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HomeMy WebLinkAboutMiscellaneous - 10 OLYMPIC LANE 4/30/2018 (2)Uf 0 a� V 0 IZ m b —j— i' it Lot & Street �Q �l y —� a"`—t Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: (/ NO Permit# N� Plan Approval: Date: 02j9' lf'f Approved by: Designer: �, .�,�,,, �& Plan Date:_ Conditions: Water Supply: Tow Well Perm' Well Tests: Che al Bacteria Bacteria H Plumbing Sign -Off: Comments: Well --Driller: Date Approved Date -Approved Date Approved Wiring Sign -Off - Form "U" Approval: Approval to -Is, Date Issued By: Conditions: YES NO Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: v r • SEPTIC SYSTEM INSTALLATION Is the installer licensed? Type of Construction: New Construction: _Certified Plot Plan Review -Floor Plan Review Conditions of Approval from Form U _Issuance of DWC permit: - _DWC Permit Paid? -- -DWC=Permit #_ _LP D L-7 Installer: _ Begin Inspection: -Excavation Inspection: -'Needed: -- Passed: .-Construction Inspection: Needed: As -Built Plan Satisfactory: YES: YES ' 1 REPAIR YES YES NO NO NO !YES NO. �..,So vG�, Approval of Backfill: Date: X By: -Final Grading Approval: Date: By: Final Construction Approval: Date: ,1 S� By: Certificate of Compliance: Approval Z zz qq Date: ,'� NO "Y-" 4e-� 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 Olympic Lane Property Address Jeffrey Goldman Owner's Name North Andover MA 01845 Cityrrown State Zip Code 4/9/2014 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor - do not use the return Name of Inspector key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA RECEIVED APR 14 2014 HEALTH DEPARTMENT 01810 State Zip Code S115 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/9/2014 Inspector s Signa re 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. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. CitylFown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box forges", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 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 Olympic Lane Property Address Jeffrey Goldman Owner's Name North Andover CitylTown B. Certification (cont.) MA 01845 State Zip Code 4/9/2014 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 �\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 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. ❑ 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 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 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins • 3/13 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is. a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area.(Interim Wellhead Protection Area — 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. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. City/rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 31 3 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 6 of 17 Water meter readings, if available: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts UTitle 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): 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: Date Pumped July 2013, owner 1500 gallons Measured tank. Inspect tank & tees ® Yes ❑ No ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Olympic Lane Property Address Jeffrey Goldman Owner Owners Name information is required for North Andover MA 01845 4/9/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 16 years old, 6/19/1998, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2.5 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall, 3" PVC in house. No leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1.5 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 3" ❑ Yes ❑ No t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is North Andover MA 01845 4/9/2014 required for _ every page. t5ins - 3113 Cityrrown D. System Information (cont.) State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" Date of Inspection How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M "t 10 Olympic Lane MA 01845 4/9/2014 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover every page. CitylTown MA 01845 4/9/2014 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Form 10 Olympic Lane D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert u 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.): D -box level & distribution equal. No evidence of carryover. No evidence of leakage. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ® Yes ❑ No" ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump tank ok. Pump ok. Floats ok. Alarm has both visual & audible. Pump tank has riser 6" deep over DumD.. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 ection Form - Not for Voluntary Assessments Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert u 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.): D -box level & distribution equal. No evidence of carryover. No evidence of leakage. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ® Yes ❑ No" ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump tank ok. Pump ok. Floats ok. Alarm has both visual & audible. Pump tank has riser 6" deep over DumD.. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 1 field 15'x 60' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 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 Olympic Lane Property Address Jeffrey Goldman Owner's Name North Andover Citylrown MA 01845 State Zip Code 4/9/2014 Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 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 Olympic Lane Property Address Jeffrey Goldman Owner's Name North Andover MA 01845 4/9/2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately Rvk_r L O c'.S-A� 2, \39 I' —6h 16 1 t p —'9 c>" ct S = u 6 vauN- t5ins - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "t 10 Olympic Lane Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 4/9/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: '4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12/23/1979 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Olympic Lane E. Report Completeness Checklist 4/9/2014 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Property Address Jeffrey Goldman Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code E. Report Completeness Checklist 4/9/2014 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Summary Record Card generated on 4/4/2014 10:52:47 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-106.B-0107-0000.0 Parcel Id 17511 10 OLYMPIC LANE GOLDMAN, JEFFREY 10 OLYMPIC LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.1 Acres FY 2014 UB Mailina Index Name/Address Type Loan Number Active/Inact. From Until GOLDMAN, JEFFREY Payor 10 OLYMPIC LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17588.0 - 10 OLYMPIC LANE Last Billing Date 4/2/2014 3170258 03 Cycle 03 Active UB Services Maint. Account No. 3170258 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 45.60 /1 UB Meter Maintenance Account No. 3170258 Serial No Status Location Brand Type Size YTD Cons 35497083 a Active ERT HH b Badger w Water 0.63 0.63 927 Date Reading Code Consumption Posted Date Variance 3/10/2014 1037 a Actual 12 4/11/2014 -16% 12/6/2013 1025 a Actual 13 1/17/2014 -85% 9/11/2013 1012 a Actual 93 10/15/2013 447% 6/12/2013 919 a Actual 17 7/24/2013 7% 3/13/2013 902 a Actual 16 4/22/2013 -36% 12/11/2012 886 a Actual 24 1/9/2013 -76% 9/13/2012 862 a Actual 104 10/15/2012 353% 6/11/2012 758 a Actual 22 7/16/2012 -8% 3/13/2012 736 a Actual 24 4/14/2012 -42% 12/14/2011 712 a Actual 42 1/17/2012 -62% 9/14/2011 670 a Actual 118 10/13/2011 122% 6/8/2011 552 a Actual 50 7/20/2011 86% 3/8/2011 502 a Actual 26 4/13/2011 -3% 12/9/2010 476 a Actual 27 1/12/2011 -87% 9/10/2010 449 a Actual 214 10/15/2010 442% 6/7/2010 235 a Actual 37 7/15/2010 29% 3/10/2010 198 a Actual 29 4/14/2010 -50% 12/10/2009 169 a Actual 59 1/12/2010 -66% 9/10/2009 110 a Actual 110 10/15/2009 0% 7/14/2009 0 n New Meter 0 10/15/2009 0% 6/9/2009 7523 m Manual estimate 30 7/20/2009 67% 3/13/2009 7493 m Manual estimate 20 4/29/2009 -61% MSG 12/5/2008 7473 m Manual estimate 45 1/20/2009 -26% MSG 9/9/2008 7428 a Actual 67 10/10/2008 134% 6/5/2008 7361 a Actual 26 7/16/2008 147% 3/10/2008 7335 a Actual 11 4/11/2008 -75% 12/10/2007 7324 a Actual 46 1/22/2008 -53% Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use•by local Boards of Health. Other forms may be'used, but the information• must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of house, Left/ Qt sl a house, Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck rwaress Cityfrown ` state 2. System Owner. Name' Trp Code Address (If different from location) Citylrown ' Ziareode Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Lf -q--1 Lf Date 2. Quantity Pumped Cesspools)eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes D'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc - Company 7. Loc 'o contents- were disposed: S: Lowell Waste WF —I Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 Town of North AndoverNORTN Of «a c 14, OFFICE OF 3? g�, °0 COMMUNITY DEVELOPMENT AND SERVICES A WILLIAM J. SCOTT Director July 20, 1998 Mr. Joseph J. Serwatka 31 Kendrick Street Lawrence, MA 01841 Re: 10 Olympic Lane Dear Mr. Serwatka: 30 School Street " `• North Andover, Massachusetts 01845"SSqCFwUSEt`y x This is to inform you that the proposed plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 SEPTIC PLAN SUBMITTALS LOCATION: / (� � � n > C, - NEW PLANS: QYES $60.00/Plan REVISED PLANS: YES . $25.00/Plan DATE: to - z .9- — 9 DESIGN ENGINEER: J O E \S r v�f Q- k a When the submission is all in place, route to the Health Secretary SEWAGE PUMP STATION DESIGN COMPUTATIONS Single Family Dwelling 10 Olympic Lane North Andover, MA OWNED & APPLICANT Connie Ireland 10 Olympic Lane North Andover, MA DATE: 6/20/98 PUMPALS I t DESIGN DATA: PUMP: DESIGN FLOW SOIL CLASS PERC RATE FORCE MAIN DIA. HAZEN-WILLIAMS COEFE 440 Gal/Day 1 2 Minlinch 2" SDR 21 PVC 150 MANUFACTURER: PEABODY-BARNES MODEL #: SE -411 HORSEPOWER: PUMP CHAMBE STORAGE PRIMARY RESERVE VOL. IN PIPE RUN TOTAL DIMENSIONS LENGTH* WIDTH* DEPTH* ELEVATIONS INLET INVERT SUMP OFF ON ALARM STATIC HEAD: DBOX INLET ELEV. PUMP OFF ELEV. TOTAL STATIC HEAD PUMP.XL3 0.4 Pee Ali 4 .0gallon �e S &1144Y ons 550.0 gallons e4tM et sw C y 7.50 4.50 4.25 *INSIDE DIMENSIONS 96.70 92.45 93.20 93.64 94.96 97.80 FT 93.20 FT 4.60 FT " ICA G•C., 1 P4 Y FGe w EQUIVALENT LENGTH: FRICTION LOSSES IN PUMP CHAMBER: 1 2"DIA 900 BEND 5.0 FT 0 2"DIA 450 BEND 0.0 FT 1 2"DIA CHECK VALVE 14.0 FT 1 2"DIA GATE VALVE 1.2 FT _ 4.6 TOTAL LOSS 20.2 FT 1.09 b E21.0 FT 5.49 30 FRICTION LOSSES IN PIPE RUN: 1.52 1.25 2 2 -DIA 900 BEND 10.0 FT 0 2"DIA 450 BEND 0.0 FT 0 2"DIA 22.50 BEND 0.0 FT 1 2"DIA TEE 12.0 FT 35 LENGTH OF RUN 35.0 FT 60 MISC. PIPE 3.5 FT 4.6 TOTAL LOSS 60.5 FT 7.32 b 61.0 FT 4.6 10.60 TOTAL EQUIV. LENGTH: 82 FT SYSTEM CURVE: Q V HF1100 HF Hs TD, GPM FPS FT FT FT FT 20 1.8 0.72 0.59 4.6 5.19 25 2.3 1.09 0.89 4.6 5.49 30 2.7 1.52 1.25 4.6 5.85 35 3.2 2.03 1.66 4.6 6.26 40 3.6 2.59 2.13 4.6 6.73 50 4.5 3.92 3.22 4.6 7.82 60 5.4 5.50 4.51 4.6 9.11 70 6.3 7.32 6.00 4.6 10.60 80 7.2 9.37 7.68 4.6 12.28 90 1 8.1 1 11.65 9.55 4.6 114.15 FROM ATTACHED PUMP CUR1(E: 60 gpm @ 9 TDH TIME ON: 1.8 minutes PUMP.XLS J BARNES ®SUBMERSIBLE NON -CLOG PUMP Series: SE; Manual & Automatic S 1-1/2" Spherical Solids Handling Series: SEA HP 1750 RPM (SE411 & SE421) THE BELOW LISTINGS ARE FOR SE411, SE411A & SE421 ONLY. S® Canadian Standards Association File No. LR16567 UL Underwriters Laboratories Inc. File No. E142177 Description: SUBMERSIBLE NON -CLOG SEWAGE PUMP DESIGNED FOR TYPICAL RAW SEWAGE APPLICATIONS. Sample Specifications: Section 1 Pages 13-14. n r-1 w 1 .— L ...�� rumrs & SYSTEMS Specifications DISCHARGE: LIQUID TEMPERATURE: VOLUTE: MOTOR HOUSING: SEAL PLATE: IMPELLER: Design. Material: S HAFT: SQUARE RINGS: HARDWARE: PAINT: SEAL: Design: Material: CABLE ENTRY SPEED: UPPER BEARING: Design: Lubrication: Load. LOWER BEARING: Design: Lubrication: Load: MOTOR: Design: Insulation. SINGLE PHASE: FLOAT: OPTIONAL EQUIPMENT: Barnes Pumps, Inc. Distributor Sales & Service Dept. Bames Pumps, Inc. Bid 420 Third StreeUP.O. Box 603 -To -Spec & Project Sales 1485 Lexington Ave. Piqua, Ohio 45356.0603 Ph: (513) 773-2442 Mansfield, Ohio 44907-2674 Fax: (513) 773-2238 Ph: (419) 774-1511 Fax: (419) 774-1530 SECTION 1A PAGE 1 DATE 5/94 REPLACES 7/93 2" NPT, Vertical 104° F Continuous. Cast Iron, ASTM A-48 Class 30. Cast Iron ASTM A-48, Class 30. Cast Iron ASTM A-48 Class 30. 2 Vane, Open, With Pump Out Vanes On Back Side. Dynamically Balanced, ISO G6.3. Zytel 70G43 Nylon, Glass Filled. 416 Stainless Steel. Buna-N 300 Series Stainless Steel. Air Dry Enamel. Single Mechanical, Oil -Filled Reservoir, Secondary Exclusion Seal. Rotating Face - Carbon Stationary Face - Ceramic Elastomer - Buna-N Hardware - 300 Series Stainless 15 ft. Cord w/Plug On 115 and 230 Volt, Pressure Grommet For Sealing And Strain Relief. 1750 RPM (Nominal). Sleeve Oil Radial Single Row, Ball Oil Radial & Thrust NEMA L Torque Curve. Completely Oil -Filled, Squirrel Cage Induction. Class A. Permanent Split Capacitor (PSC). Includes Overload Protection In Motor. Automatic Models. Wide Angle, Polypropylene, 15ft. Cable. SE411A & SE421A, Float w/Plug Attached To Discharge Piping, SE411AU & SE421AU Float Attached To Pump. ON and OFF Points are Adjustable. Seal Material, Additional Cable and Cast Iron Impeller. rteMeca SECTION 1A PAGE 2 DATE 5/94 REPLACES 7/93 SE411A & 421A SE411 & SE421 (Less Float) rumping 9.00 SE411AU & 421AU 0.75 1 14 6ilsqles 11, . 4P.MlErA '2 MODEL PART HP VOLT PH RPM NEMA FULL LOCKED NO. NO. CORD CORD CORD (Nom) CODE LOAD ROTOR SIZE TYPE OD AMPS AMPS SE 411 068701 0.4 115 1 1750 A 10.0 19.0 SE411A 082215 0.4 115 1 1750 A 10.0 19.0 14/3 SJTOW-A 0.390 SE411AU 093193 0.4 115 1 1750 A 10.0 19.0 14/3 SJTOW-A 0.390 SE421 082089 0.4 230 1 1750 A 5.0 9.5 14/3 SJTOW-A 0.390 SE421A 093194 0.4 230 1 1750 A 5.0 14/3 SJTOW-A 0.390 9.5 SE421AU 093195 0.4 230 1 1750 q 5.0 14/3 SJTOW-A 0.390 9.5 Mercury Switch on SE411A &Mechanical on SE421A, Cable 14/3 SJTOW-A 0.390 1612, SJOW-A, 0.320 O.D., Mechanical Switch (SE411AU & SE421AU), Cable 14/2, SJOOW-A Piggy - Back Plug. IMPORTANT! (UL), SJOW (CSA), 0.370 O.D. I) D4 NOT USE THIS PUMP TO PUMP FLAMMABLE LIQUIDS. 2.) THIS PUMP IS APPROPRIATE FOR LOCATIONS CLASSIFIED AS DIVISION II. 3.) THIS PUMP IS (SOT APPROVED FOR USE IN SWIMMING POOLS, RECREATIONAL WATER INSTALLATIONS,DECORATTVE OR ANY INSTALLATION WHERE HUMAN CONTACT WITH FOUNTAINS THE PUMPED FLUID IS COMMON WHILE THE PUMP IS RUNNING. 4.) PUMP CAN BE OPERATED DRY FOR EXTENDED PERIODS WITHOUT DAMAGE TO MOTOR AND/OR SEALS. CRANE PUMPS & SYSTEMS Barnes Pumps, Inc. Distributor Sales & Service Dept. Barnes Pumps, Inc. Bid 420 Third Street/P.O. Box 603 -To -Spec & Project Sales 1485 Lexington Ave. Piqua, Ohio 45356-0603 Ph: (513) 773-2442 Mansfield, Ohio 44907-2674 Fax: (513) 773-2238 Ph: (419) T74-1511 Fax: (419) 774-1530 MEMBER BARNES® MERCURY LEVEL CONTROLS Pipe Mounted & Suspended Pipe Mounted: P/N's: 073613, 073615 & 073617 Suspended: P/N's: 073612, 073614 & 073616 S CIP® CRANE PUMPS & SYSTEMS Barnes Pumps, Inc Distributor Sales & Service Dept 420 Third Street/P.O. Box 603 Piqua, Ohio 45356-0603 Ph: (513) 773-2442 Fax: (513) 773-2238 Specifications: CABLE: Material: Size: HOUSING: Material: Color CLAMP: WEIGHT: TEMPERATURE RATING.- SWITCH: ATING:SWITCH: SWITCH RATING: Description: SECTION 6C PAGE 47 DATE 7/93 REPLACES 7/92 18-2 SJO W -A, 41 Strand x #34, 90°C .29 Dia. x (See Chart for Length) Polypropylene Normally Open - Blue Normally Closed - Red Adustable 1"-3" Stainless Steel with Polypropylene Saddle. (Models 073613, 073615 and 073617) Suspended, 2.25" Sph. lead weight with Adjustable stainless steel fittings (Models 073612, 073614 and 073616) 60°C Mercury, Narrow Angle, Horizontal 4.5A @ 115VAC RES 2.25A @ 230VAC RES The Mercury Level Controls are available in either a pipe mounted or suspended configuration with 25 to 200 feet of cable on P/N's 073612, 073613, 073614 & 073615; P/N 073616' with 15 feet "(use 073612, for longer lengths). P/N 073617 with 15 & 20 feet. They are pilot duty devices which control the function of motor load devices, such as contactors, motor starters, and power relays, to automatically cycle a pump or pumps. They can also be used for alarm signaling devices. Two Mercury Level Controls for a one pump operation; three for a two pump operation. If an alarm device is used, add another Level Control. LEVEL CONTROL SELECTION CHART Control Number Cord Length Type Installation Contacts 073612 25 to 200Ft. Suspended Open 073613 25 to 20017t. Pipe Mounted Open 073614 25 to 20017t. Suspended Closed 073615 25 to 20017t. Pipe Mounted Closed 073616 '15Ft. Suspended Open 073617 15 & 20Ft. Pipe Mounted Open State cord length at time of ordering Barnes Pumps, Inc. Bid -To -Spec & Project Sales 1485 Lexington Ave. Mansfield, Ohio 44907-2674 Ph: (419) 774-1511 Fax: (419) 774-1530 SECTION 6C PAGE 48 DATE 7/93 REPLACES 7/92 0 TYPICAL SIMPLEX WIRING SCHEMATIC L1 L1 ON L2 OFF- STARTER COIL AUXILIARY CONTACT TO MOTOR TYPICAL ALARM WIRING SCHEMATIC L1 120V 60HZ N 1 F — — SILENCE —Z 3 E2 L- J 1 ALARM CONTACT ALARM LIGHT (MINI -FLOAT) R TYPICAL PIPE MOUNTED INSTALLATION: General Comments: 1. Never work in the sump with the power on. 2. Attach the Level Controls to the mounting pipe or the pump discharge pipe. The "oft" float should be below the "on" float in a "pump out" application. 3. Arrange the Level Controls so they do not tangle or hang up. 4. Insert the hose clamp through the two slots in the pipe/cable clamp, circle the discharge pipe with the hose clamp, feed the end of the hose clamp through the screw and tighten. 5. Measuring the difference between mounting points given the "pump down" differential. Important Notes -Mercury Level Controls are pilot duty devices. They cannot be used to directly power pump motors. Also, do not use Mercury Level Controls in gasoline or other combustibles. Mercury level control are compatible with intrinsically safe relays. CRANE PUMPS & SYSTEMS Barnes Pumps, Inc. Barnes Pumps, Inc. Distributor Sales 8, Service Dept. Bid -TG -Spec & Project Sales 420 Third Street/P.O. Box 603 1485 Lexington Ave. Piqua, Ohio 45356-0603 Mansfield, Ohio 44907-2674 Ph: (513) 773-2442 Ph: (419) 774-1511 Fax: (513) 773-2238 Fax: (419) 774-1530 R1 2 AUDIBLE /MOUNTING OR DISCHARGE PIPE "ON" FLOAT r__J11 DIFFERENTIAL �WA T E P, LEVELII "OFF" FLOAT BARNES®ALARMS Wall Mounted P/N: 061486 FOR INDOOR USE ONLY. 0 0 P/N: 061487 FOR INDOOR USE ONLY. Specifications: 061486 061.487 3.28 SECTION 6A PAGE 43 DATE 7/93 REPLACES 10/85 High Water Alarm includes stainless steel wall plate with red jewel light and one mercury level control with 10 ft. of 18/2 cord. 2.75 2 HOLES FOR 6-32 x 1/4 3.81 SCREWS 4.25 O- I High Water Alarm (Solid State) includes stainless steel wall plate, audible and visual alarm with silencer button and one mercury level control with 10 ft. of 18/2 cord. 4.56 . I I I 4.50 ® D_ 1.81 [CRANE PUMPS & SYSTEMS - Barnes Pumps, Inc Distributor Sales & Service Dept. Barnes Pumps, Inc. Bid -To -Spec & Project Sales 420 Third StreetlP.O. Box 603 Piqua, Ohio 45356-0603 1485 Lexington Ave. Ph: (513) 773-2442 Mansfield, Ohio 44907-2674 Ph: (419) 774-1511 Fax: (513) 773-2238 Fax: (419) 774-1530 Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director June 24, 1998 Connie Ireland 10 Olympic Lane North Andover, MA 01845 Dear Mrs. Ireland: 30 School Street North Andover, Massachusetts 01845 have reviewed the proposed plans for the repair of the septic system located at 10 Olympic Lane, North Andover, Massachusetts. Although there are some minor omissions on the plans which do not affect the design, for all practical purposes, the design submitted by Mr. Joseph Serwatka dated June 19, 1998 may be considered to be approved. If you have any questions, or if I may be of further assistance, please call Sincerely,----' Sandra Starr, R.S. Health Administrator CO940 P�y,`E BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 June 22, 1998 Sandy Starr, Agent Department of Health North Andover, MA 01845 Dear Sandy, In a follow-up of our phone conversation on Tuesday, I would like to thank you for your time and information as well as understanding my situation. The inability to sleep and that nauseous feeling are something I would like to have go away. I have a true feeling regarding the trauma and effects of Title V. Timing is everything and all is relevant. Joe Serwatka has received numerous calls after our conversation reiterating my urgency due to the situation in Atlanta relating to the scheduled June 29 closing locked with the $15,000.00 non-refundable deposit as well as the closing set for June 26 on the property in North Andover at 10 Olympic Lane. As stated earlier, the lender is willing to escrow for the closing. I am attaching the correspondence from buyer's attorney. To date the preparation work has all been completed. I found the perk test process very involved and interesting. There is nothing like first hand experience. Attached are the plans prepared by Joe. Initially we had hoped for a new leaching field, but this is not possible due to the lay out of the old system. I am dropping this information by the Health Department. I certainly hope you are feeling much better real soon. Amy told me you were down in the back. Please give me a call at your earliest convenience, My closing clock is ticking away for June 26. The buyer's attorney and lender are eager to get the Title V information in order to prepare the closing documents. I have told them I am doing everything I possibly know to do at this time. Sometimes I want to say this is all a bad dream. Please advise me of any suggestions you have to possibly expedite this process. Feel free to contact me with any questions regarding the situation. I look forward to hearing from you and hopefully the lender and buyer will work with us and get this house closed as scheduled. Sandy, please accept my sincere thanks regarding this situation. I have told people you do not have an easy job. I thought my job was a tough one. You can reach meat my home number (978)794-2551. If I am not home feel free to leave a message or attempt my cellular number (508)265-0529. Regards, Connie Ireland NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT DATE (0 02 d FEE: U& PERMIT ## DATE RECEIVED APPLICANT Ce,y)NrE MAP ZD6 PARCEL ADDRESS /6 OLYNIP/G Z4. LOT ## STREET # ENG. --J. 5E8tOP7-K4 STREET dcyMpiC ENGINEER'S ADD. /p �EA),Micg 5J- 49&,W. PLAN DATE CONDITIONS OF APPROVAL APPROVED REASONS FOR DISAPPROVAL: REV. DATE DISAPPROVED 1, T,E'&,(JGfI'ES TU j15 725-A7 3_ ,VLAVIZ,:�rti7�q G lql 55 1A)6 )V& G 6 _V)q T oN S * a � opo'e'ee-G11 AA) V b 0 5 e-5��,� -. - . Lc S lr-oe-/�1�� Town of North Andover I NORTH OFFICE OF �2 0 `t. E o etiO L COMMUNITY DEVELOPMENT AND SERVICES A 30 School Street 4 a North Andover, Massachusetts 01845 '� `°4,,,° .•a` �5 WILLIAM J. SCOTT 9SSgcHU Director June 25, 1998 Joseph Serwatka 31 Kendrick Street Lawrence, MA 01841 RE: 10 Olympic Lane Dear Mr. Serwatka: This is to notify you that the proposed septic plan for 10 Olympic Lane, dated 6/19/98 is missing the following information: I . Number of doses per day. 2. Calculation for emergency storage in the pump chamber. 3. Manual operating switch specified for the pump controls. Please call if you have questions. Sincerely, -� Sandra Starr, R.S. Health Administrator Cc: Connie Ireland W. Scott File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 / 08/11/98 Ida -FBI GILS ARTIN & M7,8MMONG, P.C. 376 Boylstua 9UVOt Bosh MA 02116 Telephone (617) 37"000 Tatccopier (617) 3754700 Td ocop or (611) 247.5300 Crstg P- GU=wft' D. Bruce lr'Itzstm wns, Jr. Jesse Geller GbM M G39biardi Jemui#er L- Rar4l jamme a- Un ' aho admitted to preutee in New York Juno 11, 1998 Rmsell Bodnar, Esquire C3=tnut Gm -en, suite 65 365 Tmrr &c Stmt Wwth Azdom,1VA 01845 RE: 14 Qlympio Lane, Nordt Andover, Mwaschaserts %tear Ituffseli: id0WAOR Tbis le= shall serve to caufmu tip its our respwewe cli ants bavc entaed into regarding the closing of the above-sfcreacedpresnises, figs following blas beau agreed to: 1. 7be closing shall rake place at 9.00 am on June 26, 1998 at this office. 2- Insofar as the septic systema has Mad. and MMOTibugly duras not eOaply with Title V, the amount of 150°!a of the amaimt agreed upon by the parties shall be held in escrow by you until the new system is insmtte6. and Bujr is provided with awritteu confeamatlon that the new syMrr psascs in numdancO with tlt Purchase and Sale ,Agmement 3. 4. Gee, ed (, . Oth , �O�--4 Yaw client shall pay the fee the Lender is rhargw g tray client. ofg 1,135.73 to allow the closing to go forward with the escrow anwacumm. T% your Client will provide the Buyer m advance of Closing allo vving suffcciev t hose far the Lender t© review and approve, *a foiiowing doioa_ tai Copy of LnviroamsnW iusp Won aec+anuna g Ttpairheplitaesaew of the septic Oysasm; (b) Copy of the engineesing r=prnt reemniumdias the wphe 4alg ; (c) Copy pf the septic permit; and VA-IT10/98 20:51 FAX 9786881582 R BODNAR ESQ Z03 06/11/08 16:11 FAY T 19 01i2/002 (d) COPY of an estimate far the repaWrWlacement of the septic system by 4L licensed septic installer. Kindly acknowledge your assent where. indicated and rc=n a copy of this letter. via factioftle, to this office. Thay3k ym very truly yours. GILMARTIN & FrrZSIN MOWS, P.C. By: �- b, Qe��n CraVP. Gilmartin, Esquire Assented to: Russell Bodnar, Esquira CC: Idhw CrvldTnm John Lawrence PLAN REVIEW CHECKLIST ADDRESS ,�� VL y/)1414 ENGINEER _ S rIC4 GENERAL 'I rnnTV0 V CTTM70 c/ T nn T Te (� rTnnmv TDDnw V Q/'TT v CONTOURS PROFILE_y (Sc) SECTION ---' BENCHMARK Z � SOIL & PERCS. ELEVATIONS WETS. DISCLAIMER L� WELLS & WETS '-� WATERSHED? /VIO DRIVEWAY ✓ WATER LINE 1/ FDN DRAIN — M&P SCH40 C-' TESTS CURRENT? L_'""- SOIL EVAL SEPTIC TANK,/ MIN 1500G (/ .17 INVERT DROP y GARB. GRINDERA2�0(2 comps +200) 10' TO FDN_,� MANHOLE ELEV GW Or- # COMPS. GB� D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET 9 7 75- -OUTLET X17-59' _ ( 2" OR .17 FT) TEE REQ' D? LEACHING MIN 440 GPD?y RESERVE AREA 4' FROM PRIMARY? 2% SLOPE le_o/ 100' TO WETLANDS L -f__ 100' TO WELLS 4' TO S.H.GW �5'>2M/IN) 20' TO FND & INTRCPTR DRAINS ` 400' TO SURFACE H2O SUPP L--� 4' PERM. SOIL BELOW FACILITY �� MIN 12" COVER vFILL? (15'} BREAKOUT MET? TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/1001) SIDEWALL DIST. 3X EFF. W OR D (MIN 61) RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >501) BOT + SIDE = X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1996 by S.L. Starr PITS MIN 440 LEACHING MIN 1 (13'x16') PIT_ GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D BOT + SIDE (L x W x ##) (2x(L+W)xD x ##) MANHOLE/PIT 12"-48" STONE x LOAD = TOTAL (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTA (L x W,x ##) (2 x (L+W)xD x ##) (G/ft2) FIELDS S MIN 440 GPD �'900 ft2 BEDy GW MIN(4) BELOW BOTTOM OF FIELD PIPE ENDS JOINED? /L --f 4" PEA STONE? -- DIST LINE SLOPE .005? > - aCO -VENTy SCH 40 MIN 12" COVER RATE Z /'�/ ( �D X �.Sr ) X TOTAL L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY ! G gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. L---' GW (Min. l' below inlet) HWL LWL _Z CHECK VALVE I,--- BLEEDER HOLE ✓ MANUAL OP. SWITCH ENUF STORAGE? TDH L' WEIGHTED? 0,1C Copyright Q 1996 by S.L. Starr TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 2/22/99 This is to certify that the individual subsurface disposal system constructed ( X ) or repaired ( ) by John Soucy at 10 Olympic Lane, No. Andover, MA 01845 has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations as described in the Design Approval Site System Permit #1027 dated 6/22/98 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (V) constructed; ( ) repaired; by oina located at was installed in conformance with the North Andover Board of Health approved plan, System Design Permit 4022 dated z� with an approved design flow of �(D gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which r Bed ins Final in, Installej Design December 8, 1998 Ms. Sandra Starr, Health Agent North Andover Board of Health Town Hall a North Andover, Ma. 01845 Re: 10 Olympic Lane As -Built Septic © AC Dear Ms. Starr: I hereby certify that the subject septic system was installed as shown on the attached sketch. Should you have any questions concerning this letter, contact me at your convenience. Sincer ly, Joseph J. Serwatka, P.E. 971 3�S" December 8, 1998 Ms. Sandra Starr, Health Agent North Andover Board of Health Town Hall North Andover, Ma. 01845 Re: 10 Olympic Lane As -Built Septic Dear Ms. Starr: I hereby certify that the subject septic system .was installed as shown on the attached sketch. Should you have any questions concerning this letter, contact me at your convenience. Sincer ly, Joseph J. Serwatka, P.E. V Town of North Andover, Massachusetts Form No. 3 P- t NORTN BOARD OF HEALTH O � 'sS,CNUSEt� DISPOSAL WORKS CONSTRUCTION PERMIT Applicant NAME �O C.J ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair an Individual Soil Absor • � ption Sewage Disposal System as shown on the Design Approval S.S. No. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:-�j�' CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALLER: SIGNATURE: TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. $75.00 Fee Attached? Foundation As -Built? Floor Plans? Approval Administrative Use Only Yes Yes Yes No No No Date: Town of North Andover, Massachusetts Form No. 1 GG NORTH BOARD OF HEALTH �'^(� 2 Q`�SIED 16 ��Q/ V /U 35� 60� 19 O_ ....F.:i \z44a •w,ep�:� APPLICATION FOR SITE TESTING/INSPECTION Applicant 0c_k .ham _ � 'v�4 .-�`�; NAME ADDRESS1 TELEPHONE Site Locationti 11 Engineer / /A ivIC , HUURC.73 I GLGr-nu1I4G Test/Inspection Date and Time -71 b01' e— / P f" CHAIRMAN, BOARD OF HEALTH Fee—05 Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. HOR71y Ot. "�o ,•,'VO O 9 � i a • u �° a rd.4 BOARD OF HEALTH 30 SCHOOL STREET TEL. 688-9540 NORTH ANDOVER, MASS. 01845 ' APPLICATION FOR SOIL TESTS 03 DATE: LOCATION OF SOIL TESTS: 1p OL �Gt2of� �iy Assessor's map & parcel number: a6,e / /o -7 OWNER: (� �z.ax�� 1,�—f_4 �v i1J TEL. NO.: ADDRESS.- CQ `u Old Ohl. Mo .4%7Do�esK_ ENGINEER:`s�P CERTIFIED SOIL EVALUATOR: Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. 5 4q � eT nor y 9 • ` `y/ 4 d% �i / - v Y / I :• i a .•`� Q 901 IV'ld 33SA iy Jam_ �VLI VVI L d4' C9 v d4' C9 v .,r I 1 FILE## 6.-x,2.l9P,4 107 Forest St. Mtddlaton, MA 01$49 (608) 774-2772 Calsingbrie SEPTIC &DRAIN 1� AIAT SERVICE SUBSURFACE. SEWAGE DISPOSAL SYST'Em INSPECTION FORM PART A ,1 p CERTIFICATION Property Address: 10 Vt yt'' !C— �J V vE'III Address of Owner: Date of Inspection: Z% AMY (if different) Y1 rte'" Name of Inspector: n � - e L� -y 1 am a DEP app Zt ved system ipspeor pursuant to Section 15,340 of Title S 1310 CMR 15.000) Company Name: /' .5 G Mailing Address: - -s trJ Telephone Number CERTIFICATION STATEMENT I certifl Thal I have personally mspec*.ed the se%age disposa! system at this address and that the information reported beloN is true, accuraii and complete as of the Time of ;nspea;on. The inspectron was performed based on m- training and eKperience m the proper function and maintenance of on-site sewage disposai systems. The s,s:em: _ Passes _ Corydo,or.al;� Passes `eels c .rther E�afuation 3y the local Approving Author,(- Fads >i Inspector's Signature' bate: T c l we The System fnspeGlor shalt subm t a copy or this inspection report to the Approving Authoriry within thirty (30l days, of completing this inspection, tt the system is a shared SvSzem o* has a design Pow of 10,000 gpd 0- greater, the inspector and the system owner tha!f submit the report to the appropriate reg on.aj Office or the Department cf Environmental Protection. The original should be sent to the system ohne ,and copies sent to the buyer, if apol cable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or O A) SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CmR 15303 Any failure criteria not evaluated are indicated below. COMMENTS: 61 SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass- section need to be replaced or repaired. The system, upo completion Of the replacement or repair, as approved by the Board of health, will pass. indicate y�sj no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If 'not determined", exp!ain why not. I[ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attachedl ind,Cating that the tank was installed within twenty (20) years prior to the date of the inspection; o; 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 conforming septic =k, as approved by the Board of Health. (ravi'ad 0�/25fs7t Pali& 1 of l0 dEP on I" Wprkj WWe Web' http./Avww rrVynet state ma us/dep tQ Printed on ReeYCie0 Parer i 20-d 90Z0 0SL 80!9 N3IN8n0l Wd 917:ZT (121M 86—L T—Nnf' ♦r 1 L FILE# 052 7-W'14 SL.-6SL)RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: l0 ply�%pyc 21✓ Owner: Date of Inspection: 2 -7 M4Y 9,09' 81 SYSTEM CONDITIONALLY PASSES +continued+ ,UL/ Se%+age backup or breakout or high static water level observed in the distribution box +s due to broken or obstr„eted p pe,si or due to a broker., settled or uneven distribution box. The system wiil pass inspection if (with approval ei the Board of He I )- 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 s.,stem will. pass inspection if (wn 1 approval of the Board of Health): ^� broken pipe(s) are replaced IV oastrudion is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reau+re further evaluation by the Board of Health in order to determine if the system is >ia ting to protea th public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or pray is within 50 feet of a surface water f' Cesspool or pnvl is within 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THA THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT, The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surtaCe water supply o 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 eater supa'y'well The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply welL The system has a septic tank and soil absorption system and the SAS is less than 100 feet but .50 feet or more from a private water supply well, unless a well Hater analysis for coliform bacteria and volatile organic compounds indicates th the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to c less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/0) Yepe 2 of 10 Vold 9020 094 809 oiid3S z!j IzNNno Wd Lt,:zT a3M 86-4T—Nnr FILE# (A5Z'79rf' SUBSURFACE SEWAGE DISPOSAL SISTEM INSPICTIO� FORM PART A CERTIFICATION (continued) Propert,. Address:/Q//(�zwp/cowner; _. r-eA/ Date of Inspection: 27141 9� D) SYSTEM FAILS: /Y Yo' s indicate either "Yes" or "No' as to each of the follov.:ng: �'. i have oeierminee that the system violates one or more of the follow ing failure criteria as defined in 310 C..MR 15 303 The oas 4 for this determination is identified below. The Board of Health should be contacted to determine c hat will be necessary to conFc- the failure. Yes No Backup of sewage into facility or system Component due to an overloaded or clogged 5.A5 or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS o- cesspooi 061 5taoc hgv.d level in the distribution box above outlet invert due to an overloaded or clogged 5A5 or cesspool liquid death in cesspool is less than 6" below invert or available volume is less than 112 da}, flow.. M Requireir pumping more than 4 times in the last year NOT due to clogged or onsuvcteci Pipe-$. Number of times pumped _- Any porion of the Soil Absorption System, cesspool or prtw is below the h:gn groundwater elevation: /� An, porion of a cesspool or privy is within 100 feet of a surface water supDi. or :nbuiary to a surface rater suppi,, a Any portion of a cesspool or privy is within a Zone 1 of a public wee'. E , w % Any portion of a cesspool or privy is within 50 fMet of a private water supp',, well. AAAn,.- poroon of a cesspool or privy is less than 100 feet but greater than 50 fee, from a private water suppFv well with r'; acceptable water quality analysis If the well has been analyzed to be acceotable, attach cop-. of well water analysis fo• coliform :,aCteria: volatile organic compounds, ammonia nitrogen and nitrate nitrogen E) RGE SYSTEM FAILS$ You use mdlCa*e either "Yes' or "No" as t ach of the following. The following crrena apply to I .ge systems in addition to the criteria above: A— T system serves a facie, with a design flow of 10,OW god or greater (Large System) and the system .s a significant threat to pub health and safer and the environment because one or more of the following conditions exist; Yes No t stem is within 400 feet of a surface drinking water supply the cyst is within 200 feet of a tributary to a surface drinking water supply the system i ocated in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone It of a public watet s ply welt) e owner or operator of any such sy m shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.10. Please consult the local regional office of the Department for further information. (rwiswd 0{/35/77) ?ape 3 of 10 S FILE# ate? 1 2k!4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: iG�%G •j ✓1G%� Oate of Inspection:77-114 96P Check If the following have been done. You must indicate either "Yes" or -No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ounng that periW. Large volumes of water have not been inlroduce<1 into the system recently or j' as pan of this inspection, / As built plans have Seen obtained and examined, Note if they are not available with N,; . The lac h or d'„eli,ng v as InspeaP0 for signs of sewage back-up. The system does not receive non,sanitary or Industrial waste flow. ✓ The site �%as inspected for signs of breakout. All system cCmpornents. excluding the Sol Obsorption System, have been located on the site. •. _ The sept,c tank manholes were uncovered, opened. and the interior of the septic tank was inspected for condition of baffles or tees, material of constri,i4Tlon, dimensions, depth of liquid, depth of sludge, depth of SCUMA t The size and iocat on of the 50 1 Absorption System on the site has been determined based on. The facia r, o* caner land occupants, if different from owner) were provided with information on the proper maintenance o+ / 5ub•Surface Disposal System. _ Existing ,niormat,on. Ea. Plan at B.O.H. �. Determined .n the field tar anv of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable; [15.30231ib1] (ravi►MC 04/25/67) 90'd Pay 4 of 10 9020 09L 809 0I 1d3S 2t3I?J TJ 11 ^1 LJ'i R -b 7.T rr-4M sic._"i 0 I SUBSURfACE SEWAGE DISPOSAL SYSTVA tvSPECTION FORM PART C �/ SYSTEM tNFORMAT10� Prepem Address: �® (.s /��fG 2� Dale of Inspection:2,�W y 9� FLOW CONDITIONS RE51DENTIAL: Design fio%+ V ,p, jbedrciorn io, S.A.S. Number of bedrooms Number of current residents Garbage g,. der (yes or not. Laundn• co -acted to system !yes or no: Seasonal use •yes or na:.4-1rz Water meter readings, if available (last two (21 vear usage (gpd): Sump Pump (ves or no>: A/ Last date of occupancy. - Iw /d Ty i estab!tshrneni Design t. gallons1aa� Grease traesent: ryes or no Industria' "m gNolding Tan resent tees or no, tion-sanitan t%a$1 d1Scnar ed to the 7i!;e a SvStt'm. tyes or not ltiater meter readnts. ' available Last date of o Lann cOTHER: `. Last a of occupancy PUMPING RECORDS and sowe o+' (_;urr ion- GEINERAL INFORMATION 'wstem pumoeo as part of inspection; iv 5 or no)j If yes, volume pumped -� ¢alloys Reason for pumping -� TYPLE OF SYSTEM iC S Septic tank/distributton bOVS011 absorption system $tng)e cesspool Overflow cesspoot Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other FILE# z �� t APPROXIMATE AGE of all components, date installed (if known) and source of information: hl,V/V ln'�- piGtJl !^ Sewage odo+s detected when arriving at the site: (yes or no) AID (revised 04125!.47) Pape 3 ot to j Z©'d 9EA�G 6iSL 82S OTld3S NJ TNZlnO WA 6iv: ZT Q3M 86 -IT -Nn FILE# SUBSURFACE SEWAGE D(SPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �relo.12d Date of Inspection:? BUILDING SEWER: (Locate on site plan) Depth below grade:: / Material of construction: cast iron 40 PVC _ other (explain) Distance from private water supply well or suction li-c Diameter �-'r, s, ( Commentctin,�ion of jo)nts, vent ag, evidence of leakage, et;.)_ V SEPTIC TANK;)/", -,- (locate on site pian) Depth below grader tilaterial of constrvCb,on: ✓concrete metal _Fiberglass —Polyethylene _other(exDlain) If tank is metal, list age is age confirmed b\ CCerwicate of Compliance = (Yeslrro, Dimensions] ��CC��t `'� lf7f'lE'I�C (�2 r /)C� f%Q / ink Sludge depth Dislance from top of sludge to bottom of outlet tee or baffle: Scum thickness -t1- r, Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to NottQm of outlet e,e or bail riow dimensions were determined. ! F e��- Comments: (recommendation for pumping, cond-it-r�o� of inlet and Q4utle tee or baffles, depth f liquid level in lrelation to outl t invert, integpri% evidence of leakage,Atc.l irate 1PPdS k� �i1tluc n? e ifiIrf -PA, m, E TRAPtA-6 on site plan) Depth below grade: Material of co ruction: Dimensions: Scum this kHess: Distance from top of s[ Distance from Bono of scum Date of last pump+ Comments: metal _Fiberglass _Polyethylene ,_other(explain) of outlet tee or baffle: bottom of outlet tee or baffle: rn (recomendaS on for pumping, condition o inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, "i{lence of leakage, etc.) (rsvided 04/]s/97) 80'1d 9020 094 809 JpRQa L bi 10 3I.LdHS 2t3I2�zlf Wd 6b:ZT 1I3M 86-2-T—NnI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / r SYSTEM IN9r11?UATIDN'confinued) Propem Address;/ �/���/� OtAner: "I%PI1� Date of Inspection: u 77/y� r� y /d GHT OR H0 DINC TANK: `Tank (io to on site plan; Depth low grade Matenal construction _concrete Ze pumped prior to, or at time, of inspectiorn+ Fiberglass _Polyethylene _,_,other(explain) Dimensions: Capac+n g ons Design flox.. gallons day Alarm level Alarm in .A orkmg order _ Yes; No bate of previous p ping Comments! 4condaion of + et tee, condrtiohof alarm and float switches. etc.) DISTRIBUTION BOX:} (locate on site plan: tit Depth of liquid level above outlet invert Comments. (note if level and dtstnbutlon +sisal. evidence f solids u ) - R CIX, i S__un er PUMP CHAMBER,z "le on site plan; into orrpvt Pu in working Or r: (Yes or No) ^farms working der (Yes or No, Comments: (note Condit; f pump chamber, condition of pumps and appurtenances, etc.) (revised 04I25/117) 60'd 9020 094 80S ae9• T o: 10 FILE# I o I Ldas 8:4f 2 NN5 Wd 0 : Z? aaM 86—Z T --Nnr i FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / Owner: 5-rero Date of Inspection:Z7 /C/, 9a] 5011 ABSORPTION SYSTE (SAS):, (locate on size plan, if possible; exca anon not required, but may be approximated by non -intrusive ethods) If not determined to be present, explain: .�ansmlIf� Type: leaching pits, number:_ leaching chambers, number:___._ leaching galleries, number leaching trenches, number,length: teaching fields, number, d:menc:ons: �5 A, X overflow cesspool, number. Alternative system: Name of Technology: Comments: (note condition of 50 f5igns of hydraulic faiI re, level pf ponding, Condit'a� f vegetation, i �In� tS 1)o or— PiKc{IQca�te. _icl�lZv4_. t5spools. A tate on site plan) Num r and configuration, Depth -t , of liquid to inlet Depth of layer: Depth of scvr`rijayer� Dimensions of c�g¢`pool: r Materials of c tru ion:_ Indication o Eroundw ler, ` flow (Cess po�{. must be pumped as part of Inspection) (Comments: f (note condition of soil, signs of hydraiflic failure, level of ponding, condition of vegetation, etc.) IVY. (I e on site plan) ktattrialf canstr ion: Dittnsions: Depth of sands Cor'nment5; (note conditi oT-Vil, signs of hydraulk failure, level of ponding, condition of vegetation, etc.) { i w trevised o�/ps/>,7) page • of a0 •tit; w 0T 'd 9020 0919- SOS oIld3S Nl iNNno Wd TS: ZT Q3m 86-.LT-Nnr SUBSURf^CE SEWAGE DISPOSAL SYSTEM INSPECTIOti FUR.M PART C ,� ! SYSTEM I`FORPVkTION (continued) Propert? Address., IQ p yiv I C—. OHner; . re/ap of Date of Inspection SKETCH OF SEWAGE DISPOSAL SYSTEM: include Ices to at least two permanent references landmarks or benchmarks local all wells within 100' (Locate where public water supply comes into house) I F ' t l i �' cry (r&vga.,2 041itF)a1i Olympta I,N I61J6 7 of iG FILE# f' S� 7j'.,>QYiz 4-e0ger A `►n T, ` 13 9 r 31W A �u ocn- T T 'd 9ozo ASZ 80S aI.Ld38 Nl xN21no wd ZS: ZT aam e6—LT—Nnr LFILE#J�r2���s3` SUBSURFACE SEWAGE DISPV5AL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION tcontinued) Property Address: !QW/C .2 0,%ner. r�' a Date of Inspection' A-51 f y,1- Depth to Groundwater �? Feet Please indicate all the methods used to determine High Groundwater Elevation: / A Obtained from Design Plans on record Observation of Site (Abvttmg woperty. observation hole, basement sump etc.) ✓ Determine it from local conditions Check with local Board of health Cheer FEMA t\Ups Check pumping records Check local excavators, installers Use USGS Data Describe in your own words hov• I-ou estabi he 1-4d the High Groundwater Elevation. (Must completed) /Ors .��Gi, t " f� ef�27 ;% /t��1 �'y'•'�"S" t +r ,+k�?, . , S 1 'f ! �. Aja � trvvLeed 04/25/97) toy* 10 of so ZT'd 9020 092- 809 011d3S aSTNNna Wd 7.9:ZT d3M 86—LT—Nnr