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Miscellaneous - 10 PURITAN AVENUE 4/30/2018 (2)
r 1 Lot &Street !�aT /4 �.e/TAN Ave- Map/Parcel a CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# Plan Approval: Date: //.5 Approved by: Designer: Conditions: Plan Date: Water Supply:, Town Well Well Permit: Driller: Well Tests Chemical Bacteria I Bacteria II Plumbing Sign -Off: Comments: ate Approved Date pproved Date Approved Wiring Sign -Off: Form "U" Approval; Approval to Issue: NO Date Issued b By: Conditions: -,' Final Approval: All Permits Paid? NO Well Construction Approval? YES NO Septic System Construction Approval? NO Certification? YES NO Other S NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:_' Q APPROVED BY: J k N SEPTIC SYSTEM INSTALLATION Is the installer licensed? NO Type of Construction: REPAIR New Construction: Certified Plot Plan Review Y NO Floor Plan Review YES-� N0 Conditions of Approval from Form U YES /i0----) Issuance of DWC permit: DWC Permit Paid? DWC Permit 9 2 7 Begin Inspection: Excavation Inspection: Needed: YES NO NO Installer:_, Z. /' -- t-onstruction inspection: Needed: Plan Satisfactory: Approval of Backfill Final Grading Approval Final Construction Approval Certificate of Compliance Date: Date: 5� By: By: Date: 7 �J'�� By: Approval: Date: f /� T Town of North Andover HEALTH DEPARTMENT SACHU I CHECK#: , LOCATION: H/0 NAME CONTRACT 70-111 TyRe of Permit or License: (Check box) 0 Animal $ El Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $ 0 Food Service - Type._ $ 11 Funeral Directors $- 0 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp $- 0 Sun tanning $ 11 Swimming Pool $ 11 Tobacco $ 0 TrashlSolid Waste Hauler $ 0 Well Construction $ SEP77C Systems: 0 Septic - Soil Testing 11 Septic - Design Approval 0 Septic Disposal Works Construction (DWC) 13 Septic Disposal Works Installers (DWI) $ 0 Title 5 Inspector $ tu Q�iHe 5 Report $ - 1� a -- 0 Other (Indicate) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 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. ISI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 10 Pudban Avenue Property Address Doreen Sennott Owner's Name North Andover Citylrown MA 01845 State Zip Code RECEIVED r,;�02014 TOWN Ur NUR I h AN 10/7/2014 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. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/town 978-475-4786 Telephone Number B. Certification MA state S115 License Number 01810 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority A4J� 3 10/7/2014 Insp ctors S nature U 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 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 Puritian Avenue Property Address Doreen Sennott Owner's Name North Andover MA 01845 10/7/2014 Citylrown 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 for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 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 Puritian Avenue Property Address Doreen Sennott Owner's Name North Andover MA 01845 10/7/2014 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 Forth - Not for Voluntary Assessments 10 Puritian Avenue Property Address Doreen Sennott Owner Owner's Name information is required for North Andover MA 01845 10/7/2014 every page. City/Town 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 1/2 day flow t5ins • 3113 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 Purltian Avenue Property Address Doreen Sennott Owner Owner's Name nformation is required for North Andover MA 01845 10/7/2014 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — 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 i ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — 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 G Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Purltian Avenue Property Address Doreen Sennott Owner Owner's Name information is required for North Andover MA 01845 10/7/2014 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with 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): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): A AM) t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Puritian Avenue Property Address Doreen Sennott Owner Owner's Name information is required for North Andover MA 01845 10/7/2014 every page. Cityrrown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 9 ( y 9 (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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Puritan Avenue Property Address Doreen Sennott Owner Owner's Name information is required for North Andover MA 01845 10/7/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): t5ins - 3113 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: Pumped 2012, 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts 64 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Puritian Avenue Property Address Doreen Sennott Owner information is required for every page. t5ins • 3/13 Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code 10/7/2014 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 16 years old, 6/4/1998, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 16 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" PVC through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass U feet ❑ 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: 10'x 5'x 4' Sludge depth: a Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 10 Purltian Avenue Owner information is required for every page. t5ins - 3113 Property Address Doreen Sennott Owner's Name North Andover \AA Cityrrown State D. System Information (cont.) Septic Tank (cont.) 01845 Zip Code 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 3011 3" 811 12" 10/7/2014 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 leakage. Inlet & center covers under paver patio. Grease Trap (locate on site plan): 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 Date of last pumping: feet ❑ polyethylene ❑ other (explain): 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 10 Puritian Avenue Property Address Doreen Sennott Owner Owner's Name information is required for North Andover MA 01845 10/7/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. t5ins - 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Puritian Avenue Property Address Doreen Sennott Owners Name North Andover Citylrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert u 10/7/2014 Date of Inspection 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 leakage. Evidence of carryover, pumped d - box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: 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 Pudban Avenue Property Address Doreen Sennott Owner information is required for every page. Owner's Name North Andover City/Town MA 01845 State Zip Code 10/7/2014 Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches 2 trenches 46' number, length: long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 Ind' f f Ica Ion o groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection forth: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Puritian Avenue Property Address Doreen Sennott Owner Owner's Name information is required for North Andover MA 01845 10/7/2014 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Puritan Avenue Property Address Doreen Sennott Owner Owner's Name information is required for North Andover MA 01845 10/7/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: t5ins • 3113 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 10 Puritian Avenue Property Address Doreen Sennott Owner _ -- information is required for every page. Owner's Name North Andover MA 01845 10/7/2014 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: 5 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: 6/5/1996 ' 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: As per 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 Pudban Avenue Property Address Doreen Sennott Owner Owner's Name information is required for North Andover MA 01845 10/7/2014 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 i -V _......... ; cad Gard Bon4ratal on 1MM014 by Karen Hallon Town of North Andover Tax Map # 210-1073-0134-0000.0 Parcel Id 18247 10 PURITAN AVENUE SENNOTT, GEORGE 10 PURITAN AVE NORTH ANDOVER, MA 01845 .1 � I I Pepe t Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.64 Acres FY 2015 UB Maiiinn Index Name/Address SENNO7 GEORGE 10 PURITAN AVE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 13230.0 - 10 PURITAN AVENUE 2100028 02 Cycle 02 UB Services Maint. Account, No. 2100028 Service Code MISCFEEADMIN FEE WTR WATER UB Meter Maintenance Account No. 2100028 Serial No Status 36153132 a Active Date Reading 8/6/2014 886 5/12/2014 656 2WO14 843 11!112013 831 617/2013 766 5/7/2013 651 2/4/2013 636 10130/2012 610 8/112012 654 6/112012 495 2/112012 483 11/1/2011 466 8/3/2011 405 5/3/2011 314 21712011 303 11/212010 290 .812/2010 187 6/5/2010 102 212/2010 01 11/3/2009 60 8/1112009 0 8/11/2009 2029 518/2009 20-18 2/2/2009 2003 MSG .73% 11/5/2008 1983 8/512008 1905 MSG 91 5/112008 1845 Type Loan Number Payor Activellnact. From Occupant Name ActiVe/Inactive Last Billing Date 9/4/2014 Active Rate Charge Multiplier/Users 0.535/8 7.82 1I 01 ALL METER SIZE 131,50 11 Until Location Brand Type Size YTO Cons ERT HH b Badger w Water 0,630-63 886 Code Consumption Posted Data Variance a Actual 30 9/11/2014 166% a Actual 13 6112/2014 4% a Actual 12 3/17/2014 -83% a Actual 65 12/20/2013 -40% a Actual 115 9/18/2013 619% a Actual 16 6/1812013 5% a Actual 16 3113/2013 -77°% a Actual 65 12113/2012 13% a Actual 59 9/26/2012 381% a Actual 12 6/20/2012 -2810 a Actual 17 3/14/2012 .73% a Actual 61 12/1512011 -31% a Actual 91 9/14/2011 664% a Actual 11 6/13/2011 -3916 a Actual 13 3/15/2011 -88% a Actual 103 12/13/2010 17% a Actual 85 9/13/2010 6990/0 e Actual 11 6/9/2010 -1 Sy a Actual 11 3/11/2010 -87% a Actual 80 12111/2009 -100% n New Mater 0 9/11/2009 -1000/0 r Replacement 11 9/1112008 -270 m Manual estimate i5 6/16/2009 41°% m Manual estimate 10 3116/2009 -88% a Actual 88 12/10/2008 53% m Manual estimate 60 9/12/2008 369% 2 Actual 12 6118/2008 17% Commonwealth of Massachusetts Elm City/Town of System Pumping- Record Form 4 DEP has provided this form for us&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 / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town Zip Code 2. System Owner. Name Address (if different from location) Cityfrown ' state Trp Code Telephone Number B. Pumping Record 1. Date of Pumping Dater r f uantit)r Pumped: Gallons 3. Type of system.- ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? El Yes ❑ No 5. Condition of System: 6. System Pumped By - Neil. Bateson Name Bateson Enterprises Inc' Company 7. Location where contents were disposed: C S: Lowell Waste Water t5forrn4.doc 06/03 F5821 Vehicle License Number Data ' System Pumping Record • Page 1 of 1 Town of North Andover, Massachusetts Form No. 3 NoRTM BOARD OF HEALTH O ^ F 9 DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSEt Applicant_ Site Location NAME G,1 L,' . R ESS r (SSa�� �r LEPHONE Permission is hereby granted to Constructor Repair ( ) an Individual -Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. NO. �� -/ Fee CHAIRMAN, BOARD OF HEALTH D.W.C. No. /6 0 7 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System �y) constructed; ( ) repaired; by located at Z c, 70t- / Li Y • z�� -� C:.. n was installed in conformance with the. North Andover Board of Health approved plan, System Design Permit rt 7 ,dated S17 % with an approved design flow of y YD gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed irraccordance 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 has been submitted to the Board of Health. Installer: Lic. #: Date: Design Engineer: Date: &ORTN L O 9 f ♦. �1'�o•�r�o ��'h ,SSACHUSE� Applicant NAME Site Location Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH 19 DISPOSAL WORKS CONSTRUCTION PERMIT .e - TEL Permission is hereby granted to Construct`(,, f or Repair ( ) an Individua)oil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. � // CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. APR 28 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT 0`2 c� (� 8 DATE: CURRENTINSTALLER'S INSTALLER S LICENSE# LOCATION: L! �y `� �✓ &wQ_ LICENSED INSTALLER: C"r- 6 SIGNATURE:MsjS,,�<;u�—TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes 'v/ No Floor Plans? Yes No Approval Date: ,:�5_,f' r k PLAN OF LAND ' �g /N NO, ANDOVER, IVASS. SCALE IN _ w I NM 29, 1998 mms ENC/NEERma /NC. ► MY MUW STREET oxt ENC/NEERS &WAKEfT£LD, MASS. 01880 LAND S 7EZ. (781) 246 2800 / awAFY 7mr 7H/S Azwa471AN /S LOCATED ON wr Gm&*D AS SHOWN, ANO THAT /T CONFORMS 7O THE zawVC BY-LA#S OF ME' roWN OF NORM ANDOVER / FURTHER CERAFY 7mr 7H/S PROPERTY Does NOT UE N7N17V A ROOD MZM ARSA (ZONE A OR V) AS P1OWN ON fZ00D /NSURAIVX RAM MAP COMMUN/lY NEL NUMBER 250098 00108. E7�fF'MPE aME 15 ✓UN£ 198.3 - -- ���• rr((, OFPROfES'S NAL LAND SURWMRETER J. GREN 3604 OPEN SPACE LOT 13 238.36 LOT 15 =n ZONE PRD (R-2) KR. M�''/MpMUyM�r .- _Iwmc FRO f 20' .SSW 20'(sem SEC D.5.6.0. �% REAR = 20' o� PURITAN AVE. 2s 9 t (50' W/DE) ' r R=60.00 L=101.00 � �i THE WINDSOR ® r EATING -DINING 9 '1 AREA ROOM o KI T HEN r o FAMILY ROOM I CE�LT SAl !NG - : v/;%!G COM FOYE.? l i i � J i, PORCH • ' GARAG- S � + a. 1 0 '� -v- ---- Fp7ST FLOOR AN A _CAA C ROIL 1 W ri FORM U - IAT 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: A("' 73CC i lolers 1. �tPhone g5 �3 LOCATION: Assessor's Map /Number Parcel Subdivision _A/V�/2a2,1 hd Esta`'G,ceS Lots) /4 _ Street &Yd 2 3 h 0, rC/e St. Number ************************Official Use only************************ RECOMMENDATIONS OF TOWN AGENTS: L' Date Approved Conservation Administrator Date Rejected Comments Town Planner Comments Food Insvecto - ealth `c. spector-Health S5pi r' Comments Public Works - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date Town of North Andover, Massachusetts Form No. 2 f NORTH BOARD OF HEALTH A 0,� DESIGN APPROVAL FOR ss CHU SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant AUxepEl� Test No. Site Location1 j1�; Reference Plans and Specs. _/Yigi/'--'-z5 //A-1 `� 7 ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD OF HEALTH Fee &O Site System Permit No. qF,7 ' Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director 30 School Street North Andover, Massachusetts 01845 October 27, 1997 Hayes Engineering, Inc. 603 Salem Street Wakefield, MA 01880 RE: Lot 14 Puritan Avenue This is to inform you that the proposed plans for the site referenced above have been disapproved for the reasons below. If new plans satisfactorily addressing all these issues are submitted to the Health Department by November 5, 1997, then approval for the plans should be given by November 11, 1997. `Y. Wetlands disclaimer missing. g (N.A.8.02s) Map and Parcel missing. (N.A. 8.02a) V7sl V72' after D -box to be laid level note missing. (310 CMR 15.232c) sufficient leach area — 432 gpd. Trenches 46' would suffice. Please be aware that all revision submittals must be accompanied with a $25.00 fee. 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 cc: Wm. Scott, Dir. CD&S Aurele Cormier File CONSERVATION - (978) 688 9530 - HEALTH - (978) 688-9540 - PLANNING - (978) 688-9535 *BUILDINGOFFICE - (978) 688-9545 - *ZONING BOARD OF APPEALS - (978) 688-9541 - *146 MAIN STREET Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director December 18, 1997 Hayes Engineering, Inc. 603 Salem St. Wakefield, MA 01880 Re: Lot 14 Puritan Ave. 30 School Street North Andover, Massachusetts 01845 This is to inform you that the proposed plans for the site referenced above have been approved. to 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 cc: William Scott, Director, P&CD File CONSERVATION - (978) 688 9530 • HEALTH - (978) 688-9540 • PLANNING - (978) 688-9535 *BUILDING OFFICE - (978) 688-9545 • *ZONING BOARD OF APPEALS - (978) 688-9541 0 *146 MAIN STREET Date: July 30, 1998 Town of North Andover, Massachusetts BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( X ) or repaired ( ) by Charles Zaher at #14 Puritan Circle, North Andover, MA 01845 has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit # 987 dated November 5, 1997. The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. L-y�-J� jttk�- QV Board of Health SS/cjp Revised: 7/20/98 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System j) constructed; ( ) repaired; by J� ✓ Zr located at Z.0 -74- / z/ 6:11--e-le was installed in con for mance with the. North Andover Board of Health approved plan, System Design Permit # tT/ ,dated 11,14-17 %with an approved design flow of y �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 has been submitted to the Board of Health. Installer: Lic. #: Date: Design Engineer: PC A, Z1 t "py-- Date: 1-51) 1%k- 9� 1998 Cc?�O = _ O —• vl O Q to Soco-0 N m n m Cl) v a Hma0 3 Z - = H -4 o �� 0:o o M ,•r �n�-►n = m C m Homy c ti _• o �mm m n _� c : � _ d Q oo= C(> o ZS ow CO) Oyn: 'v p pp P -4o m CD Z CO) ►� c �y r ..} p R a cD co o �r C• c, mmy no am y l„O H O �. O H d d \ C C.) CD CO) C L'1 to �J co CD CL CO) CO) = Q�m dCD CD g 2 -1 == CD rl LAI co O CDD Q Q o 0 co 00 3 Z QCD 0„-_ c CD CD C!1 H �! CL v `�' Z _ ` . 0 0 CD _CD '� a \70 CO) co) Z t71: d o �j .« � . r p d d d : !� 'mCD C n n CD b: � __ n c")= G 10 ' U7 3 '77 7U ° ° qty aO `' c a an o o c a � R c) nye M n fi. d `ate I• tt • �y 0 c HAYES ENGINEERING, INC. 603 SALEM STREET WAKEFIELD, MA 01880 ,, ,� �� (617) 246-2800 IIjLJ11���Lti FAX (617) 246-7596 No. ----- JOB FILE 11'0lz N1 I I - SOff, F\ I I "I,0Ez 1;OIZ:. of, ,t Cott moilwealth of Massachusetts North Andover , Massachusetts Soil Suitability Assessment for On-site Sewage Disposal Performed By: .-Gordon.Rogerson......................................... Date: Witnessed By: --Susan Ford-- . ..................... - L non Address cK s O.M. Namc. La. A.C. BUILDERS ,da�fs..n TdcpMrc No. Andover, Mass. ew Construction 0 Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes ❑� Year Published/____. Publication Scale../��3d1__v__._ Soil Map it ...._._(�_ Drainage Class-.-...__.�..... Soil Limitations i'�� Surficial Geologic Report Available: No ❑ Yes ❑ Year Published Publication Scale Geologic Material (Map Unit) - -- - ----- - ----- - Landform. ---... ----.. _ ... Flood Insurance Rate Map :................. : ............... --........... . Above 500 year flood boundary No []Yes Within 500 year flood boundary No ❑ Yes ❑ Within 100 year flood boundary No ❑ Yes 0 Weiland Area: National Wetland Inventory Map (map unit) ...................._.__._____.-. Wetlands Conservancy Program Map (map unit) Current Water Resource Conditions (USGS): Month Range :Above Normal ❑ Norma! ❑ Belt Normal Other References Reviewed: nt:r A1TR0%T..n FORM 1'107/96 [ OItt11 (( Soil, FIVALUATOR OIt11 1,ocalloll Address of I'm UV41 ON —9— On-Slle Review Deep Hole Number l ..._, Date:.. w l .- s . Time: Location (ide tifny site plan) o' ..... _ Land Use _..._......,...... Slope (�o) ..� Surface Stones Vegetation. W. Landform... . Position on landscape (sketch on the back) Distances from: Open Water Body .....N�'. feet Drainage way ..... .... feet Possible Wet Area..71-od//. feet Property Line... ^'r...feet Drinking Water Well..QU�4'..feet Other . . . .............. DEEP OBSERVATION HOLE LOG' Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) �S I '-3 / n / 13,E /2 � s/ S y 7,51 sy s . 1 I MINIMVrn Ur [ "ULntUU(rstU ' t to r i,.'J CU U13rUZ) 1L HnctA Parent Material (geologic) DepthtoBedrock. Y Depth to Groundwater: Standing Water in the.Hole _ 9a •, Weeping from f'it f=ace i Estimated Seasonal High Ground Water: Ut:P ,1'11140%T.1) FORM 12107:95 '•'�• •-I�lll/\1.: L.[111\17111\1/- , 603 SALEM STREET' JOB FILE WAKEFIELD, MA 01880 FORM 11 - SOIL EVALUATOR FORM (617) 246.2800 FAX (617) 246-7596 r� rage 3 of 3 c DEP APPROVED FOUJ. 12M7/95 Location Address Address or Lot No. Tt Determination ,for Seasonal H h Water Table Method Used: ❑ Depth observed standing in observation hole ...1a inches ❑ Depth weeping from side of observation hole .....%a . inches ❑ Depth to soil mottles .0. inches ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date .................. Index well level... Adjustment factor .................. Adjusted ground water level ...... ... .......... ...... ......... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in II areas observed throughout the area proposed: for the soil absorption system? If- not, what is the depth of naturally occurring pervious material? Certification I certify that on Nov. 1994 (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date DESCRIPTION OF HORIZONS TEXTURE.' peril rin^r Cower send —revs coarve land —Cos send --e /Jere send —fe rw^r /JM swod —Yfe Joam' Coar" sand --Jeri JoAW send --1s Joew fine send --ifs SAW Joy —sl fins saw loss—fel --stcJ sear afle —W Jar =rfel CUNSISmscE:- Aret aoll.' noastlatr --Ileo ellg'htlr stlatr -yeas atlatr -es wry selarr waplestJC . --Keo alightly plastic --eps Plastic • -,Ip to plastic —rip "roily sandy Jose -o'sl loss —1 pvtojir lose --VJ stony for --stJ SIR --eJ SIR lose --eJJ Clay lose --Cl sJJty clay lose --alcl sandy clay lose --ecl atony Clay lose --stcJ silty clay ---sic clay --C Mist soil., loose -'YJ W7 frlaOJe yrlr frlaDis - Wfr Fore or rrpc ray fires --wrfl extnwly f" -'srfJ try soil.* loose -OJ soft --dr slightly hero -~ h.ro -a, rerr hese -;dash extrerely ha+0 .--oyh STRUCTURE.' &Vde.' size., Fore or rrpc str%WWWess -o reser fine -rf platr --OL: "at -J fine -f p-!s«tu -W- ICderete ---z /wdAff --e coluw r '--O' strong --.f wave --t Oloatr --+r rerr Coorlf -rc rigida^ OJO07 -fir o"50wJar OJoety --O*t pvx/Jw^ --vr- IJlwl1 p'Vfe tic-' sesseri MOTTLING.• A&m4ftwe.• sire: anuvst.- few -f to-ev fine -! faint -� coewn -,o /r4%r! erdiur -2 distinct --- W ewrr -e 47-10av cowve pvNiflont --w FORM 1- APPLICATION FOR DSCP No. Fee COMMONWEALTH OF MASSACHUSETTS Board of Health, North Reading, MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components Location U )-T E Owner's Name 4,C, U l L PMZ- C) 64 G Map/Parcel # Address -33 QL V—OUi✓ R Lot # Telephone # Installer's Name Designer's Name E CA& Wc Address Address W , SALKrv► S ^IROLP Telephone # Telephone # 6, 7 'Z44, 2. v V V Type of Building: Dwelling - No. of Bedrooms 4 - Other - Type of Building Lot Size 27 9 38 sq. ft. Garbage grinder (q b No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 4-4-(� gpd Calculated design flow gpd Design flow provided Plan: Date j Q - k - 9 D� Number of sheets 1 Revision Date Title )C�l� �`fSi' ��4�(�14 11>a WA �4N&07-) m A gpd Description of Soil(s) oY L U � L— Soil Evaluator Form No. Soil Evaluator (A L Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Inspections No. Date DEP APPROVED FORM 5/96 FORM 3 - CERTIFICATE OF COMPLIANCE COMMONWEALTH OF MASSACHUSETTS Board of Health, North Reading, MA CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System Fee The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 1.5.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated . Approved Design Flow (gpd) Installer Designer: Inspector The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. DEP APPROVED FORM 5/96 COMMONWEALTH OF MASSACHUSETTS Board of Health, North Reading, MA DISPOSAL SYSTEM CONSTRUCTION PERMIT Date FORM 2 - DSCP Fee Permission is hereby granted to: ( ) Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. , dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. DEP APPROVED FORM 5/96 Date Board of Health 603 SALEM STREET' JOB FILE WAKEFIELD. MA o188o 17) 246-2FORM 11 -SOIL 1:VALUATOR FpM1 FAX (617) 247596 ,'� - rage 3 of 3 DEP APPROVED FORM - 12W195 Location Address or LotNo. �?j �GZVl�ah five, 1_1/3 Determination ,for Seasonal ,Flih Water Table Method Used: ❑ Depth observed standing in observation hole — inches ❑ Depth weeping from side of observation hole inches ❑ Depth to soil mottles /. : inches ❑ Ground water adjustment ................... feet Index Well Number .................. Reading Date .................. Index well level... Adjustment factor ................. Adjusted ground water level ...... .......................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material'exist in II areas observed throughout the area proposed: for the soil absorption system? if not, what is the depth of naturally.: occurring pervious material? Certification I certify that on Nov. 1994 (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature DateL> DESCRIPTION OF HORIZONS TEXTURE.' peril wrr caws s ~e —rcoa aaw�re sand —cos ares --s fine swnd —fs rerr fine sine —rfe JowRr carve emw —Jcas Jowly sand —Js lower fine swod —ifs ssfw JOws ---sl am wary J*" --fsl rery fine O&W lom —rfsl CV"..rSTENCE.• N*t mfr.' paweic r -'WO 40149tJr stlatr -was stle" -rs wry' stlatr --ws ~Jsstic *J100), RJ"tic --Ms piwstle wrr plastic --wrp pvr*JJr srwr Joss —ysJ losA —i pvrlJJr lows --pl stanr Jowl --etJ slit - r1 slit loss —eJl Clef lo" --cJ slier clef loses --sJcl awdy clay loss — aci staff CJey JOes --etcl silty cisr —elc clay —c Abut sOJJ.' JOOse --NJ rsrr frlwDJe -,srfr rrlaois --sfr fJh -rrl rrr firw '_srfJ axtr~jr !lir -fan 07 roti: love -dl soft -ds 9"Oh"r A" -dsA Jwm --dy rsrr Aw^d - Ifrh axt—Jr nww -dM STRUCTURE.• Avdr.• size: Fav or rrPc strwtuvless -o rrrr ring -rf Ostr rave -J fine -r prls"M Y Aadwvts - ? AgdJug -f coJunw. etlww -J carve --c OJoatr -des rerr cores --re r vJJSr 40Joee7 -+oe SL4*Wlwr Olacty -rOr p'YWJJr Y 01ro1e PVJr. -c Amssre MOTTLING.• AouWrus: size., coat we: rig -f ro_@ I ring -J fiJnt --e c mw a --c t, -%RW Aedim -p OJltlnet -� —r --* <M-ioav corer -v P'grJnr,t SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: YES v $60.00/Plan REVISED PLANS: YES $25.00/Plan DATE: M1131 7 DESIGN ENGINEER: 17'W Vl- 7 ham( When the submission is all in place, route to the Health Secretary Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director 30 School Street North Andover, Massachusetts 01845 October 27, 1997 Hayes Engineering, Inc. 603 Salem Street Wakefield, MA 01880 RE: Lot 14 Puritan Avenue 0 This is to inform you that the proposed plans for the site referenced above have been disapproved for the reasons below. If new plans satisfactorily addressing all these issues are submitted to the Health Department by November 5, 1997, then approval for the plans should be given by November 11, 1997. 1. Wetlands disclaimer missing. (N.A. 8.02s) 2. Map and Parcel missing. (N.A. 8.02a) 3. First 2' after D -box to be laid level note missing. (310 CMR 15.232c) 4. Insufficient leach area — 432 gpd. Trenches 46' would suffice. Please be aware that all revision submittals must be accompanied with a $25.00 fee. 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 cc: Wm. Scott, Dir. CD&S Aurele Cormier File CONSERVATION - (978) 688 9530 • HEALTH - (978) 688-9540 • PLANNING - (978) 688-9535 *BUILDING OFFICE - (978) 688-9545 • *ZONING BOARD OF APPEALS - (978) 688-9541 • *146 MAIN STREET �,c� PLAN REVIEW CHECKLIST ADDRESS -f fir' /� / U.e /7 � 4iy ENGINEER Ip yC-S GENERAL 3 COPIES L/ STAMP (/ Locus 1-� NORTH ARROW SCALEy CONTOURS PROFIL ( SECTION �� BENCHMARK SOIL & PERCS ELEVATIONS WETS.,DISCLAIMER� WELLS & WETS WATERSHED? DRIVEWAY L --'WATER LINE Ll--- FDN DRAIN �/':::f M&P-- SCH40 tl--' TESTS CURRENT? L/ SOIL EVAL SEPTIC TANK / r MIN 1500G � .17 INVERT DROP C� GARB. GRINDER k) C)(2 comps +200) 10' TO FDN L/ MANHOLE f/ ELEV �- -•GW ## COMPS. GB L� D -BOX SIZE # LINES CIL FIRST 2' LEVEL STATEMENT INLET 17a. 3 - OUTLET /7a as = �� ( 2" OR .17 FT) TEE REQ' D? -A/6- LEACHING MIN 440 GPD?,"( RESERVE AREA6---'4' FROM PRIMARY?L� 2% SLOPELf 100' TO WETLANDS 41-- 100' TO WELLSL-' 4' TO S.H.GW L� (5'>2M/IN) 20' TO FND & INTRCPTR DRAINS 400' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY Z/ MIN 12" COVER '--- FILL? (15') BREAKOUT MET? TRENCHES MIN 440 gpdSLOPE (min .005 or 6"/100')�SIDEWALL DIST. 3X EFF. W OR .D (MIN 61) L---- RESERVE BETWEEN TRENCHES? L --- INFILL? MUST BE 10' MIN. L/ 4" PEA STONE? VENT? (>3' COVER; LINES >50') BOT X60 + SIDE 34�6 _ 7,-26 X LDNG '60 = TOT % (L x W x #) (DxLx2x#) (G/ft2) Copyright Q 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 M MANHOLE/PIT 12"-48" STONE + SIDE x LOAD TOTAL: (2x(L+W)xD x #) (G/ft2) S 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 60') MIN 13' X 16.' PIT` BOT + SIDE' X -LOAD = TOTAL (L x W x #)' (:2 x (L+W)xD x. #) (G/ft2)• FIELDS MIN 440 GPD '90,0 ft2 BED ,GW MIN. 4' BELOW: BOTTOM; OF FIELD PIPE ENDS JOINED?':------. -4" PEA STONE?, DIST LINE SLOPE`' .. 0.057' >3' COVER -VENT. SCH 40� MIN. 12" COVERL=-'— RATE ( X ) X = TOTAL Copyright © 1996 by S.L. Starr. SEPTIC PLAN SUBMITTALS LOCATION: l , /)� / T�l� NEW PLANS: YES REVISED PLANS: YES v DATE: l l 7 DESIGN ENGINEER: A/"�V'0-S $60.00/Plan $25.00/Plan c 2Ley When the submission is all in place, route to the Health Secretary Town of North Andover, Massachusetts RnA R 1) OF HEALTH Form No. 1 ORTH s D 0 - 0 19 APPLICATION FOR SITE TESTING/INSPECTION Site L( Engineer NAME ADDRESS TELEPHONE Test/ Inspection Date and Time T;l I zf-7-, Fee D L-) CHAIRMAN, BOARD OF HEALTH Test No. 4 S.S. Permit No._-----D.W.C. No. C.C. Date-Plbg. Permit No 16 Town of North Andover, Massachusetts BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION Form No.1 19 Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/inspection Date and Time Fee f I CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No.-D.W.C. No.-C.C. Date-Plbg. Permit No. Tablet Page 1 3/2/98 Coffee Time Food Service 40 Danton Dr., 0076-7 $50.00 John D. Haroian/Johnny Ca 122 Olympic Lane N. Andover, MA 0184 107-8FH $15.00 Dom's Catering Truck 26 Park Dr., 111-8FS $50.00 North Andover High School 675 Chickering Road 675 Chickering Rd., N 106-8FS $0.00 DerAnanian, Souran, dba S 1 Dean Circle, Andover, MA 01810 192-8FS $25.00 N.A Council on Aging (Seni 120R Main Street 101-8FS $0.00 Kittredge School Main Street 107-8FS Donovan, Louise A. 12 Johnson Street 102-8FS $15.00 Rosie's Cakes & More 56 Water Street 170-8FS $100.00 Atkinson School Phillips Brooks Rd. 675 Chickering Rd., N 102-8FS Star Pizza 15 First Street 175-8FS $150.00 Mei Xie 28 Meadow Wood Ro 0113-7 $15.00 Upper Crust, The 125 Waverly Road 201-8FS $150.00 Top of the Scales 4 Johnson Street 176-8FS $150.00 Harrison's Roast Beef 80 Chickering Road 152-8FS $150.00 J & M Subs 69 MainStreet 133-8FS $150.00 Schneider Auto.(Modicon) 1 High Street 173-8FS $150.00 Greenery, The 75 Park Street 155-8FS $150.00 Compass Group USA @ Lu 1600 Osgood Street 150-8FS $150.00 Orzo Cafe Trattoria 1077 Osgood Street 161-8FS $150.00 Perfecto's 1077 Osgood Street 164-8FS $150.00 Merrimack College Volpe Ct 315 Turnpike Street 142-8FS $0.00 Barnes & Noble/Merrimack 315 Turnpike Street 143-8FS $50.00 Sargent School Abbott Street 675 Chickering Rd., N 110-8FS $0.00 Quinn, Janet 19 Surrrey Drive 106-8FH $15.00 Brigham's Ice Cream 350 Winthrop Ave. 116-8FS $150.00 CVS Pharmacy 350 Winthrop Ave. 1 CVS Dr., Woonsock 147-8FS $100.00 Jimmy's Pizza 1591 Osgood Street 134-8FS $150.00 Eaton Apothecary 1077 Osgood Street 187-8FS $50.00 Main Street Liquors 64 Main Street 149-8FS $50.00 English Ivy Tea Shoppe 10 Main Street 181-8FS $150.00 McDonald's Restaurant 660 Chickering Road 141-8FS $150.00 Sam's Mobil Station 12 Massachusetts Ave 172-8FS $50.00 Royal Crest Estates 22 Royal Crest Estate 0079-7 $150.00 Mango Grille, The 535 Chickering Road 153-8FS $150.00 CVS Pharmacy #209 115 Main Street 1 CVS Dr., Woonsock 148-8FS $100.00 Messina Liquors 117 Main Street 211-8FS $50.00 N.Andover Star Market 109 Main Street 189-8FS $150.00 Nevins Adult Day Center 3 Great Pond Road 157-8FS $150.00 Smolak's Farm Stand 315 S. Bradford Street 174-8FS $150.00 Sal's Just Pizza 476 Chickering Road 171-8FS $150.00 China Blossom 946 Osgood Street 124-8FS $150.00 Steven's Pond Concession Pleasant Street $0.00 Dunkin Donuts/Charlotte Do 535 Chickering Rd. 130-8FS $150.00 Lobster Claw Rest., The 1077 Osgood Street 138-8FS $150.00 Loft Restaurant, The 1140 Osgood Street 139-8FS $150.00 Dunkin Donuts/NA Donuts 129 Main Street 128-8FS $150.00 Page 1 3/2/98 Tablet Page 2 3/2/98 Tablet ... . ...... ............ ... ........ . ........ . ......... ......... Landers, Matt 41 Second Street 1301 $50.00 Barker's Farm Stand 1267 Osgood Street 0042-7 $50.00 Sutton Hill Nursing Home 1801 Turnpike Street 194-8FS $150.00 Joe Fish 1120 Osgood Street 135-8FS $150.00 Boston Hill Farm Stand 397 Farnum St., No.A 115-8FS $150.00 NHD Hardware 50 Peters Street 158-8FS $50.00 Richdale Dairy Foods #24 533 Chickering Road 167-8FS $150.00 Burger King/Carroll Corp.#2 Turnpike Street 118-8FS $150.00 Forgetta Farm 1210 Osgood Street 184-8FS $50.00 Osco Drug 525 Turnpike Street N. Andover, MA 0184 162-8FS $100.00 Butcher Boy Market 1077 Osgood Street 120-8FS $150.00 North Andover Shell 17 Massachusetts Ave 160-8FS $100.00 Jasmine Restaurant 733 Turnpike Street 190-8FS $150.00 Den Rock Liquors 350 Winthrop Ave. 127-8FS $50.00 Middlesex Market 127 Marblehead Stree- 156-81-R $100.00 Prescott Nursing Home 140 Prescott Street 165-8FS $150.00 N.A Rest.dba Rolf s 39 Main Street 169-817S $150.00 N.A.Country Club -Snack Ba 500 Gr. Pond Rd. N. A $50.00 Rolling Ridge Conference C 666 Great Pond Road 191-8FS $150.00 N.A.Country Country Club -K 500 Great Pond Road 159-8FS $150.00 ,Kinsman Service Station comer of Park & Chick 11 40-8FS $50.00 Page 3 3/2/98 Tablet Page 4 3/2/98 IAORTF1 i —'� �-' , Applicant Site Location Engineer Town of North Andover, Massachusetts BOARD OF HEALTH Form No.1 14 APPLICATION FOR SITE TESTING/INSPECTION 0r- I Test/I nspection Date and Time " t CHAIRMAN, BOARD OF HEALTH Fee -5b Test No. 1, S.S. Permit No.-D.W.C. No.-C.C. Date-Plbg. Permit No Town of North Andover, Massachusetts Form No.1 BOARD OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION 19 Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No.-D.W.C. No.______C.C. Date-Plbg. Permit No. - -- �1-- - i &y: f G U/VN 7-67;,-9.4- 1:2L19 7-e)7A,� iii' 150 Midway Road Cranston, Rhode Island 02920 (401) 946-1030 Manchester, New Hampshire (603) 434-8725 WobLrn, Massachusetts (617) 938-1037 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: �-7-0�1 SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) 9f e,� 04 -- DATE OF PUMPING -J- ?—c e-IQUANTITY PUMPED (��� GALLONS CESSPOOL: NO �YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE ` EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: �(� TOWN OqP ORTH DOVER SYSTEM PING RECORD DATE:y U� 0 C T 2 4 2005 SYST OWNER & ADDRESS TOV W '`OVER vT SYSTEM LOCATION— (example: (left front of house) �-- �l a �%- k - `4 DATE OF PUMPING: CQUANTITY PUMPED `a GALLONS CESSPOOL: NO t --AYES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIVED DEC 15 2009 TOWN OF NORTH ER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Otfmr farms 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 L tial -Left side of house, Right side of house, Left front of house, Right front of house, eft rear of housed ight rear of house. Address L �p City/Town t 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Qe V\nO4 Zip Code State Zip Code Telephone Number Date 2. Quantity Pumped: Cesspool(s)0-S'eptic Tank Gallons ❑ Tight Tank MIM 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: V\O 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G LL. . D Lowell Waste Water Vehicle License Number F5821 [-6--7-� Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of a w° System Pumping Record Form 4 SV eee RBCEIV KoV 12 NIZ TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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, iormation 1. System Loc_ ai. ' Left side of house, Right side of house, Left front of house, Right front of house, rear , Right rear of house. Left rear of building. Right rear of building. Address A City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: Date ❑ Cesspool(s) ❑ Other (describe): State U\(f)++ Zip Code State Zip Code Telephone Number — 2. Qua Pumped Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Ems' o If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi jn f System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Loc ' where contents were disposed: L . /I /-N Lowell Waste Water of Hau F5821 Vehicle License Number Date 16 -3/ -- L� t5form4.doc• 06/03 System Pumping Record • Page 1 of 1