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Miscellaneous - 100 CRICKET LANE 4/30/2018 (4)
r a Lot & Street / 9 ("'el - r Z/ Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: SES NO Permit / Plan Approval- Date: /�/ Approved by: Designer: 1?%, , j/Yj,9��Plan Date: Conditions: �' eaolly6 8,5cotp 00,,--c Water Supply- Well Permit: Well Tests: Bacteria Bacteria U Plumbing. Sign -Off Comments: Well. D G c, ►�-` --� � ✓` w � S. Driller: j ate Approved Date-Approved- Date-Approved pprovedDateApproved -Wiring Sign -Off - Form "U" Approval: Approval to -Issue: Date Issued BY: Conditions: NO Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? ,YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FLNAL BOARD PF HEALTH APPROVAL: DATE:4-7'10C27/ APPROVED BV: / 1 SEPTIC SYSTEM lei tSTALLATION Is the installer licensed? Type of Construction: NO New Construction: Plot Plan Review REPAIR -_._Certified -Floor Plan Review 9Ep NO — Conditions of Approval from Form U YES NO NO _Issuance of DWC permit: - EUD NO _DWC Permit Paid? _— ---DWC-Permit - _ Installer: Lt). ion -1 NO. &_15 Bedmrnspection:_ NO -Excavation Inspection: -Needed: Yra n t2 S, — Passed: -.-Construction Inspection: Needed: As.BuiltPlan Satisfactory: YES: Approval of Backfill: ---Final Grading Approval ME Date:! / By: Date: 0`7 Gid By Final Construction Approval: Date: '7/ py By: Certificate of Compliance: Approval: Date: Cmmnwealth of Massachusetts CftYffown of NORTH ANQQYER. MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for us* by local Boards of fk aith. The System pumping Recpnd rtmst ie subrMbtsdtatire ioca&&rard-nFthn#ir gar other appy r1F=C.=E1VE7D�j A. Facile Information roans on the CWvUW. use _ I 1c) CC i, c-! -- C' Y1 only fttab koy AWWrass - '° "� N o A� vet �r -aa � mom, use the return Cay/rowState Zip Code 12 n,/ S"0 wme Address (if difkmnt from bcahon ) Wrow n Sate Zip Code 13 Teieghone Number 5-M U 2014 TOWN OF NUR IH,ANpOVER M ng Record I. Date & Pumping 2 /SSU Deft Quantity Pumped: 3. Type of system: Cesspool(s) Septic Tank ❑ Tight Tank 0 tither (deCht?e): 4. Ef%mnt Tea Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By 7. Lmaton where oantants W.". GLS D eQ 7-- 0f httpyt www:mass.govideplwawlapprovsIM5farms.h"nspect WMNA - OBW If Yes, was it cleaned? ❑ Yes [2. No en+ct I t tcense lYurnber Date PW0VRamM-pagef oft Important: When filling out fors on the computer, use only the tab key to move your cursor - do not use the return key. Ab ISI Commonwealth of Massachusetts - C ity/Town of ''�'Ln System Pumping Record�� p 7 2013 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health- Othdr fdt is__ � fa-�e�'�sed;�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 Sy&tg(rt Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: Address ke,3- mG Cityrrown state 2. System Owner: e�� nti SS4 r Name Address (if different from location) Zip Code Citylrown State ' Zip Code :i 7e— -3 - Yi 30 Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)Septic Tank'' ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes )61No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number 0�'S�C Z � k S eai'►`C Company 7. Location where contents were disposed: LS 6 eo!22 r' Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc- 03106 System Pumping Record • Page 1 of t 4 ^ NORT1� Of 0 r Town of North Andover + r' Ur A i Til "r D A D'1rXXV MrV ,SSACN�St� CHECK #: LOCATION: H/0 NAME: CONTRACT( `76�-S 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 Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑Title 5 nspector $ itle 5 Report �0 $ . ❑ Other. (Indicate) $ (.. �Ilel 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. t5ins • 09/08 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Cricket Lane Property Address Richard Sippel Owners Name North Andover Cityrrown MA 01845 State Zip Code 12/18/2009 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 forma A. General Information 1. Inspector: Neil J. Bateson Name OT Inspector Bateson Enterorises Inc Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification JAN 1 ?g90 Tglyhl AR Nd��� ��p�u�R 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails XE]Nee s Furthe Evaluation by the Local Approving Authority 12/18/2009 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 h(w the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 oa Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Cricket Lane Property Address Richard Sippel Owner's Name North Andover MA 01845 12/18/2009 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 • 09/08 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 110 Cricket Lane Property Address Richard Sippel Owner's Name North Andover MA 01845 12/18/2009 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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): ❑ 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 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 110 Cricket Lane Property Address Richard Sippel Owner's Name North Andover MA 01845 12/18/2009 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 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 Y day flow t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 110 Cricket Lane Property Address Richard Sippel Owner Owner's Name nform equine fo d for tiis requireNorth Andover MA 01845 12/18/2009 very page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No 1:1® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El® Any portion of the SAS, cesspool or privy is below high ground water elevation. El® 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. El® Any portion of a cesspool or privy is within 50 feet of a private water supply well. E]® 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.] i e ❑ ® 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 ra 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 ❑ ® 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 ra 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 110 Cricket Lane Property Address Richard Sippel Owner information is Owner's Name required for North Andover MA 01845 12/18/2009 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 110 Cricket Lane D. System Information Description: 12/18/2009 Date of Inspection Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: 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: Gallons per day (gpd) ❑ Property Address ® Richard Sippel Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code D. System Information Description: 12/18/2009 Date of Inspection Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: 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: Gallons per day (gpd) ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 09/08 Ttle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 110 Cricket Lane Property Address Richard Sippel Owner Owner's Name information is required for North Andover MA 01845 12/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Pumped two years ago, 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): t5ins • 09108 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Cricket Lane Property Address Richard Sippel Owners Name North Andover Cityrrown State 01845 Zip Code 12/18/2009 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 9 years old, 6/20/2000, as built plan Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 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 to septic tank, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ Yes ® No 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 2" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Owner information is required for every page. t5ins - 09108 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Cricket Lane Property Address Richard Sippel Owner's Name North Andover Cityrrown D. System Information (cont.) State 01845 12/18/2009 Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 25" Scum thickness 2° Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 19" 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 invertNo evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 110 Cricket Lane Property Address Richard Sippel Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code 12/18/2009 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 E] other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 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 110 Cricket Lane Property Address Richard Sippel Owner Owners Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) 12/18/2009 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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 light carryover. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 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 110 Cricket Lane Property Address Richard Sippel Owner Owner's Name information is required for North Andover MA 01845 12/18/2009 every page. Cityrrown State Zip Code Date of Inspection t5ins • 09/08 D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 55'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 Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Cricket Lane Property Address Richard Sippel Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code 12/18/2009 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Cricket Lane Property Address Richard Sippel Owner's Name North Andover MA 01845 12/18/2009 City1rown State Zip Code D. System Information (cont.) Date of Inspection Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately �C Eve.Wcr,� I tr 5� = Qro (O S0c.,T0AAtrja��o� TO-A&N\ 4ous,e_, t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 110 Cricket Lane Property Address Richard Sippel Owner Owner's Name information is required for North Andover MA 01845 12/18/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: '4 feet Please indicate all methods used to determine the high ground water elevation: /1 Obtained from system design plans on record If checked, date of design plan reviewed: 8/11/1997 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 - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Cricket Lane Owner information is required for every page. Property Address Richard Sippel Owner's Name North Andover City/rown 12/18/2009 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 s: Commonwealth of Massachusett: R City/Town of System Pumping Record w Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. SystemLacatiQn: Left side of house, Right side of house, Left front of house, Right front of house, eft rear of house�Right rear of house. Left rear of building. Right rear of building. Address 10 CA;z �c Ly� �� City/Town State Zip Code 2. System Owner: Name Aaaress (it aitterent trom location) Cityrrown B. Pumping Record 1. Date of Pumping S1 pPe.l States 1-7,^� ZCode Telephone Number Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter. present? ❑ Yes No Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Y\0'�F t4"uat � V�'_ C� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: F5821 Vehicle License Number .(:)- — k cs —v `e1 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Summary Record Card generated on 12/11/20091:28:51 PM by Lisa Evans Page 1 Town of North Andover Tax Map # 210-107.A-0289-0000.0 Parcel Id 18111 110 CRICKET LANE SIPPLE, RICHARD & VICKYE 110 CRICKET LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.14 Acres FY 2010 UB Mailina Index Name/Address Type Loan Number Active/Inact. From Until SIPPLE, RICHARD & VICKYE Payor 110 CRICKET LANE NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 13872.0 - 110 CRICKET LANE Last Billing Date 12/4/2009 2100709 02 Cycle 02 Active UB Services Maint. Account No. 2100709 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 57.00 /1 UB Meter Maintenance Account No. 2100709 Serial No Status Location Brand Type Size YTD Cons 16106719 a Active ERT METE METE w Water 1 1 117 Date Reading Code Consumption Posted Date Variance 11/2/2009 776 a Actual 15 12/11/2009 -10% 8/4/2009 761 a Actual 17 9/11/2009 2% 5/4/2009 744 a Actual 16 6/16/2009 -30% 2/5/2009 728 a Actual 24 3/16/2009 1 % 11/5/2008 704 a Actual 24 12/10/2008 16% 8/4/2008 680 a Actual 21 9/12/2008 -7% 5/2/2008 659 a Actual 21 6/18/2008 0% 2/5/2008 638 a Actual 23 3/14/2008 -40% 11/2/2007 615 a Actual 37 1/15/2008 76% 8/3/2007 578 a Actual 21 9/14/2007 28% 5/4/2007 557 a Actual 13 6/22/2007 -14% 2/21/2007 544 a Actual 23 3/23/2007 3% 11/3/2006 521 a Actual 15 12/22/2006 -36% 8/21/2006 506 a Actual 34 9/13/2006 80% 5/5/2006 472 a Actual 15 6/20/2006 -24% 2/8/2006 457 a Actual 22 3/13/2006 -34% 11/4/2005 435 a Actual 32 12/14/2005 -31% 8/4/2005 403 a Actual 47 9/12/2005 159% 5/3/2005 356 a Actual 15 6/8/2005 -15% 2/15/2005 341 a Actual 21 3/15/2005 9% 11/15/2004 320 a Actual 19 12/17/2004 -14% 8/16/2004 301 a Actual 22 9/20/2004 4% TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received ✓� /� Date Issued: IMPORTANT: Applicant must complete all items on this page 111 XPIOU PROPERTY,'OWNER, C�ZIC� _ LSI Print VA rJrt � P -ht? iQQ)YearpQlajStructure yes:, no:3. MAP°NO: PARCEL: ZQNI,NGID`ISaTRICT: _ Histonc:District yes,, no. Machine.ShopjVillage yes, no; TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New'Building ❑ One family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition CkOtherCzCK peptic DWell Dfloodplain- 0Wetlands ❑ Watershed'District o ,Water%Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: �E fC �' 3(#(_0 AAf Leo `DOCK Identification Please Type or Print Clearly) OWNER: Name: '��N Iy,4 14—k Phone: � -- ArirlrPcc• PJ (AM/ce L4/1c-". G.ON� RACTOR< ,Name:, Z))99)?CA/ /n/-k7-//V0Phone:. T-7-6 -qO7- Address: P l fes✓' AvZ:�- - N-7- /77/4 _. ' Supervisors Construction License:. C'n G 3 1-o-, Exp':- Date: Home Improvement',License: % L( Exp: Date: 9 -1`7- 13 ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ 12 4W OJ FEE: $ _ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund _Sigriat6re of Agent%Owner Signature of,contr'actor Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i ft Plans Submitted Plans Waived F] Certified Plot Pian ❑ Stamped Plans El F] TYPE OF SEWERAGEDISPOSAL pools El Public Sewer ❑ Tanning/MassageBody Art ❑ Swimming Well ❑ Tobacco Sales ❑ Food Packaging/Sales Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS NS OFF F OFFICE FORME ONLY INTERDEPARTMENTAL SIGN DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS -Si .CONSERVATION Reviewed on nature COMMENTS HEALTH Reviewed on / Si nature G _ COMMENTS Zoning Board of Appeals: Variance, Petition No; Zoning Decisionlreceipt submitted yes Planning Board Decision: Comm Conservation Decision: Comments Water & Sewer Connectionisi nature & Date Drivewa Permit DPW Tow ]Engineer: Signature: - Located 384 Osgood Street FIRE :DEPA-►RTM' EN' T Temp Dumpster on site yes Located at'124,Mairi Fire Departiner#1signature/date COMMENTS."'.. no O N -��, � G" � � �. c •? K .G•' �. rc c 't'" fj "1 � 6 r FORM 4 - SYSTEM PUWNG RECORD Commonwealth of Massachusetts pv\Aov<-r , Massachusetts S stent pum in Record ystem ocat►on N e-, sS , — e(, c J(,-4 Ln ll a-j:S b�C-k ©-r 27cv5=- BrIc - a Wo HEALTH Type: 1. Emergency ❑ Routine /6 Cesspc ol: No ❑ Yes ❑ S,-ptic Tank: No ❑ Yes �� yio Quantiry Pumped: %Say _ gallons Date c :• Pumping: IBO.R,ACZEWS-'- Permit .. Svstei:: Pumped by (Company). Conic .ts transferred to: Cont:.tt.s disposed at: G�.wr-c�G� Date fl�S/-Pumper Signature Conc ition of system other comments: k--,) DF -P APPROVED P00.�1 • 1:/07195 �Z/ TOWN OF _P�- A-�,L rec SYSTEM PUMPING RECO REECEI!!IE® DATE: UG 0 5 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER & ADDRESS (�� LVII SYSTEM LOCATION (example: left front of house) b"k � hou6e DATE OF PUMPING: - 0 QUANTITY PUMPED: L C, O GALL NS CESSPOOL: NO YES PTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste FORM U -LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all nec:-ssary 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 or requirements. ' AFPLICA�T FILLS OUTTHIS SECTION`�'"*"`*"'"""`�"'��'"'�"' � APPLICANT Citcue�- \/cyC��11 �� �'' PHCNE LCCATION: Assessors Map Number PARC_ q SUEDIVISION l.-� S�� �`"� 5� LOT (S) / STREET ii I � d Cc ST. NUMEE.R OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: I CO ATION ADMINISTRATOR DATE APPROVED A DATE REJECTED- COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATEAPPROVED DATE REJECTED IKePECTOR-HEAL DATE APPROVED DATE REJECTED COMMENTS ( /J l PUBLIC INORKS-SEWERPNATER CONNECTIONS DRIVE -NAY PERMIT FIRE DEFARTMENT RECEIVE, EY EUILDING ii ISPECTCR DAT- nevi<ed 9l97 im /1 BUILDING TIES BUILDING CORNER A B C SEPTIC TANK 23.8' 19.5' PUMP TANK DIST. BOX 21.1' 40.7' CORN. LEACH FIELD #1 22' 40.7' 70.7' CORN. LEACH FIELD #2 69.8' 86' CORN. EACH FIELD #3 75.4' CORN. LEACH FIELD #3 36.3' 56.Tl- 0 0 U) a i w INVERT ELEVATION 4" PIPE ® FDTN. _ SEPTIC TANK IN = SEPTIC TANK OUT = PUMP TANK IN PUMP TANK OUT DIST. BOX IN — DIST. BOX OUT = END LEACH LINE #1 = END LEACH LINE #2 = AS- BUILT OF SUBSURFACE DISPOSAL SYSTEM LOCATED.IN NORTH ANDOVER, MA. AS PREPARED FOR COPLEY DEVELOPMENT 50 COPLEY DRIVE RK E T NOTE: THIS PLAN & CERT A WARRANTY OF THE SUE SYSTEM. IT IS A RECORD AND ELEVATION OF THE E COMPONENTS. �i TRIM BUILDING CORNER A B C SEPTIC TANK 23.8' 19.5' PUMP TANK DIST. BOX 21.1' 40.7' CORN. LEACH FIELD #1 22' 40.7' 70.7' CORN. LEACH FIELD #2 69.8' 86' CORN. LEACH FIELD #3 1 75.4' CORN. LEACH FIELD #3 1 36.3' 56.2' I 4" PIPE ® FDTN. = 208.74 SEPTIC TANK IN = 208.33 SEPTIC TANK OUT = 208.04 U13 1. QUA IN = LU /.00 DIST. BOX OUT = 207.7 END LEACH LINE 1 = 207.31 END LEACH LINE W2 = 205.37 AS- F OF SUBSURFACE LOCATED IN NORTH ANDOVER, MA. AS PREPARED FOR COPLEY DEVELOPMENT 50 COPLEY DRIVE METHUEN, MA. 01844 I I W IL. 11 ttJ 1 L/117 U. %A -IN 111 IVA IIVI\ IJ INV 1 A WARRANTY OF THE SUBSURFACE DISPOSAL OF THE DISPOSAL SYSTEM ANDTEMELE ELEVATION OF THEDEXISTING SYSTEM LOCATION COMPONENTS. SCALE: 1"=20' DATE: JUNE 20, 2000 SUBDIVISION LOT #9 CRICKET LANE MERRIMACK ENGINEERING SERVICES PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL (978) 475-3555 FAX (978) 475-1448 Commonwealth of Massachusetts.. City/Town of W° System Pumping Record Form 4 M DEP has provided this form for use by local Boards of He; information must be substantially the same as that provide local Board of Health to determine the form they use. The the local Board of Health or other approving authority. ED - JAN JAN 1 1 2010 , but the i, check with your ;t be submitted to A. Facility Information 1. Systgran Lacatipn:_Left side of house, Right side of house, Left front of house, Right front of house, �Ceft rear_ of hoE; fight rear of house. Left rear of building. Right rear of building. Address City/Town State 2. System Owner: P-�— � Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Zip Code State^ ! :-0t ZCode TeleppphhooGnne Number Date 2• Quantity Pumped: Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofd ystem: \No�� L v 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: Q. Lam. D n n Lowell Waste Water of F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 'L\ Commonwealth of Massachusetts City/Town of Merrimac System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board'of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. IRRIECEIVED A. Facility Information Important: When filling out forms 1 on the computer, use only the tab , System Location: //0 C ( "r? 1 �` /Y1 key to move your Address cursor - do not a�i use the return key. City/Town 2. System Owner: I t5form4.doc• 03/06 gel? Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: MA State JUN ZOi2 TOWN OF NORTH ANDOVER - HEALTH DEPARTMENT 01860 Zip Code State Zip Code 57)"P- X33 - &6)F3 Telephone Number 5-- `/— /.)- Date o)- Date 2. Quantity Pumped: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By: Name BORACZEK'S SEPTIC & DRAIN Company 7. Location where contents were disposed: 6f2 -S D L-�'ra'5�e Signature of Hauler Signature of Receiving Facility /5-00 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Date Date System Pumping Record Page 1 of 1 AS -BUILT CHECKLIST fO LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER f� LOT LINES & LOCATION OF DWELLINGS t/ LOCATION & DEIIENSIONS OF SYSTEM, V INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LE ATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES W/IN 150' OF SYSTEM r (/ LOCATION OF WATER; GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX STAMP & SIGNATURE IMPERVIOUS AREAS -DRIVEWAYS, ETC. / y NORTH ARROW FINAL CONTOURS LOCATION & ELEVATION OF BENCHMARK USED LOCUSPLAN z 3. 4. INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at /i� e relative to the application of a-' /4orr �/�Ce dated �' 17 - Z #-p for plans by Z& C/`i/ and dated /-Z -4 with revisions dated 2 I understand and agree to the following obligations for management of this project: As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 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 my company. a) Bottom of Bed — generally first inspection unless there is a retaining wall which should bo.- done first installer must request the inspection but does not have to be present. b) Final Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to BOH, after which installer calls for inspection time. installer must be present for this inspection with 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. Does not have to be on site. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work 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 in the Town of North Andover plus significant fines to all persons involved. 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. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. 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, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licer4d Septic Installer Date: S' -/7- 2000 T(- iT' ")RTH A. 901K:R/ W cd �Q V\ Cy r L. ifH Z :O O i cm y 0 A O Of C m O cm C 'c N CD Z r 0 Z 0 v �! co 0 CD L 0 v Z � Q. O CO) C cm CA CD y CD m m CD H � CL �•+ CD 3� G3 C L L - C3 d CL C 4 cc O C v C FL a G3 CL �..� h � C C CO3 0 U) U) w w W V �¢ w O y 5 0 3 .CD c 0 m w O z �J c7 `o a C3 •CCL �. L c. cc -v O v p O C O` C O C O w v) w a w U) a: crl cn V) r L. ifH Z :O O i cm y 0 A O Of C m O cm C 'c N CD Z r 0 Z 0 v �! co 0 CD L 0 v Z � Q. O CO) C cm CA CD y CD m m CD H � CL �•+ CD 3� G3 C L L - C3 d CL C 4 cc O C v C FL a G3 CL �..� h � C C CO3 0 U) U) w w W V y 5 0 3 .CD c 0 m .A: ots H C3 •CCL �. L c. cc b: �: m C O CE CD O. ?: ES :220 O C" �: : CL �• h R o : �' 3 % I'D N cm ' O C � C _ : A � 2 'L C d�H Ao: O O A: CZCJ Of p C N Q Ct SID �•aZ 0 d O o123 H W eo Z umiEL °C MCO •E ca 4.2.y Q m o c CL_ C-3 O co O 90 = OM= N •_ 1--L �p yam+ d 0- m r L. ifH Z :O O i cm y 0 A O Of C m O cm C 'c N CD Z r 0 Z 0 v �! co 0 CD L 0 v Z � Q. O CO) C cm CA CD y CD m m CD H � CL �•+ CD 3� G3 C L L - C3 d CL C 4 cc O C v C FL a G3 CL �..� h � C C CO3 0 U) U) w w W TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 7/6/00 This is to certify that the individual subsurface disposal system constructed (X) or repaired ( ) by William Sawyer at Lot 9 (#110) Cricket Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System (instructed; ( ) repaired: by located at LvT C 12i was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # 'dated , with an approved design flow of - - allons 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. Bed inspection date: (o —x Engineer Repr entative Final inspection date: 7f- --? F j Engineer—Representative Installer: Lic.#: Date: Design Engineer: Date: JUL 3 �� W. TOWN OF NORTH ANMOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System cons-,ructed; ( ) repaired; by --- located at Zor `�' f'/'iC��z /na„yel was- installed - n conformance with the North Andover Board of Health approved piarL System Desiomn.Pe =IL t dated with an approved design flow. of - gallons per day. The mate teals used were in coruornance with those specified onthe approved plan; the systern was installed in accordance with the provisions of 310 Ova 15.000, Title 5 and local re`ulations, and the final grading agrees substantially with the approyed plan. Ail work is accurately represented on the As -built which has been submitted to the Board or Health. Bed inspection date: Final inspection date: Installer: Design Engineer: Engineer Re-'resentative Engineer Representative Lic.m: Date: Z Z b - Zvy Date: JUL 3 M W C p 2 ° E a a `o w J ° LL ^V�' W N �. U ~ Q ` 0 J N Q I W �� LLro \ O Z — a 3 c m p N w `° Z c Z u O -- L cn \•` Q U rz 1= v ro F- a 0 Q w N w L O 1 Z w C O O a _� "° N p N V L Q N Y z o U 3 ° N O �, r1 1 bA w v +r i � N T \Q ( N Z OVER sem} C �ro N N O o , a h N h 00 ro Q "MO.L s s • Q V1 Vi LL I FORM U -.LOT RELEASE FORM f. 1 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 or requirements. *. ******* APPLICANT FILLS OUT THIS SECTION APPLICANT PHONE 66`4 -�( Pd,(✓ _(L�u wcic� LOCATION: Assessors Map Number `dam R PARCEL SUBDIVISION L-,JGUA- LOT (S) STREET Cr\ c uc. ST. NUMBER 110 ***** OFriCIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED S C 1N ECTOR-HEALTH DATE APPROVED Z 7 DATE REJECTED 7 COMMENTS - c/' j PUBLIC WORKS - SEWER/WATER CONNECTIONS Gf/ DRIVE'NAY PERMIT FIRE DEPART'NIENT RECEIVED BY BUILDING ii (SPEC T ORy DATE Revised 5197 jm MORTM O'�t�.e �e'�•1.O O � � w F ♦ i i ;,SSACMUSft� Town of North Andover, Massachusetts Form No. 2 BOARD OF HEALTH 2;�� 4,44 Z 19.� DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant ejjp/-Ey 'Dcueo,�iy�,vT Test No. Site Location 9IC,rCL� i`" L/acJC Reference Plans and S ENGINEER DESIGN Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee AIRMAN, BOARD OF HEALTH Site System Permit No. /6.3 Town of North Andover NORTH OFFICE OF �� o COMMUNITY DEVELOPMENT AND SERVICES ° . A . , 27 Charles Street North Andover, Massachusetts 01845 WII LIAM J. SCOTT 9SSACHUS�t Director (978)688-9531 Fax(978)688-9542 March 25, 1999 Les Godin Merrimack Engineering 66 Park Street Andover, MA 01810 Re: Lots 1-10 Cricket Lane, North Andover Dear Sir: This letter will serve as your notification that the proposed septic plans for the lots specified above have been approved for dwellings with a maximum of nine (9) rooms. If you have any questions, please do not hesitate to contact this office. Very truly yours, Sandra Starr, Administrator SS/gb cc: Copley Development BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 SEPTIC PLAN SUBMITTAL FORM LOCATION: J -0-T— 9 ee--) 1016 h�97r 4,A uC- NEW PLANS: YES REVISED PLANS: YES SITE EVALUATION FORMS INCLUDED DATE: S— 1 1—q $125.00/Plan $ 60.00/Plan YES LNO DESIGN ENGINEER: Hsi MA G K E5U61uOW-1 1 -CG DATE TO CONSULTANT: *If you want your plans expedited, please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Part Engineering. When the submission is all in place, route to the Health Secretary. r TOWN OF NORTH ANDOVER/ T� BOARD OF HEALTH_ FEB -I iM FORM 11 - SOIL EVALUATOR FOMI Page 1 Date....lb.....:7..-�i Commonwealth of Massachusetts WoZTH AWWVaR , Massachusetts Performed By:....W. I..LLi^ .I ....... Av-.Fh.-M-Si*4E................ ..... WitnessedBy:.::.:R.l:l!':A.w.:..STirR.:.:.::::::::.::.w::.:.::.:.w.::.:::::...::::::::..::..::::..::.::....:.:...:.:.::..:v..v�.....M.:�....w::.:::::::::.::.....::.: L'=11M Addrat OF Lar New Construction Pr Repair ❑ Office Review oma'. N&M. Addrcu. ud Sv , pco—%j D e I Ni gs TekpMtk 1 � MaTN LIf- Ki , " P► . o i Soy Published Soil Survey Available: No ❑ Yes Year Published ... Publication Scale 1.•..15�+n Soil Map Unit .Cb � Drainage Class ....�....... Soil Limitations .......Mad 9A. ..............................•........ n;tTo.4 Surficial Geologic Report Available: No ❑ Yes ❑ Year Published .....`. Publication Scale Geologic Material (Mp Unit)....—.............................................................................................................................. OF ..... Landform.......................................... .......................... Flood Insurance Rate Map: 'Z!;0)6 q 15 Flo L Above 500 year flood boundary No ❑ Within 500 year flood boundary No With Y Within 100 year flood boundary No .................................................................... . ...................... 4 oce>01(f, Yes �( Yes ❑ Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) .......O1 j......S.k..Tf,:r .DZ44 E T C,.4 ................ Wetlands Conservancy Program Map (map unit).................................................................................................... Current Water Resource Conditions (USGS): Month Av...605T- Range : Above Normal ❑ormal Below Normal El (PASSUM6-0 Other References Reviewed: V S 6.S i HAP -S 101 10 � FoRm it - SOIL EVALUANOR FORM Page 2 On-site Review Deep Hole Number .1 -1-100 Date: Time:Weather ............ Location (identify on site plan) .....�V-Z .... .... ME51-MIT-Ima ....... �'&Di . ...... ... . A . . ....... ..VT 1 ......................................... Land Use Slope ... Za.. Surface Stones .... ....................................................... Vegetation-D-fFZ ................................................................................................................................................................................................. Landform......i'. OZAJ-14e........................................................................................................................................................................ ...................... positionon landscape (sketch -on the back) ............ —= ................................................................................................................................. Distances from: Open Water Body ....... 1004teet Drainage way 1-00--t feet Possible Wet Area 100-f feet Property Line ..... 1.0 ± feet Drinking Water Well ..100-t feet Other ......................................... DEEP OBSERVATION HOLE LOG Depth from Surface (inches) Soil Horizon Soil Texture (USDA) Soil Color IMunsaill Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) Ott 60 A P s L I 26" Li . .. ....... 60AV- git— Z'K'! S-/9 JieF �N (P 17- -76 -2 e 6A1 P c rc'tO A OF 1"S. Parent Material Igeologic) 'A 6w.—, -A.8. .... . . �.J.J ........... .................................................... Depth to Bedrock: .... O/A Depth to Groundwater: Standing Water in the Hole: 11/4.- . Weeping from Pit Face: JWA... Estimated Seasonal High Ground Water: 9 iqo FORM 11 - SOII. EVALUATOR FORM Page 3 ❑ Depth observed standing in observation hole ....inches ❑ D pth 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....... ............................. Does at least four feet of naturally occurring pervious material exist in all.areas observed throughout tho area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on Jam' ' T� (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistentwith the required training, expertise and experience described in 310 CMR 15.017. Signature Date FORNI 12 - PERCOLATION TEST COMMONWEALTH OF MASSACHUSETTS Woel+t / LftVL2 , Massachusetts Percolation Test Date. J - `�.7 Time: . ...,.......................... Observation Hole Depth of Perc Start Pre-soak 10 End Pre-soak ; 2 b Time at 12" lo" 2S Time at 9" — =�v.sZ ; Time at 6" Time (9"-6") �-� Z , .. Rate Min./Inch Site Passed Site Failed ❑ ............................................ Performed By: tel Witnessed By: S V SA o Comments:......... Y SEPTIC PLAN SUBMITTAL FORM LOCATION: ADT w CfLI&MI GA 1_tI< (WALijvT LSIO&L Sod NEW PLANS: YES $125.00/Plan V REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: (AP NO DATE: DESIGN ENGINEER: HM)Z1 I -1A Ck'_ E5 . 6. 2-rQ111CF—S DATE TO CONSULTANT: Jrl *If you want your plans expedited, please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. t+ORTM A4, I �� Ot 4t�to t•s OOL n* of Nortb An T wn 060 f T AIMSE q 'l SSACH�f � Y OpME f street COIN 21 chat les ' cwFax $etts 01g45 918) 688-95 42 North Andover, Massa t ,1 �,L1AM J SCOL Director 1 688-9531 p ebruary 25' 1999 Les m c En�neerin� M 66 Park Street 01910 01810 Andover' lots 1'10 Cricket Lane ropo$ed for the e septic systems P • reasons. Mr. Godiri. for th e f°ll°wing e plans, for th 'Deal form yoxj that been disapproved 10 inches This is to in ut Ridge have imiiiYi of 0 o f W ala Ia the tees. (31 let tee e' terldinabove subdivision e Ila etail ow does not there nee s to be a 3 inch spaces. (310 CNU • The septic tank I. ive,not that (1) 5 feet o f the septic system I below the f i 6 and 15 ? o� Within C� 15-22 no benchm arks sh • There 15.220(q))- Lot (3100 addition for Lo A 802�):iing" all axe missing• 1 In s are not shown- o osed Teta: AbuheTsI name s for the pr P • s ecification • Desi p as to be located in the 15.255(2)) 3 •. chamber isnot specified For Lot for the pump 255(2)) iniTniam abam e alarm 310 CNIR l 5 8% and at m ` i h water 15 231(9)) Lot 4.11 be iIi excess of plea$e consider a The h g M 3 (a» house. (310 ent is required from es 5 232( ) lope ease Of two lower tren� ty (310 Cie trenches S e of the e veto o to The slop decrease th end of the tw aired to at the high Is req reducer velocity pyTH 688-9540 CONSgRV ATION 688-9530 _ _ _ _ ------ 688-9545 � -- --------------------------------- -- ---- AppE?+LS 688-9541 -- --- - BOARD OF ---- -- I PL�iN G 6g9-953 Lot 4: • Please note that the septic tank is drafted incorrectly. Lot 5 and Lot 6: • Scale of the Plan view is not shown. Lot 7: • The scale of the Plan view is not shown. • Pump Note #4 neglects to state that the high water alarm is to -be located in the house. (3 10 CMR 15.231(9)). Lot 8: • The estimated seasonal high water elevation- has not been adjusted to the highest existing grade. This results in the leaching area being less than 4 feet to groundwater. (3 10 CMR 15.212 a&b). Lot 9: • Slope easement required from Lot 10. (3 10 CMR 15.255(2)) • Slope to d -box exceeds 8%, therefore, at minimum, a baffle is required. (3 10 CMR 15.232(3)(a)) Lot 10: • Fill around system runs to property line of abutter. Toe of slope required to be 5 feet off the lot line. (310 CMR 15.255(2)) • Trenches # 1 and # 1 do not show 4 foot separation to groundwater. (3 10 CMR 15.212 a & b). Please feel free to call the Health Office with any questions you may have. Sincerely, Sandra Starr, R.S. Health Administrator Cc: W. Scott File TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: q 'I-I-boL YSTEM OWNER &j ADDRE Pf� 1 t© Cd �C�t� LV (example: left front of house) lex baA DATE OF PUMPING: L4—1-1 r�UANTITY PUMPED C ` GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: UO-T-e;OtA 74kl- COMMENTS: CONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) TOWN OF NOR SYSTEM PUMP DATE: It—to--cy ;TEM OWNER & ADDRESS lc -L -V\ [ ANDOVER ,T:.- G RECORd % NOV 19 2004 TOWN OF NORTH A vDOVER HEALTH DEPAR !v?ENT (example: left front of house) DATE OF PUMPING: CLQ ljn-�%QUANTITY PUMPED Z-L`2�e—�GALLONS CESSPOOL: NO L ---YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE V EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) Commonwealth of Massachusetts LEALTH ® City/Town of System Pumping Record 007 rForm 4 NDOVER MENT DEP has provided this fort for use by local Boards of Health. Other fout the information must be substantially the same as that provided here. Before using this fort, 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 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 1�1 rsu�v 1. System Location: Address D LV \. . A-/ r Cityrrown State Zip Code 2. System Owner: 99P-4LA (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State 7"S_Q3 J a Code Telephone Number Date t `q�2. Quantity Pumped Cesspools)eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditionof�m:u"� 6. System Ru :l Name Company 7. Signature Conten re L"1--1 2 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of w° System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. DEP has provided this form for use by local Boards of Health. Oth information must be substantially the same as that provided here. local Board of Health to determine the form they use. The System the local Board of Health or other approving authority. A. Facility Information RECEIVED I No r forms maykJuS668but i e I wo PI S this form, the with your bO¢�i4r�ro�t,bebmitted to 1. System Location: Left fron, e rea , left sidef ous . Right front, right rear, right side of house. Address P (/' , i. C� / Cityfrown State Zip Code 2. System Owner: S ) P � Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: 0 0 Other•(describe): atatJ W Telephone Number v Date 2. Quantity Pumped Cesspool(s) _ eptic Tank Gallons [] Tight Tank 4. Effluent Tee Filter present? 0 Yes Eg-lq—o-� If yes, was it cleaned? 0 Yes [j No 5. Condition of System: Lo_�J> � CA 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L.S.D Lowell Waste Water F 5821 Vehicle License Number of Hgruj�r Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1