HomeMy WebLinkAboutMiscellaneous - 100 OLD CART WAY 4/30/20189
WATER SUPPLY: TOWN WELL
WELL PERMIT DRILLER
WELL TESTS: CHEMICAL DATE APPROVED
BACTERIA I DATE APPROVED------
FORM
PPROVED____
FORM U APPROVALS APPROVAL TO ISSUE YES NO
DATE ISSUED BY�c�/2
CONDITIONS:
FINAL APPROVALS
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
SEPTIC SYSTEM CONSTRUCTION APPROVAL
..OTHER
ANY VARIANCE NEEDED
FINAL BOARD OF HEALTH APPROVAL:
YES NO
YES NO
YES NO
YES NO
NO
DATE :/�/46f� BY: "
APPROVAL TO BACKFILL: DATE: -Liz
BY_
FINAL. GRADING APPROVAL: DATE
BY
FINAL CONSTRUCTION APPROVAL: DATE:iz�� _BY
.J
1 �Boayd of Health
North Andover, Mass
I61DIla
�t a
Water Su 1V Town own Well Approved Date
S.S. Septic System Design
Approved Date yF/?6 ry /)
Approving Authority
Lot I%
Applicant
CONDITIONS+
Disapproved Date
Reasons=
DWC Septic System Installation
Excavation Inspection Date
Pass
Final Inspection
Approved Date
Additional Inspections (if any)
Disapproved
Final Approval
Date
Reasons
Fail
Approving Authority
Dare Approving Authority
1.
2.
CHECKLIST FOR
PLAN REQUIREMENTS
FOR
SUBSURFACE SEWAGE DISPOSAL SYSTEMS
TOWN OF NO. ANDOVER BOARD OF HEALTH
MARCH, 1990
Loc,us__Map (Suggested Scale: 1 " = 2000, )
Locus identified.
__— ___B• Streets and names within 1/2 mile.
_..__C. North arrow and scale
Site Plan. (Suggested Scale: 1" = 20')
A. Lot to be served, its dimensions and area.
B. Fronting street.
C- North arrow and scale.
D. Assessor's designation.
._E. Abutters names and lot numbers.
Easements.
Property lines.
_H. Footprint of proposed house to be served showing
garage (attached or detached).
Where applicable setbacks to house.
Number of proposed bedrooms.
Location and type of material (if known) of
driveway.
_._.L• Water service line from main in street srrz-
_M•
Location of existing or proposed well.
_.N. Location of deep observation holes and percolation
tests.
O. Existing and proposed contours.
_P. Bench marks (2) and ties to proposed system
leaching facility .from bench marks or other
permanent physical features (stonewalls, etc.)
`O. Location and dimensions of sy tera (septic tank,
pipes and leaching facility) including the reserve
area.
___._...R. Profile and section arrows.
Location of any streai,is, water, bodies, surface and
subsurface drains, known sources of water supply
within 200 -feet, and wetlands within 100 -feet
(locate wetlands, specify type of resource and show
100 -foot buffer zone line if applicable).
_ T. Erosion control devices as required by Con. Comm. ,
Board of Health or Planning Board with detail arrd
description of device proposed.
3• Desiyn_Calcul_a_t ions_and.._No.tes.
A• percolation rate used for design.
B. Soil log results - designate various strata depths
and description, depth to ledge and/or groundwater
if encountered.
C. Date of percolation and deep hole tests.
Number of bedrooms.
til Calculations for leaching area requirements.
4. Profile of_Sst_em (Suggested Scale: 1" = 41 )
A. Finished floor of house.
--
B. Invert elevations at house, septic tank (inlet t�
outlet), and distribution box. If applicable for -
pump systems, inlet and outlet of pump chamber and
Pump bloat switch settings with supporting
calculations.
-----C. Length, type and grade of pipe and length of
leaching facility.
__.__._..D. Elevationof ledge and/or groundwater.
_.E• Elevation of bottom of leaching facility.
Existing and proposed grades.
__ _ _�.__.G• Slope (breakout) requirement and calculations.
_H. Scale.
5. Cross=Section of System (Suggested Scale: V
6.
A• Elevations of various components.
_B. Existing and proposed grades.
C• Type, dimensions and stone and system components
specifications.
A Elevation of ledge and/or groundwater.
E. Elevation of bottom leaching facility.
F. Dimensions.
G. Slope (breakout) requirements and calculations.
H. Scale.
et A....1 s
Owner? s name, address and phone number.
B. Applicants name, address and phone number.
_C•
Engineer's name, address and phone number.
D. The designer should indicate any notes or special
conditions peculiar to the site of interest to the
Board, Installer, or Owner.
E. plans should be dated. Any revised plans after the
initial submission should show a revision date and
abbreviated explanation of the revision.
F. If a pump system, type, make, model, operation head
and pump rates should be provided. All required
alarm, power and float switch data should be
provided for review and approval.
............. ... ........ G~ System components (sOptic tank,
r D -box etc.)
details should be provided if other
'
than standard
as required from local supplier/- C
Should be indicated somewhere �^ Component spec
standard items, on the plans for
Reviewed and recommended by:
____
Da�e --'------
REVIEW FORM
FOR
SUBSURFACE SEWAGE DISPOSAL SYSTEM PLANS
TOWN OF NORTH ANDOVER BOARD OF HEALTH
OWNER - NAME:
ADDRESS:
PHONE:
--- ... . . ............... . . ......
.A.P.PL ICAN.T.
NAME:
ADDRESS:
PHONE:
ENGINEER
NAME:
ADDRESS:
PHONE: 7 j
PROPERTY. -PLAN DATA
ASSESSOR'S MAP___ _LOT
STREET LOCATION —& PLAN DATE
.REVIEW COMMENTS
CHECKLIST DEFICIENCIES
. .. . . . .... .... ........
OTHER -
RE-QOMKERQRjI.Q-N-S
RECOMMENDED DENIAL
REASONS
REASONS (CONT.)
........ ... ....... . . ......... ...
. . . . ........ ............ ........... ............ . ............
RECOMMENDED APPROVA
CONDITIONS/COMMENTS
.: �,'�;N�,y.♦��r%•tib, •jt a 4 !•Sri �,'nf.'^.�',4': '• '', .
ti -.4. •pct \. t'�i♦t�� .r�f''d�jt�i'1�.1i',�'•'a'••"" .
JAN 0 6 2005
TOWN OF AUK I'ti ,�
V.1 I't /a .` 5 Y9'1'�t,.I PIJMPIN 4"N•OF NORTH ANDOVER
.,!,Ci
(1 _ Zj LTH DEPARTtJENT
i1"'3rgM p QR � �{7DR�5s "_'"_"-~�5,�•--- FMi:�.� ; ::;�..__ ......__.....___.
/oo _G59_�
DAA OF PIAN
.14
POOL. NO /
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N� rvKtt Or s�RYlc,�e: xvvrlN�.•���tnu,:,tit, , • .
ub�>j�Y�'fiUNJ.
OOOp CO�pI'I'IUN ,,VY
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Ramis ; drtl' U IN
BXC�\98rY8 sOl,lpe ♦\_.. PLOOD p0
K�NBn�'►. .
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1
NEW ENGLAND ENGINEERING SERVICES
INC
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 100 Old Cart Way, North Andover, MA
Dear Sirs:
July 7, 2003
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
-6 (f o
Benjamin C. Osgood, J�—
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
COMMONWEALTH OF MASSACHUSETTS
I UV EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMETSN
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM..•
- PART A <<; ;.y
CERTIFICATION \`,`
Property Address: /oo i oc lACI? 4�702M 20 *D
A)L) (Z- .div �� DUc 2 M4
Owner's Name: _ H AtR U E'i G �- o v G -H '°�-�G• �t
Owner's Address: io,�o ;yc,K C R i�9/L+•t 0�0,40 �F �ifHVAEN-t�
ov
Date of Inspection: / 7J 03 g
e
Name of Inspector: (please print) Benjamin C. Osgood, Jr. e i.
CompanyName:N_ew England Engineering Services Inc. .1
Mailing Address: 60 Beechwood Drive
North Andover MA O1R45
Telephone Number: 9 7 8- 6 8 6 -17 6 8
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of 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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:/j _ l Date: 7/6 —�
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.
Notes and Comments
****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.
Page 2 of 1 I
r
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _ / oo -r-,,c ACA Fh(Livt WD
No W-0-1 AN D nye A -u .4
Owner: N #+2%j ey c o�vN
Date of Inspection: 7 f -l/ 0'4
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
'4 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
L The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes,ot determined (Y,N,ND) in the for the following statements�'ot determined" please
explain.
The septic tank i etal and over 20 years old* or the septic tank ( er metal or not) is structurally
unsound, exhibits substan I infiltration or exfiltration or tank failure ' inent. System will pass inspection if the
existing tank is replaced with complying septic tank as approv the Board of Health.
*A metal septic tank will pass in ion if it is structurally d, not leaking and if a Certificate of Compliance
indicating that the tank is less than years old is availab
ND explain:
Observation of sewage backup or cak t or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, ed or un en distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are il laced
obstruction is removed
distribution box is leveled replaced
ND explain:
K11he system required pumping more than 4 times a year due to
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
or obstructed pipe(s). The system will
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: L o o ruc x E2 64 w1
an�D ,je ,A /���
ivoazze
Owner: u H C Lo- &14
Date of Inspection: /- /„ a
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. Syste ' I pass unless Board of Health determines in accordance with 310 CMR 15.303( ) that the
system is of functioning in a manner which will protect public health, safety and the a 'ronment:
_ Cesspool 0)TrivY is within 50 feet of a surface water
Cesspool or p 'vy is within 50 feet of a bordering vegetated wetlanXaa
2. System will fail unless the Boar f Health (and Public W er Supplier, if any) determines that the
system is functioning in a manner that otects the public alth, safety and environment:
_ The system has a septic tank and soil a orpti system (SAS) and the SAS is within 100 feet of a
Surface water supply or tributary to a surface supply.
_ The system has a septic tank and S and th%SA n a Zone I of a public water supply.
The system has a septic tank d SAS and thn 50 feet of a private water supply well.
The system has a sept' tank and SAS and thhan 100 feet but 50 feet or more from a
private water supply we �. Method used to dete
"This system pp4s if the well water analysis, performed at a D certified laboratory,
bacteria and v atile organic compounds indicates that the well is fr from pollution from that facility and
the presen of ammonia nitrogen and nitrate nitrogen is equal to or I than 5 m rovided that no other
failure feria are triggered. A copy of the analysis must be attached to s forme p
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: joy, Tic rc�,2 �g,2 Cyt /Zo qp
Nb &TV
Owner: i -I i9-Rogy Lo J6 H
Date of Inspection: 77.1 7 / J
T
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
r Required pumping more than 4 times in the last year NOT due to clogged or obstructedpipe(s). Numberof 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 a1 or
cesspoo 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 a1 n
cesspoo 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
AI-2� (Yes/No) 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 now of 10,000 gpd to 15,000
gpd•
You m tindica'te either `yes" or `no" to each of the following:
(The foliow'"
ng criteria apply to large systems in addition to the criteria above) /
yes no
— — the system is in 400 feet of a surface drinking water
— — the system is within 2'1111,�eet of a tributary to
— -4.& ui1ace drinking water supply
— — the system is located in a
Zone II of a public wester
area (Interim Wellhead Protection Area - IWPA) or a mapped
If you have ans "yes" to any question in Section E stem is considered a significant threat, or answered
"Y�" in ►on D above the large system has failed. The own r operator of any large system considered a
significant threat under Section E or failed under Section D shall up de the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional offic f the Department.
Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: io.> ��Kc✓t F/1�.�,t /L�►4p
N� rti>i I
Owner: N Rcir'y LLOcJCr�
Date of Inspection:7if-7/Tz
Check if the following have been done You must indicate-,
or "no" as to each of the
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 uncover
of the baffles or tees, material of construction, dimensions, depth oed, and f liquid, depth of l he interior of the tank
aninsd depth of the
condition
Was the facility owner (and occupants if different from owner
maintenance of subsurface sewage disposal systems ? ) provided with information on the proper
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
/
Ii
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) [3 10 CMR 15.302(3)(6)]
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /ov
Ivo p-itl �jD 0--1 „Q_ .�.,✓+
Owner: H,4 (L�k.y trp�lG H
Date of Inspection: _ -7171 „ 2 -
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms desi
DESIGN flow based on 310 CM15.203 (for examof ple:: 1�l Os (actual):
Number of current residents: _'9
gPd x # of bedrooms): 60 o Ga [ s
Does residence have a garbage grinder (yes or no):."
Is laundry on a separate sewage system (yes or no):N [if
Laundry system inspected (yes or no): Yes
separate inspection required]
Seasonal use: (yes or no): Ato `—
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): _&Q
Last date of occupancy 4n r _C e' 7
COMMERCIAUINDUSTRUL
Type of establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/
r no): s/sgft,etc.):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no): _
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
Pumping Records GENE' INFORMATION
Source of information: Z' z w a-EKS
Was system pumped as part of the Inspect'on
If yes, volume um (yes or no): �/,�
pumped:
gallons — How was quantity Pumped determined?
Reason for pumping: —
TYPE OF SYSTEM
Septic tank, distribution box,
Single cesspool soil absorption system
_
Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ hmOvative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
Other (describe): _ _
Approximate age of all components, date installed (if known) and source of information:
1780
Were sewage odors detected when arriving at the site (yes or no):/4 �nSj2vc���
V O
Page 7 of i l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ! O c, —�K t2
Owner: --u�yif A&vo
H�QuEY ci-00 vty MA
Date of Inspection: -11
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of construction:'
Distance from private water cast yon 40 PVC —other (explain): —
Comments (on condition "joints, entin upply welf r suction line:
4 / .v r�z) 4' e'v, evidenAJO ce leakage, etc.):
SEPTIC TANK: _ (locate on site plan)
Depth below grade: (6 ",
Material of construction -concrete metal
_othar(explain) —fiberglass __polyethylene
If tank is metal list age; — Is age confirmed by a Certificate of Compliance (yes or no): ) — (attach a
Dimensions: ,, o copy of
p}c�s
Sludge depth"� G
Distance from top of sludge to bottom of outlet tee or baffl
Scum thickness: �_ e: 33"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee o
How were dimensions determined: r bade rrt r.�s�. 4 s
Comments(on
Pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,li liquid levels
as related to outlet invert, evidence of leakage, etc.):
AN 9, ! nV "'>;>
q
C >Ai
^LAS N �T'C� V fl
GREASE TRAP:11(locate on site plan)
Depth below grade:
Material of construction:
(explain): —concrete metal —fiberglass
--Polyethylene other
Dimensions: --
Scum thickness:
Distance from top of sc m o top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffl�_
Date of last pumping; _
Comments on pump -
as
( porn In recommendations, inlet and outlet tee or baffle conditionintegrity,
as related to outlet invert, evidence of leakage, etc.):
, structural liquid levels
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 00 —,, K r
At c 2?1Y A,
Owner. '' r4l2y CY c
Date of Inspection•
R"�o
MA
TIGHT or HOLDING TANK: A11- (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:
Dimensions:
concrete metal —fiberglass
----Polyethylene other(explain):
Capacity: oa lions
Design Flow: _ lIons/day
Alarm present (yes or no):
Alarm level: Alarm in workingorder
Date of last pumping: (Yes or no):
Comments (condition of alarm and float switches, etc.):
DIMIUBUTION BOX: (if present must be o
Pened)(locate on site plan)
Depth of liquid level above outlet invert: (�
Comments (note if box is level and di
leakage into or out of box, etc.): stribution to outlets equal, any evidence of solids cryover, any evidence of
Ca
PUMP CHAMBER:/ -(locate on site plan)
�Ji fl.D✓l�,v �Q.��l-- Nv eve
.� ac.vrF
Pumps in working order (yes or no): k
Alarms in working order (yes or no): L pL�
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
P
ART C
SYSTEM INFORMATION (continued)
Property Address:FA2M
._fL �f ,� ` lL
Owner: 7 n
-y� Ci-oo6m
Date of Inspection: 1 .�
2D
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, excavation not required)
If SAS not located explain why.
Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
Bleaching trenches, number, len
leaching fields, number, dimensions. Z 4-0
, in " c Nt s
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.):
"FYA ^C " . - __ n'
i A,L
'CESSPWLS:MA (cesspool must be pumped as part of inspectionXlocate 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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRI'V1'- i� (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.):
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: / 0,3 T-,) c i 2 F,4fZP
No
Owner: RTIC
1t, 2�ley 6-N
Date of Inspection•
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two
permanent reference
benchmarks. Locate all wells within 100 feet. Locate where public water suppyentthe building. dmarksor
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: lo,) TvcKg 2FA2 K IZD
12 alh OoGa u,4
Owner: H&avEY C -1,0.i"
Date of Inspection: :11:71 C, 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
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:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
ITNI OWNER & ADDRESS SYS I'E*M'LOCATION---.
(exam pie: -left-.fr-.-on t of house)
oy
Mll)
��`
L OF PUMPING: QUANTITY P U.M 1) F Q/ G.A L L
L: NO y F s S F PTI CTA N K: NO y1,
V\TURE OF SERVICE: ROUTINE EMERGENCY
13 S FR \ IATI 0 N S:
GOOD CONDITION ✓
I I FA V y G R E 'A S F
ROOTS
EXCESSIVE SOLIDS
-SOLIDS CARRYOVER
M PUMPED 13Y:
C. I.N I ENTS:
(. ON FE'NTSTRANSFERRED TO:
FULL, TO COVER
BAFFLES IN PLACE
LEACIIFIELD RUNBA(..'K
FLOODED
O'I'll ER (E X 1) LA I N)
� r'`•
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION
APPLICANT J06, * ��,�,.,� �2/� PHONE ii - 7-(66�
LOCATiON: AzSe--S ; s Map Number—,!Y' PARCEL_ � ` 5—,
SUBDIVISION LOT (S)
STREET_/ UU 01J .CA lLr A 4 ((� ST. NUMEER 0-b
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS: _ yAP-
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE- REJECTED
COMMENTS
TOWN PLANNER
1
1'
COMMENTS
FOOD INSP.ECTOR-,!-�F
DATE APPROVED
DATE REJECTED_
TH DATE APPROVED
DATE REJECTED
INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
PUELIC WORKS - SEINERJWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED EY EUILDING INSPECTOR DATE
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AS PREPARED FOR
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DATE: IJOVEMBER I(o, l495'
SCALE: 1" = qd
- LOT I67 OLD GAIT kj/Z r
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS.
bb PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (gb@) 475 3355, 373-5721
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LOCATED IN
NORT}+ ANDO\/ER , MA.
AS PREPARED FOR
LEN C ETT'/
DATE: IJOVEMBER I(o, l495'
SCALE: 1" = qd
- LOT I67 OLD GAIT kj/Z r
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS.
bb PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (gb@) 475 3355, 373-5721
E!
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41
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,SS�ICMUSEt•A
Applicant_
NA
Site Location
Town of North Andover, Massachusetts Form No. 3
BOARD OF HEALTH
C)I-0 y 19
DISPOSAL WORKS CONSTRUCTION PERMIT
1-1- 1 l., d
Permission is hereby granted to Construct 1�4 or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
� A
Fee D.W.C. No.
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: t Phone:LP- — 2 7F
LOCATION: Assessor's Map Number [,'-7 Parcel
Subdivision Gv A Zq 1 k- - Lots)
Street C� 1 CL. `� - f St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Date Approved
Date Rejected
Date Approved
town Planner Date Rejected
Comments
Food Ins�pector-Health
Septic Inspector -Health
Comments
Public Works — sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
DATED Z
Sheet
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
of
SUBSURFACE
DISPOSAL
REVIEW
qJ/
FEE_ &) PERMIT
/DESIGN
# �o
DATE
RECEIVED /o /Q/Z,
APPLICANT
ADDRESS
ENGINEER .1,�,C�,�'j/�'J/aC
ADDRESS
ASSESSOR'S MAP 12)7-Z
PARCEL #
LOT #
STREET
PLAN DATE REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED A-
1,/N2T�'-'� TE57
EQvi REP,
A
Town of North Andover, Massachusetts Form No. 2
f MORTIS BOARD OF HEALTH
F w
P
*moi
•'''��-����-++++---- DESIGN APPROVAL FOR
SSACM°SES SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Site Location (t a 04--& cal �jj� --
Reference Plans and Specs�nlm n
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 6&6'
PLAN REVIEW CHECKLIST
ADDRESS ,L, /,,/ 0GD C.9Pr Z�- A'Y ENGINEER //y/ cgl? /2C/l
GENERAL
3 COPIES STAMP L/ LOCUS L/ NORTH ARROW SCALE
ge-
CONTOURS L/ PROFILE L/ SECTION BENCHMARK �SE�` SOIL &
PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS &
WETLANDS WATERSHED? /U0 DRIVEWAY L�--( Elev) WATER LINE �--Y
FDN DRAIN L/ SCH40� TESTS CURRENT? q8�p
SEPTIC TANK
MIN 1500G. l,-' .17 INVERT DROP �._ GARB. GRINDER_A (+200% EDF)
25' TO CELLAR MANHOLE TO GRADE C/ ELEYOL GW
D -BOX
SIZE /3 # LINES -L FIRST 2' LEVEL STATEMENT L�
INLETa /--5-6.5- OUTLET gj,- . ¢,q = 17 ( 2" OR .17 FT) TEE REQ' D? /Y v
LEACHING
RESERVE AREA 4' FROM PRIMARY? L,--"' 100' TO WETLANDS v 2% SLOPE L--'
100' TO WELLS ✓ 35' TO FND & INTRCPTR DRAINS L- 4' TO.S.HH.GW ��
325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY Y
MIN 12" COVER L --'-'FILL? ✓((25' above natural elev; 101if below)
BREAKOUT MET?
TRENCHES
MIN 660 gpd - SLOPE (min .005 or 6"/1001) v >3' COVER? - VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN
TRENCHES? IN FILL? �^ MUST BE 10' MIN.'S 4" PEA STONE? 61C
BOT 1qo X LDNG + SIDE 660 X LDNG = TOT
(L x W x #) (G/ft2) (DxLx2x#) e90used - /DerG -,4711„_.
r 3ZO r 7,1
TOWN OF NORTH ANDU 4Ek JAN 0 6 2005
I I A I'l./ SYSTEM pUMpj CORD
SYS EM OWNER ADDRESS
161 (Ir7_ wa
SYSTEM LOCA I JON
&Gk
DA.1E0FPVMMNQ:
PUMPED:
�:b$SPOOL: NO_.� Sop(ic Tank: Nu ye . s
NA rURU OF SERVICE: ROUTINE
011SURVA'nON&
GOOD CONDITION .. .... ... FULL 'ro COVER
Huyy ov.WE BAFFLES IN PLACL
.ROOTS w LEACKPIELD RUNBACK
OXCUSSIVE SOLI]DS.__. FLOODED
-SOLID CARRYOVER„._, 071fER EX P L A IN
systvm Pump,,d by
0hc...32/
VUMMENTS.
PEN'I'S rKANsybituD I'L,
m
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ild 1 /Tntein.tnfr111AQTIJ'J4��/A 11 1511-1.1, RNA e+C%
��,SystemrPumping Recird'
` "lJ&. has'provided this form for use by local Boards of Health.
be submitted to the.local' Board of Health or other approving a
' A: Facility information
,Wt n r�ilun9 out', :1:'. System Locatlon•''
forma. on the
computer;use r�0 -- M�z C
only the tab key Address
f f ✓
v
4CHUSETTS
.,RECEIVED*'
MAY '0 6 2009 .
he System Pumping Rec rd must
TH
to move your.:: y%�il1CD� U
cursor • do not • -
.; ''use the return'::_ Clty/Town : , • :. State ZIp Code
k 2 :.System Own'er'.","'
or L ... F Name`.
' �; •.•::;,,.,".:'.. r.': ;,, r.,,::,.;.:. . • J. Viii'/c•(C� � ..
Addra" (If different from location) ;
City/own.; State Zip Code
Telephone Number
as
Pumping, Ftecord:
.a 1 Date of PumpingDate 2• Quantity Pumped:
,. Gallons
.3 ;Type of system:. ❑ Cesspools) ❑ Septic Tank
J.. P ❑ Tight Tank
t . ❑' Other (descrlbe)
.: 4 Effluent.Tee Filter present?, ❑ Yes. ❑ No' Ifyes, was It cleaned? ❑ Yes ❑ No
r 6 Syry em Pumped BY
{ , Name ; : , _ rx ;:..•,r� Vehide- Llcen a Number
� rd < J r. r r)r, ,� t, ;r,t .n•i�a +i' (",. ... o �• /1
n / U ,
Sr, Company• �•,.�.,, , ,.
1 '• rl f< 1 hrf'.'V r+ly.\SW .. M1 f Y-..� �•• ,
" :� ' 7 ' Location where contents
,.� • � were disposed:
� - rS i r : rti o n' ���/// ��./XXYYJJJJ �-`-+�ylWVj'• T � . ///Y
� / S r i �,r\.rat -a '.1F X+ ;,a4 kr,^' ,. ••,..' It tl ,';''Y •.. " 2�� ..
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lure of Hauler
DateSigna
:mas.gov/depMater/approvals/t5forms.htm#inspect
t5forrM.doa'06/03 System Pumping Record • Page t of 1