTS, ORDERS OF CONDITIONS,ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE.EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PR0HIBITED.CHRIS7IANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MAITON CONTAINED HEREON. BASED ON SCALED DATA ONLY THE PRIMARY STRUCTURE SHOWN IS NOT LOCATED IN A FLOOD HAZARD ZONE AS SHOWN ON FEMA FLOOD INSURANCE RATE MAP. COMMUNITY NO.: 250098 0005C DATE: 6/2/93 �0H OF �qs sq EL cy G1 uy !STERES LW', DR G No. • 93067016 NORTH Ott,�•o ,°1�'O Oc O F 1SSACHUS�t Town of North Andover, Massachusetts BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT Form No. 3 Applicant NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 73 � Fee r /' / A G ? ll7L.� — AIRMAN, —BTA—VD OF HEALTH D.W.C. No. 776 I h N i h 93.44' h M O O -J M ZoI M 18.50' : - 1 55.22' WHITE BIRCH LANE 0 W V) W Z U 0 LM W 2to� 0 O% w o 0 to �q M �� M �o CX6 cu m �1 o PZ 2Vw� �o=° v3Z wwUv° a � �;•� •� w~ow CL �n,t� �; •� �ZQQ� - t y ti 0 w4�,2�2 �oQ2� I.,� QwQj Qj ( n j N q ►� '� ^ h h to h h hj h to to h to h h h h h Lf) r. 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