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Home My WebLink AboutMiscellaneous - 10 WOODCHUCK LANE 4/30/2018 (2)f �� N O n S 0 0 0 0 O v n x c n 1 s C`Ay' 16-oo PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: November 20, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box Repair of On -Site Sewage Disposal System By: James Boraczek of Boraczek's Septic & Drain Inc At: YO Woodchuck Lane Map 106.0 Lot 0028 Nort Andover, MA 01845 this ce jfi ac,*shall fiot be construed as a guarantee that the system will function satisfactorily. Michele E. Grant Public Health Inspector 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov 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. 1-51 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Woodchuck Lane RECEIVED NOV 16 2017 le TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Carol Strout Owner's Name North Andover Ma. 01845 11/15/17 Cltylfown State Zip Code 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. General Information Inspector: Lap - Ron Jenkins L Name of Inspector R. Jenkins & Sons Company Name 58 Pleasant St. vvn.Nauy r%UUl=5 Rowley Cltyrrown 978-314-0503 Ieiephone Number rs. certitication Ma. State S14268 License Number 01969 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 11/15/17 Ins ectoes Signatur 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. t5'ars • 3113 Title 5 Official Inspection Forth: submaface Sewage Disposal System - page 1 of 17 �o Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is required for every North Andover Ma. 01845 11/15/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Distribution Box was replaced and Outlet Tee was installed on 11/9/17, All work was performed by Jim Borachek who is a licensed Installer in the town of North Andover All work and materials used are in compliance to Title 5 regulations Septic Tank was also pumped 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 [ficial Inspedion Form: subsurface Sewage Disposal System - Page 2 or 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is required for every North Andover Ma. 01845 11/15/17 page. City/Town 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 ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ 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. I. 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 15ins - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 3 of 17 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. YQ 17Im Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Woodchuck Lane Property Address Carol Strout Owner's Name North Andover City/Town Ma. 01845 State Zip Code RECEIVED NOV 0 8 2017 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 10/28/17 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in way. Please see completeness checklist at the end of the form. I A. General Information 1. Inspector: Ron Jenkins Name of Inspector R. Jenkins & Sons Company Name 58 Pleasant St. Company Address Rowley City/Town 978-314-0503 Telephone Number B. Certification Ma. State S14268 License Number RY 01969 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 f 10/28/17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 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 Woodchuck Lane Property Address Carol Strout Owner's Name North Andover Ma. 01845 10/28/17 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 Woodchuck Lane Property Address Carol Strout Owner's Name North Andover Ma. 01845 10/28/17 City(rown 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): D -Box is in poor condition and needs to be replaced ❑ 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 . 3113 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 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is required for every North Andover Ma. 01845 10/28/17 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 % day flow t5ins • 3/13 Title 5 Oficial Inspection Farm: 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 Woodchuck Lane Property Address Carol Strout Owner owner's Name information is required for every North Andover Ma. 01845 10/28/17 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 . 3/13 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 wM °r 10 Woodchuck Lane C. Checklist Ma. 01845 State Zip Code 10/28/17 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ rroperty Aaaress ❑ ® Carol Strout Owner Owner's Name information is Have large volumes of water been introduced to the system recently or as part of required for every North Andover page. Cityrrown C. Checklist Ma. 01845 State Zip Code 10/28/17 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ 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): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins • 3/13 Title 5 Official Inspection Forth: 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 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is North Andover required for every page. Cityfrown Ma. 01845 State Zip Code 10/28/17 Date of Inspection D. System Information Description: Number of current residents: 1 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 ears usage d 97,500 total 9 ( Y 9 (gp ))� Detail: 97,500 total gallons / 730 = 133.56 gallons per day Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Woodchuck Lane D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: Ma. 01845 10/28/17 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Last pumped 2001, info. from home owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy E 1 - @ IIIM ❑ 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 Property Address Carol Strout Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: Ma. 01845 10/28/17 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Last pumped 2001, info. from home owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy E 1 - @ IIIM ❑ 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 `t 10 Woodchuck Lane D. System Information (cont.) Ma. 01845 State Zip Code 10/28/17 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 36 years old, installed in 1981 info. from home owner Were sewage odors detected when arriving at the site? 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 line' 36" feet n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): condition of joints good, proper venting, no evidence of leakage Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 26" 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'x5'x5'dK Sludge depth: 91 ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Property Address Carol Strout Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) Ma. 01845 State Zip Code 10/28/17 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 36 years old, installed in 1981 info. from home owner Were sewage odors detected when arriving at the site? 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 line' 36" feet n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): condition of joints good, proper venting, no evidence of leakage Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 26" 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'x5'x5'dK Sludge depth: 91 ❑ Yes ❑ No t5ins • 3113 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 �M 10 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is required for every North Andover Ma. 01845 page. CityrFown State Zip Code D. System Information (cont.) Septic Tank (cont.) 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 n/a 2" n/a n/a 10/28/17 Date of Inspection How were dimensions determined? Measuring stick and ruler Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank should be pumped every 2-3 years, inlet baffle in fair condition no outlet baffle, structural integrity was good,liquid was level to bottom of outlet invert, no evidence of leakage Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins - 3113 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 01 1 10 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is North Andover required for every page. City/Town Ma. 01845 10/28/17 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Woodchuck Lane Yes Property Address No* Carol Strout Owner Owner's Name information is required for every North Andover Ma. 01845 page. Citylrown State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0"— 10/28/17 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.): Box was level and distribution was eqaul, no signs of solids carryover, D -Box is in poor condition and needs to be replaced D -Box is 36" below grade size of box is 16"x16"x14" deep 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: t5ins - 3/13 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 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is required for every North Andover Ma. 01845 10/28/17 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 3 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): drt gravel soil, no signs of hydraulic failure, no ponding, leach pits located on left side in front of house under mowed grass, top of pit is 36" below grade, bottom of leach pit is 63" below grade Opened LP 1 2" liquid . Note: Did not open LP2 & LP3 due to under ground Fios cable running over Leach Pit covers 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts ID Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 10 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Ma. 01845 10/28/17 State Zip Code Date of Inspection 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 W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is required for every North Andover Ma. 01845 10/28/17 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 - 3/13 ® hand -sketch in the area below ❑ drawing attached! separately Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 �9 Commonwealth of Massachusetts ITitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Woodchuck Lane Property Address Carol Strout Owner Owner's Name information is every North Andover required for eve Ma. 01845 10/28/17 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. 7'+ 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: info. from next door (252 Reliegh Tavern Ln.) ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Info. from 252 Raleigh Tavern Lane Seasonal High Water Table = 115.5 elev. (7'9" below grade) Test Hole performed by Frank Gelinas & Associates Dated 5/24/80 Soil Observations by J.J. Barbagallo Witness T. Murphy 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 Woodchuck Lane Property Address Carol Strout Owner owner's Name information is required for every North Andover Ma. 01845 10/28/17 page. City/Town 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 Summary Record Card generated on 101251201711:20:59 AM by Tara Hurley Page 1 r Town of North Andover Tax Map # 210-106.C-0028-0000.0 Parcel Id 17662 10 WOODCHUCK LANE STROUT, CAROL, A. Since Jan 2016 10 WOODCHUCK LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.23 Acres FY 2018 UB Mailing Index Name/Address Type Loan Number Activellnact. From Until CAROL STROUT Owner 10 WOODCHUCK LANE NORTH ANDOVER MA 01845 STROUT, WILLIAM Payor Inactive 1/8/2013 10 WOODCHUCK LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Activeflnactive Bldg Id. 13243.0 -10 WOODCHUCK LANE Last Billing Date 9/12/2017 2100090 02 Cycle 02 Active UB Services Maint. Account No. 2100090 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63518 7.82 1/ WTR WATER 01 ALL METER SIZE 57.00 /1 UB Meter Maintenance Account No. 2100090 Serial No Status Location Brand Type Size YTD Cons 35078131 a Active ERT FRT.b Badger w Water 0.63 0.63 1014 Date Reading Code Consumption Posted Date Variance 8/112017 1015 aActual 15 9/20/2017 21% 3°% 5/1/2017 1000 aActual 12 6126/2017 2/1/2017 988 a Actual 12 3/14/2017 -26°% 2311/6 11/1/2016 976 aActual 16 12/19/2016 44°% 8/212016 960 aActual 13 9/21/2016 -15% 5/3/2016 947 aActual 9 6/21/2016 -76°% 212/2016 938 a Actual 11 3/2812016 -61% 10/30/2015 927 aActual 42 12130/2015 1005% 8/4/2015 885 a Actual 113 9/14/2015 28% 5/4/2015 772 a Actual 10 6/22/2015 17% 2/3/2015 762 a Actual 8 3/20/2015 -6°% 11/3/2014 754 a Actual 7 12/1512014 -34% 8/1/2014 747 a Actual 7 9/11/2014 15% 5/5/2014 740 a Actual 11 6/12/2014 -40% 2/3/2014 729 a Actual 10 3/17/2014 80% 10/31/2013 719 aActual 16 12/20/2013 -19% 8/1/2013 703 aActual 9 9/18/2013 20% 5/112013 694 a Actual 10 6/18/2013 -19% 217/2013 684 a Actual 10 3113/2013 -5% 10/30/2012 674 a Actual 11 12/13/2012 30°% 8/2/2012 663 a Actual 12 9/26/2012 -22°% 512/2012 651 a Actual 9 6120/2012 -74% 2/2/2012 642 a Actual 12 3/14/2012 -47% 1111/2011 630 aActual 45 12/1512011 ` of NORTH 9a - 8078 3.p a r`•. .. '• OC Town of North Andover HEALTH DEPARTMENT SACMUSf CHECK #: 3o4 DATE: LOCATION: fD 1 , H/O NAME: 571I"ouT CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report - / $50-- 0 50— ❑ Other: (Indicate) $ Hea !`gent Initials White - Applicant Yellow - Health Pink - Treasurer North Andover Health Department (ommunity and Economic Development Division November 8, 2017 Address: 10 Woodchuck Lane ?N� co'�Al' c�Qaa�� All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdeptknorthandoverma. gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincerely, rian aGrasse, CEHT Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov North Andover Health Department (ommunity and Economic Development Division a� r ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 10 Woodchuck Lane MAP: 106.0 LOT: 0028 INSTALLER: James Boraczek DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: DBox Repair Outlet tee Baffld — inspection 11/14/2017 Michele Grant INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ® Installed on stable stone base ® H-20 D -Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: Two risers on D -Box put "T" in Tank F SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches).- Comments: trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: flCommonwealth of Massachusetts Map -Block -Lot 106.00028 ----------------------- • BOARD OF HEALTH Permit No North Andover BHP -2017-1092 ----- ----------------- P' I. FEE F. 1. $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby anted James Boraczek to (Construct) an Individual Sewage Disposal System.?atNo 10 WOODCHUCK LANE as shown on the application for Disposal Works Construction Permit No. BHP- 011-5109- ISated1► Rd'vember 08, 2017 r-�� ------- --------- Issued On: Nov -08-2017 BOARD OF HEALTH ' Application for eptic Disposal System /�- 8 A0/7 �'. Construction Permit —TOWN OF TODAY'S DATE - Full Repair NORTH ANDOVER, MA 01845 $i5 00 - Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key Repair or replace an existing system component — What? 0'-130 (— yo Mc/ to move your cursor - do not use the return A. Facility Information key. /0 (V,000 cityc`C L nr Address or Lot # rad �] (� C,% *—'+V Df/ V tr � /J' o 1 S '5-' City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump &Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ➢ KConventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D-Box) ------------------_----➢---❑-Pressure�P�os'ed(D-13ox-Present)-S°�A°:5---------------------------------____----------- ➢ ❑ Does the system require an effluent filter? Yes Nom_ If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the M&C? 2. Owner Information Name Address (if different from above) City/Town Email address Installer Information AM '5 �nrRCtciC Name [khat is the Model. State Zip Code 9-A- 611- S28IL Telephone Number 13or'f}C,-La,j Name of Company Address AM A041 071M City/Town t State Zip Code Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 f •-�,=-i Application for Septic Disposal System Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: AResidential Dwelling or ❑Commercial B. Agreement TODAY'S DATE $350.00 - Full Repair $175.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. N Date clon App a y: oard of Health Representative (q zlo p Date catio isapproved for the following reasons: For Office Use Only: 1. Fee Attached? 2. Ptoject Manager Obligation Form Attached. 3. Pump System? If so, Attach coP�ofElectrical Permit Applicantreceived copy of "Electrical Inspection Notes for Septic Systems" Handout? 4. Reviewedapprovalletter, allpaperworkfeceived.? 5. Foundation As -Built? (new construction only): (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes / No Yes V No Yes No V Yes No Yes No Yes o Application for Disposal System Construction Permit • Page 2 of 2 V SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: /0 WOOd C44 GN (Address of septic system) /� Relative to the application of 42ptcJ 130/,/K ZtX (Installer's name) Dated //7 o ay s ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or My company a. Bottom of Bed — Generally, this is the first (Vinspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept(acr�,townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer. I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner. Lyeneral contractor. or anv other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) J QN4Cs />o/'�C L t/C (Name — Print (Name — Signed) 8075 __. OF NORTF� 1ti O �y f _ 9 � - s Town of North Andover s HEALTH DEPARTMENT SACMUSf q CHECK #: % % $ Jc I DATE: LOCATION: &104 ckjc✓C H/O NAME: CONTRACTOR NAME: A01-0LC. Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ . Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic -Design Approval (p �Q'i $ Septic Disposal Works Construction (DWC) $ /75- 75— 0 ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ 61D Hea gent Initials White - Applicant Yellow - Health Pink - Treasurer r r �9-�� ! FORM - U - LOT RELEASE FORM a' INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANTll ! c� �U c�TJ PHONE . S . ASSESSORS MAP NUMBER l , * � LOT NUMBER SUBDIVISION LOT NUMBER /� JCVI CI` ✓� — STREET NUMBER STREET ........................................................................... OFFICIAL USE ONLY I Bosom Manama 0 Mae a woman *mom on onomem 0 a saw am mannommm a me Musson am a a lem as MENA Monson RECONR,AENDATIONS OF TOWN AGENTS CONSERVATION ADMINISTRATOR COI��IIvIENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED l �( /1 DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED COMMENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT COMMENTS RECEIVED BY BUILDING INSPECTOR DATE APPROVED DATE REJECTED t LoT 15 _ _ ?oo 00 ' . 1 I � ' � N 1 Ilo T i I I -0 14 h -o'gpirf AK�GC IlJ 00 b• I s� V..`o , -:PW I I c' T c w16E.HFq-s ) _�...6.��JE�Y To B _ .:_ �E5-��1�'(10►15 � Ga�lt�lTlotls ... .. opt F"Ga 1zv V; 30.00' L; 21.40' �oobG�JGK LA�� MORTGAGE INSPECTIO14 PLAN . LOCATED IN ��`tJ o Art noJ�i� 4? 4p -c��BUYER " . 4"�iQVT MASSACHUSETTS a AND ITS TITLE INSURERS _Q f SOC' TO THE fAIZALIIJT MloizTliA�iE -wQ I HEREBY CERTIFY THAT I HAVE EXAMINED THE PRLMIiES AND ALL EASEMENTS. Q ENCROACHMENTS AND BUILDINGS ARE IOGATLD ON THE GROUND AS SHOWN. /"�!`iA"�/ I fURTHER CERTIFY THAT TME BUILDING SHOWN 00{ )CONFORM TO THE ZONING LAWS AND AMENDMENTS, L..' (FRONT, SIDL B REAR YARD SLT BACK ONLY) OF _ ,Q... WHEN CONSTRUCTED. t FURTHER CERTIFY THAT THIS PROPERTY 1S 7,ona t. Land C �+I0DEED 2 LOCATED IN THE ESTABLISHED FLOOD. HAZARD ARIA' MBOOK NOTE : THIS CERTIFICATION IS BASED ,ON Tilt LOCATION Of SURVVEYEY MARKERS OF OTHERS, AND ARPALL _19-�l DOES NOT REPRESENT A PROPERTY SURVEY' EXAMINATION OF THE RECORDS 19 MADE QNLY SUBSEQUENT TO THE RlCORDED DAT! OF THE LATEST DIED AND DOES NOT INCLUDE VERIFYING THE .ACCURACY OF THE DEED DESCRIPTION PLAN PREVIOUS TO ITS DATE OF RECORD. THIS COMPANY IG NOT RESPONSIBLE .FOR ANY INDENTURES NAGE SUBSEQUENT TO THE BOOK— REcORRTY LINE IT IS DEO DATE OF THE LATEST :DEED OF RECORD. _ ..._..- WHENEVER BUILDINGS ARE SNQWN LS:SS THAN ONE FOOT FROM THE PROPEPAGE -_- ADVISED THAT A MORE PRECISE SURVEY .BE MADE TO VERIFY THESEM95UREMLNTS. CERT. NO. AOR MORT_�_PURPOs�� THIS cERTIFI ATIQN T4i9E lJG-(�L�..1886 ••.- TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE:' t I & ADDRESS (example: left front of house) DATE OF PUMPING1+— lq—r��UANTITY PUMPED f GALLONS CESSPOOL: NO AYES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: __ EMERGENCY FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) 4674-AP-0F/,(�NORrH F . 10._ Boar! of '�Jealth North Andover,Mass APPROVED DATE Provided: SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # Z_X_ _�_> DISAPPROVED Reasons: DATE jj -S i Wv Title 0 FAJ1 C� � -_-.— -— - -- � Reg 2.� The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot `,abutters location and log deep observation hoes -distance to ties cation and results percolation tests -distance to ties design calculations & calculations showing required leaching area location and dimensions of system-including.seserve area existing and proposed contours g) location any rat areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or -disclaimer (i) location any drainage easements tdthin 140' of serge disposal system or disclaimer-Pl iing Board files (j = sources of water supply within 2001 of sewage disposal stem or disclaimer ovation of any proposed well to serve lot -1001 from leaching facilityll 41 location of water lines on property -101 from leaching facility cation of benchmark Ar iv+ewarys arbage disposals no PITC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, ,14 stribution box inlets and outlets, distribution field piping and er elevations maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such. plans Reg 6 Septic ,ranks ( capacities -150% of flow, eater table, tees, depth of tees, ,-access., pumping _170eanou.t ,110, from cellar wall or inground swimming pool (d) 25+ from subsurface drains Reg 10.2 Distribution Boxes &a) slope -gfeater than 0.08 Reg 10.lt1_ Zb) sumsp Reg 11.2 11.4 11.10 11.13. Reg 15.1 15.4 15.8 3.7 Reg 14.1 14.4 14.6 14.7 14.10 Reg 9.1 9.6 asiga Check List FAIL I P e2 Leaching Eits Leaching pits azre referred where the installation is possible (a) calculation of leaching area -minimum 500 sq ft fib) s/2''A" acin �inage 2% erial splash pad bow n pipe from d -box to pipe eaching Fields o`gr greater than- 20 minutes/inch -minimum 900 aq ft struction of field surface drainage 2 % ,e) 201 Brom cellar va11 or inground swindng pool Leaching Mvenche A) c c ons o eaci�ing area -min 500 sq ft ;b) spacing -4 ft 6 ft with reserve betwaen ;c) dimensions ;d) constrncti e) stone f) surface ainage 2% t. Do e a) s pe y to be shows) b) y/x x (to be shown) $ I a) app val �� ' b) s d -by power Board of Fealth North Anejc-,ar,Y`.ass APPROV ID DATE Provided: SUBSUFFACE DISPOSAL DESICN, CF ECK LIST � LOT #�..._... _-_..�.._ DISAPPROVFD DATE Reasons: Title V Reg 2.5 FAIL OI The submitted plan must ow a a zitmun: a) the lot to be served-area,dimensions lot abutters b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties design calculations & calculations showing required leaching area e) location and dimensions of system -including reserve area f) existing and proposed contours (g) location -any wet areas Athin 1001 of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer i) location any drainage easenefnts -odthin 100' of se,age disposal system or disclaimer -Planning Board files (j) known sources of water supply within 2001 of sage dispo ral system or disclaimer location of ang proposed well to serve lot -1001 from leaching facili location of water lines on property -101 from leaching facility location of benchmark n) driveways W)garbage disposals no FVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank,, distribution box inlets and outlets, distribution field piping and Other elevations r) maximum ground water elevation in area s" -age disposal system (s) plan must be prepared by a Professional Figineer or other professional authorized by law to prepare such plans 4#o A_ Reg 6S tic Tanks a) capacities -150% of flow, water table, tees, depth of tees, access, Inu ping (b) cleanout �d101 from cellar wa7.1 or inground s-A=dng pool ) 251 from subsurface drains Reg 10.2 Distribution Boxes * ( a) slope greater than 0.08 Reg 10.1 b) sump +D WATETZ LIME IS SWDwc4 i13U ' DIDN%S' PKINT i50 WSLL.CoCEREcTM.P. ®ADDF,0 `M — I to01 ' M SNIST SM . �e- Subs+irf€tce Dosig FAIL Reg 15.1 15.4 15.8 3.? Reg 14.1 14.3 1.4.2 14.6 14.7 14.10 Reg 9.1 9.6 Check LI I OR Page 2 Leaching Fits Leaching pits are referred vhere the installation is possible �) calculations leaching area -z nimum 500 sq ft Vie) spacing Via) • surface a 2% cover erial ,e) 2 � x2 t splash pad , ,f) tee elbow g) no bends in pipe from d -box to pipe Leachihg Fields r A) no gree 20 minutes/inch b) area- 900 sq ft c) constracti of field d) surface dr e 2 % e) 201 from cellar or inground se3amdng pool LM". Tienches -- a) c s-` of leaching area -min 500 sq ft b) spacin -h ft min 6 ft with reserve betwaen c e) stone f) surface dr• a 2% Douahill Slope a' slope 77x- =to be shown) b) y/x 2 150 = (to be shown) Pump s Or approve b) stand-by power if Health ,ncj..averiHaas. - BB�PTiv �TE�€ ., INSTALLATICK CHECK LIST LOT M DATE DISUEROVID WE rXMV�ATICNOK FAIL eaepnst OK - 1. Distance Tot a. Wetlands b. Drains c. Well 2. Water Line Location 3 • , Ido PVC / it: Septic Tank •" ". - a* .-Tess -_Length Ec To Clean flat Comers b. Cement Pipe -to Tank - Oa Both Sides of Tank, '- 5• Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Ejual Amounts C. No Back Flow 6.. Leach •Field or Trench - ' a. Dimensions c b. Stone Depth _ c: Capped Inds - d. Clean Double- Washed Stone, 7. Leach Pits f a. Dizaensions b. Stone Depth .. _ . /r c. Splash Pads d. Tees , e. Cwt Pipe to Pit - Both Sides f f. Clean Double Washed Stone -No Garbage Disposal �9. Final Grading Inspection _ 10. Barricading Covered System - 11_. As Built Submitted___ -._ a. Lot Location-- - b. Dimensions of System c. Location with Aegar&to Pere Test d. Elevations e: Water Table