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Miscellaneous - 1000 FOREST STREET 4/30/2018 (2)
W 0 0 0 T 0 x m m m m rt Commonwealth of Massachusetts E BOARD OF HEALTH North Andover P.I. J�(� I � tit F.I. Vfl Cl � DISPOSAL WORKS CONSTRUCTION 1 1.:,111v111 Permission is hereby granted John-SOUCy--------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 1000 FOREST STREET - ---------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2013-060 Dated March 20, 2013 _______________________. Issued On: Mar -20-2013 OF HE LT- SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ )< Title 5 Report $�cJ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 0 4 L. O, MOR7 :7y O . = Town of North Andover HEALTH DEPARTMENT CIN CHECK 4 5 DATE- 5 11 Vt V V LOCATION: V H/O NAME: r n CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ )< Title 5 Report $�cJ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab t5ins • 11/10 Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form APR 09 2013 Subsurface Sewage Disposal System Form - Not for Voluntary Assessment TOWN OF NORTH ANDOVER 1000 Forest Street HEALTH DEPARTMENT Property Address Lisa Min Owner's Name North Andover MA 01845 03/26/13 City/Town State Zip Code Date of Inspec I Inspection results must be submitted on this form. Inspection forms may not be altered iral way. Please see completeness checklist at the end of the form. A. General Information Inspector: John Soucy Name of Inspector Soucy's Sewer Service, Inc. ; Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner's Name North Andover MA 01845 03/26/13 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 =�1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner's Name North Andover MA 01845 City/Town State Zip Code B. Certification (cont.) B) System Conditionally Passes (cont.): 03/26/13 Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 �i Commonwealth of Massachusetts - Title 5 Official Inspection Form I_ ili Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover required for every — -- page. City/Town t5ins • 11/10 B. Certification (cont.) _ MA 01845 State Zip Code 03/26/13 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes' In Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 03/26/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes' In Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °wM 1000 Forest Street C. Checklist MA 01845 State Zip Code 03/26/13 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Property Address ❑ ® Lisa Ming Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist MA 01845 State Zip Code 03/26/13 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® E] Was the facility owner (and occupants if different from owner) provided with Was 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 • 11110 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 1000 Forest Street D. System Information Description: MA 01845 03/26/13 State Zip Code Date of Inspection Property Address ❑ Lisa Ming Owner Owner's Name information is required for every North Andover page. City/Town D. System Information Description: MA 01845 03/26/13 State Zip Code Date of Inspection 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 Number of current residents: 2 ❑ No Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� Well Detail: Sump pump? ❑ Yes ® No Current Last date of occupancy: Date 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 t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover MA required for every page. City/Town State D. System Information (cont.) Last date of occupancy/use: Other (describe below): 01845 03/26/13 Zip Code Date of Inspection Date 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: 2010 gallons ❑ Yes ® No Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover MA 01845 03/26/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): 2 Depth below rade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 100' feet Comments (on condition of joints, venting, evidence of leakage, etc.) Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 12" 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) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Insp Subsurface Sewage Disposal System Fo 1M , 1000 Forest Street D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 0" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 0" Distance from bottom of scum to bottom of outlet tee or baffle 0" How were dimensions determined? N/A Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank replaced see permit. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 11/10 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 ection Form rm - Not for Voluntary Assessments Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 03/26/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 0" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 0" Distance from bottom of scum to bottom of outlet tee or baffle 0" How were dimensions determined? N/A Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank replaced see permit. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 11/10 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 03/26/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): New tank installed, tested new inlet and outlet tees W/gas baffel. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M . 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) MA 01845 State Zip Code 03/26/13 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.): Resealed "D" box and pipes with hydraulic cement, flow checked good. 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ec^M 1000 Forest Street State 01845 Zip Code 03/26/13 Date of Inspection D. System Information (cont.) Property Address Type: Lisa Ming Owner Owner's Name information is North Andover required for every number: page. City/Town State 01845 Zip Code 03/26/13 Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 20'x45' 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.): No siqns of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 03/26/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts w= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1000 Forest Street MA 01845 03/26/13 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Property Address Lisa Min Owner Owner's Name information is required for every North Andover page. CitylTown MA 01845 03/26/13 State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins • 11/10 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 1000 Forest Street D. System Information (cont.) Site Exam: ® Property Address ® Lisa Ming Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 03/26/13 State Zip Code Date of Inspection LSI Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: W/ 3 LI Obtained from system design plans on record 4/7/1979 If checked, date of design plan reviewed. Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Dug hole with auger in low drop off area, 4' no water, 2' elevation difference. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,^M 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover page. City/Town MA 01845 State Zip Code E. Report Completeness Checklist 03/26/13 Date of Inspection ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 „Ltp.// wro-mai 1.coiiicast.nevservice/lioi-ne/'—/20130320110755748.1. .. ......... . Commonwealth of MassachLISett-, 1) 0 cl 5) Z9 BOARD OF I -H HEAI North Andover 81-ip "D 3-Cir�o I P.I. F. 1. .. ........... Sl 2 5 �'i 1000 FOREST ST',',lFJ"f lilt, TiPP-201,34,16o Oallcd i k. It 20� 2(;i 011” . ..... . .... . .......... ...................... . ..... .... ........ 1 of 1 3/20/2013 11:42 AM Soucy - Test Certificate.pdf Manufacturer Of Septic Tanks Bulkheads Concrete & Brick Steps Manholes Catch Basins Dry Wells Bumper Blocks Well Tiles ReCon Retaining Walls http://web.mai].comcast.net/service/home/—�/Soucy- Test Certificate \, STATE CERTIFIED .+ �' PLANT / SHEA..CONCRETE PRODUCTS ' New England's Premiere Precasfer! UPCH Bulkheads Precast Steps rivi f':`o PLANT 800-696-SHEA (7432) 773 Salem Street } P.O. Box 520 �sl Wilmington, MA 01887 Manholes (978) 658-2645 Fax (978) 658-0541 Septic 'Tank Test Certificate Date: March 28, 2013 To: Michele Grant North Andover Board of Health 1600 Osgood St (Unit #2035) North Andover, MA 01845 (978) 688-9540 Fax (978) 688-8476 RE: Testing of Septic Tank 1000 Forest St North .Andover, MA Michele: Septic Tanks Contractor: Soucy's Sewer 1000 Forest St Salem, NH 03079 603-898-9339 We certify that the tank delivered to the above job (1500 gallon 2 -piece septic tank) passed Title 5 requirements for leakage as stated in the ASTM 01227 specification. If you should have any questions, please feel free to contact me at 978-658-2645. Thank you amey Robichaud Engineering cc: Soucy's Sewer, 78 North Broadway, Salem, NA 03079 1 of 1 3/28/2013 8:44 AIV Member of Septic Tanks Contractor: Soucy's Sewer 1000 Forest St Salem, NH 03079 603-898-9339 We certify that the tank delivered to the above job (1500 gallon 2 -piece septic tank) passed Title 5 requirements for leakage as stated in the ASTM 01227 specification. If you should have any questions, please feel free to contact me at 978-658-2645. Thank you amey Robichaud Engineering cc: Soucy's Sewer, 78 North Broadway, Salem, NA 03079 1 of 1 3/28/2013 8:44 AIV 20130402105207885.pdf http://web.mai i.comcast.net/service/home/—/20130402105207885.pd... PU13LIC HEALTH DEPARTMENT Town of Not -tit Andover coninxttnity Development Division CERTIFICATE OF COMPLIANCE As of: 3/27/2013 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Septic Tank and Pipe Only By: John Saucy At: North Andover, MA 01845 The Issuance of this certificate shall clot be construed as a guarantee that the systerii will function satisfactorily. Susan Sawyer Public Health Agent 1600 Os#good Street, North Andover, Mossnchuselts 01845 Phone 918.688.9540 fox 918.688.8476 Web www.townofnorthnndover.com 1 of 2 4/2/2013 11:30 AM 20130402105207885.pdf nomorm—_ http://web.mail.comcast.net/service/home/—/20130402105207885.pd... PUBLIC HEALTH DEPARTMENT Town of North Andover CoInInuility Mvelopment Division CERTIFICATE OF COMPLIANCE, As of: 3/27/201.3 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Septic Tank and Pipe only By: John Soucy At: 1000 Forest Street Map 105D Lot 0059 North Andover, MA 01845 The ISSU 110� Of this certificate shall not be construed as a guarantee that the system will function satisfactorily. it us, it Sawy9i Public Health Agent 1600 Osgoo(l Street, North Andover, Wissa(husetts 01845 Phone 978.688.9540 Fox 978,688.8476 Wel) www.toy4ilofnortilall(lovef,conI 2 of 2 4/2/2013 11:30 AM PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of 3/27/2013 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: Septic Tank and Pipe only By: John Soucy At: 1000 Forest Street Map 105D Lot 0059 North Andover, MA 01845 Alssuofhis certificate shall not be construed as a guarantee that the system will function satisfactorily. Public Health Agent , 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 03/28/2013 16:39 Soucy -'fest Certificate.pdf Manufacturer Of Septic Tanks Bulkheads Concrete & Brick Steps Manholes Catch Basins Dry Wells Bumper Blocks Well Tiles ReCon Retaining Walls 6038981876 SOUCV SEWER SERVICE PAGE 01101 http://web.mail.comeast.net/service/home/—/Soucy - Test Certificate.... STAVE CERTIFIED SHEA PLANT CONCRETE PRODUCTS New England's Premiere Precasted 10 '0#4npca Bulkheads Precast Steps cm tmo nANr $00-696SHEA (7432) f 773 Salem Street P.O. Box 520 o Wilmington, MA 01887 ly Whales (978) 858-2845 Fax (978) 658-0541 Septic 'Funk Fest Certificate Date: March 28, 2013 To: Michele Grant North Andover Board of Health 160o Osgood St (Unit #2035) North Andover, MA 01945 (978) 68$-9540 Fax (978) 688-8476 RE: Testing of Septic Tank 1000 Forest St North Andover, MA Michele: Member of Septic Tanks 1� Contractor: Si s 603-898-9339 MAR �.� w°�1R i r. riiVv�.SVER We certify that the tank delivered to the above job (1500 gallon 2 -piece septic tank) passed Title 5 requirements for leakage as stated in the ASTM C1227 speacation. If you should have any questions, please feel free to contact me at 978-658-2645. Thank you amey Robichaud Engineering cc: Soucy's Sewer, 78 North Bmadway, Salcm, NH 03079 1 of 1 3/28/2013 8:44 AM 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 k�eyy. "V l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner's Name North Andover City/Town MA 01845 State Zip Code 03/05/13 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: John Soucy Name of Inspector Soucy's Sewer Service Inc. Company Name 78 N. Broadway Company Address Salem NH 03079 City/Town 603-898-9339 Telephone Number B. Certification State 13397 License Number Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: - ❑ Passes ® Conditionally Passes ❑ Fails rther Evaluation by the Local Approving Authority 03/05/13 Date Kw-%, . 3' 2013 TOWN OF NORTH ANDOVER HwALTH CE PART.' =— ' f The system inspector shall submit a®copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner's Name North Andover MA 01845 03/05/13 City/Town 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. t5ins • 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal, System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner's Name North Andover MA 01845 03/05/13 City(Town 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 obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): 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 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 1000 Forest Street Property Address Lisa Ming Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 03/05/13 State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The -system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins • 11/10 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 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover MA 01845 03/05/13 required for every --- page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 03/05/13 page. City/Town 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 03/05/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� Well Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available t5ins • 11/10 Title 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 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 03/05/13 State Zip Code Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date 2010 ❑ Yes ® No gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street M Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 03/05/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2 CYz5 — ,� 14 Were sewage odors detected when arriving at the site? ❑ Yes ® No 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: 100' feet Comments (on condition of joints, venting, evidence of leakage, etc.) Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 12" 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) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 03/05/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" 9.. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): *Septic tank not holding normal static level. 2 1/2 below outlet invert. (retested 1 day later with normal water use.) Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 11/10 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover MA 01845 03/05/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M , . 1000 Forest Street D. System Information (cont.) nnn 01845 Zip Code Distribution Box (if present must be opened) (locate on site plan): 03/05/13 Date of Inspection 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.): flow checked ok, some solids carry over in leach & field pipes. 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Property Address Lisa Ming Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) nnn 01845 Zip Code Distribution Box (if present must be opened) (locate on site plan): 03/05/13 Date of Inspection 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.): flow checked ok, some solids carry over in leach & field pipes. 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover required for every page. City/Town 03/05/13 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 20'x45' 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.): No signs of hvdraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is North Andover required for every page. City/Town MA 01845 State Zip Code 03/05/13 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 • 11/10 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 1000 Forest Street Property Address Lisa Ming Owner's Name North Andover MA 01845 03/05/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately INVERT 6L_EVAEM!1Ay_':'5 A rIT A100.56 1 1L /37 goo ou7 � � - 1 375' 33 Alb OF 89b - . , 3 /,37.1-1 t5ins • 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 1✓ t5ins • 11/10 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 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Ed h h' h d t' Ld 03/05/13 Date of Inspection stimated ept to Ig group wa er. feet Please indicate all methods used to determine the high ground water elevation: 21 Obtained from system design plans on record If h k d date of desi n Ian reviewed 4/7/1979 c ec e , g p 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: Dug hole with auger in low drop off area, 4' no water, 2' elevation difference. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1000 Forest Street Property Address Lisa Ming Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist 03/05/13 Date of Inspection ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 U North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 1000 Forest Street MAP: 105D LOT: 59 INSTALLER: John Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 3/27/131C_,in DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan X Bottom of tank hole has 6" stone base ❑ Weep hole plugged X 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction - NO ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: X Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port X Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ❑ Installed on stable stone base ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) Street & Trench Opening Permit.pdf ,t -, http://www.townofnorthandover.com/Pages/FVI-00024FEC/Street &... Town of North Andover Pursuant to Policy & Town Bylaw Chapter 161-3 Street Excavation permit (as amended) With PERFORMANCE BOND AGREEMENT AND The Commonwealth of Massachusetts Jackie's Law— Trench Permit Pursuant to G.L. c. 82A §1 and 520 CMR 14.00 et seq. (as amended) PERMIT APPLICATION — Street Permit Number - Dig Safe Number: SITE EMERGEN( iening Permit Wor Trench Permit Applicant: Date Issued: Commonwealth of Massachusetts BOARD OF HEALTH North Andover CERTIFICATE OF COMPLNCE THIS IS TO CERTIFY, That the I ivi 1 Sewage Disposal yste (Repair) by ...Jahn Soucy --------- Map-Block-Lot 105.D0059 ----------------------- -----------------%-----------------•----%-------------f------------------------ at No 1000 FOREST STREET has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. -BHP-2013-060------ --- Dated March 20, 2013___--- ------------------- Printed On: Mar -20-2013 BOARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot 105.D0059 BOARD OF HEALTH - Per -mi --t - No ----------- North Andover ---- -- - BHP -2013-0601 ------------ FEE DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John_Soucy------------------------------------------------------------- $125.00 to (Repair) an Individual Sewage Disposal System. at No 1000 FOREST STREET as shown on the application for Disposal Works Construction Permit No. BHP -2013 60 Dated'March 20,,-2013 U Issued On: Mar -20-2013 BOARD OF HEALTH Street & Trench Opening Permit.pdf http://www.townofnorthandover.com/Pages/FV1-00024FEC/Street &... Competent Person as defined by 520CMR 7.02 Printed Name: Massachusetts Hoisting License #: 3 License Grade : License Expiration Date: 1 2.3 Name and Contact Information of Insurer: I Address Telephone Insurance Certificate #: 0-r0JAQ 7,,2 --7:�3 ez;, Policy Expiration Date: Whereas pursuant to the provisions of Chapter 161 Section 161-3 of the North Andover Town Bylaws, the grantee agrees to provide a plan and a bond in the sum of $10,000.00 bound unto the Town of North Andover and an additional refundable amount of $ to assure proper performance and completion as defined in the general specifications and conditions below and as attached. By signing this form, the applicant/excavator and owner, acknowledge and certify that they are familiar with, or, before commencement of the work, will become familiar with, all laws and regulations applicable to work proposed, including OSHA regulations, G.L. C. 82a, 520 CMR 7.00 et seq., and any applicable municipal ordinances, by-laws and regulations and they covenant and agree that all work done under the permit issued for such work will comply therewith in all respects and with the conditions set forth below. The undersigned owner authorizes the applicant/excavator to apply for the permit and the excavator to undertake such work on the property of the owner, and also. for the duration of construction, authorizes persons duly appointed by the municipality to enter upon the property to monitor and inspect the work for conformity with the conditions attached hereto and the laws and regulations governing such work. The undersigned applicantlexcavator and owner agree jointly and severally to reimburse the municipality for any and all costs and expenses incurred by the municipality in connection with this permit and the work conducted thereunder, including but not limited to enforcing the requirements of state law and conditions of this permit, inspections made to assure compliance therewith, and measures taken by the municipality to protect the public where the applicant owner or excavator has failed to comply therewith including police details and other remedial measures deemed necessary by the municipality. The undersigned applicantlexcavator and owner agree jointly and severally to defend, indemnify, and hold harmless the municipality and all of its agents and employees from any and all liability, causes or action, costs, and expenses resulting from or arising out of any injury, death, loss, or damage to any person or property during the work conducted under this permit. In witnesswiereof those signed below «- \ - . 1 GNA OWNER'S SIGNATURE (IF DIFFERENT) Date For CitylTown use -- Do not write in this section PERMITAPPROVED BY PERMITTING AUTHORITY Division of Public Works Date 2 of 5 3/14/2013 1:04 PM JackiesUiwPermitAppI ication. pdf TOWN OF NORTH ANDOVER NOR7'H ANDOVER, MAISAC1-(USE'tTS 01845 I+OR`M .t= O' � .tea � .. ° •y00t N � � 1`S�GNU54: littp://Nveb,niaiI.comcast.iiet/service./hone/-/Jackiesl.,,a"-PeriiiitAppli( Pennit Number Date Issued :expiration Date Jackie's Lav — Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT 1VIUST BE FULLY COMPLETED PRIOR TO CONSIDERATION I Name of Applicant FYe1 r),k— m i /) Phone Cell Street Address f?h Fbr4eS+ I{L�U3-ZA--2i.7,) m 01 W (;itvrl,nwn A' )-CWavea- MA �fpApws- I ZIP Name of E%cavator (if different from applicant) nn C� Phone c� Cell �3 ' �ci 3 7/7f Street address 7% . City/Town 1 N1:k ZIP In�� , Name of Owner(s) of Property t -y -o- n 1c. Phone Cell W3 0 3 4 3 3 q Z- i 71 Street address IUoo T Cityfi"own :VIA � ZIP i Ui � L -i Other Contact Permit Ree Received No Yes Description, location and purpose of proposed trench: { Please describe the e,act location of the proposed trench and its purpose (include a description of what is (or is intended) to he laid in proposed trench (ey; pipesicahle lines etc..) Please use reverse side if additional space is needed. Insurance Certificate #:� n rl v 3 1 of 3/19/2013 9:02 1 JackiesLakvPermitAppI ication.pdf http: //web.mai l.comcast.net/service,liome/--/Jacki es Lav PernlitAppl i Name and Contact Information of Insurer:(/ U3 -8-, � , if -33 j P s Policy Expiration Date:,____.._ Dig Safe #: Name of Competent Person (ac defined by 520 CMR ;.02): 1. assachusette Hoisting License # 1 / License Grade: Expiration Date: BY SIGNTNG THIS FORM, THE APPLICANT. OWNER, AND EXCAVATOR ALI, ACKNOWLEDGE AND C FRTIFI' THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMM OF THE WORK. WILL BECOME FAMLLLIR WITH. ALL LAB'S AND REGULATIONS APPLICABLE: TO NVORK PROPOSED, I`CLUDING OSHA RFGXIL.%TIONS, G.L. c. 82A. 520 CNIR 7.00 et seq., AND ANY AP PLIC ABLE 'IUNICIPA1, ORDINANCES. BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE TH AT ALL WORT{ DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND NVITTI THE CONDITIONS SET FORTH BELOW, TIIE: I:NDFRStGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE: PERMIT AND THE L\CAVA"TOR TO UNDERTAKE SUCH WORK ON 'THE PROPERTY OF TIIE O11'NER, AND ALSO, FOR THE DURATION OF CONSTRUCTION. AUTHORIZES PERSON'S DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPER'T'Y TO MONITOR AND INSPECT''I'HE WORK FOR CONFORMITY R'ITII TIIE CONI)ITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS GOVERING SUCH WORK. THE UNDERSIGNED APPLICANT, OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MI�NICIPALITV FOR ANY AND ALL COSTS AND r..XPF.\SFS INCURRED 81' THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUC.rED -THEREUNDER, INCLUDING BUT NOT LIMITED TO ENFORCING TIIE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT, INSPFCTTONS MADE; TO ASSURE COMPLIANCE THEREWITH, ANDMEASURES TAKEN BYTHE 1IUNICIPALITY TO PROTECT THf. PUBLIC WHERE APPLICANT O1V`NER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH I\CLU'DING POLICE DETAILS AND OTHFR REMEDIAL MEASURES DEENIF.D NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT, OEVNF.R AND EXCAVATOR AGREE. JOINTLY AND SEVERALLY TO DEFEND. INDEMNIFY. AND HOLD HARMLESS THF NI NICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANYAND ALL LIABILITY. CAUSES OR ACTION, COSTS, AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DrL1VIACE TO ANY' PERSON OR PROPERTY DURING THE WORK CONDUM. D UNDER THIS PERMIT. APPLTCAI`T�NATVRE VAJTOR SIGMA' 'S SIGNATURE (IF 2�ra��• DATE (IF DIFFEREIN"T) DATE: FFF.IZENT) DATE: 2 of 5 3/19/2013 9:02 Of `NORT .1h F • r 9 Town of North Andover sm•'•�,,, o :: HEALTH DEPARTMENT �SS�cNust� CHECK #: L DATE: 1 X 13 LOCATION:JM)A�)00 H/O NAME:�1 CONTRACTOR NAME: 1 y) ► 't T_yRe of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ Septic Disposal Works Construction (DWC) $I l ru ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ YL -2 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer It °RrN AApplication for Septic Disposal System - AConstruction Permit — TOWN OF i ORTH ANnc)VF.R- MA 01R45 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rad rensn Application is herebv made for a permit to: TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal system* ` f �epair or replace an existing system component — What? S � i A. Facility Informattiipn n l / 1 i 1 �\i'� L. �n �- _L \.tel- //) Address or Lot # 2.- *TYPE OF SEPTIC SYSTEM*: h�hli ' u tO13 ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application' TpHEALTH DEPARTMENT ANDOVERN OF NORTH ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. /20 () fyYPS *-il- Adss (if di rent frpm above) 7� LI/0-,Ir o%ys City/Town c State Zip Code 3. Installer Information -JO h n 3. Sock ww W r- /1,2 ,_ _ / 1 a. Des6 ner Information Name Address City/Town Telephone Number 1w"14 S�_ t4z-ex- � S�ZC2::�L� Name of Compa y 3Q 7g SZip Code M Telephone Number (Cell Ph�on #if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 a NaRTh Application for Septic Disposal Svstem � AConstruction Permit -TOWN OF TODAY'S DATE 000 ORTH ANDOVER MA 01845 250.00 —Full Repair • $125.00 - Component 9SS4CNIl��i PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: XResidential Dwelling or []Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envi tal Code, as well as the Local Subsurface Disposal Regulations for the Town of No And ver, and not to place the system in operation until a Certificate of Compliance has br;*ss I by chis Bo of Health. a e Date (Board of Health Representative) for the following reasons: For Office Use Only: L Fee Attacbed? Yesl No 2. Project Managet Ohligatron Form Attached-; Yeses No 3. Pump System? Ifso, Attach cgREofElectdcalPermit Yes No� 4. Foundation As Built- (hew construction ronly): Yes No (Same scale as approved plan) 5. Floot Plans? (hew construction only): Yes No Application for Disposal System Construction Permit - Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGAJRO1JtS,( ' tr i'213 As the North Andover licensed installer for the construction for the septic system for the pro er TF NORTH ANDOVER i. E - H DEPARTMENT (Address of septic system) For plans by (E gineer) Relative to the application of D (--A ©"kQ (Installer's name) Dated 41JI? ay s ate And dated N (4— rigina ate With revisions dated (Last r ised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or My company a. Bottom of Bed — Generally, this is the first (V5 inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdeptQtownofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the me of this obligation. Undersigned Licensed Septic Installer: `�J Xam (Today's Date)yame — rint igne �_14 r� a ��I h41 cn bli c 2 v ^co c N p o U o ° qh: m �Q • N r 1� FORM U - LOT RELEME 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 tate applicant and/or landowner from compliance with any applicable local or state lav, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: "I rCc V1 ►C- to ►`�) 1 Phone LOCATION: Assessor's Map Number Parcel 57 Subdivision Lot (s) Street 9 �vr2S-� �{ D 60 St. Number _ ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: ' Date Approved _M10% Conservation Administrator Date Rejected Comments ".111, -A To P1 Comments Health Agent Comments Public Worcs - sewer/water connections - driveway permit Fire Department Date Approved Date Rejected Date Approved Date Rejected Received by Building Inspector Date 6W ZZi - N LQ v� ZQO Wh�O �O V �WO R`` �' ,h WOtcj W L4 t.S Z Q �� i_,j lyhou ` O�qOJz LCI M�QQp WQ Rc�v2 �C)cZO O�L�O h� O ll Qc �vQJCQ Z�� V c� ( m M�tV 0LZ 00 �I.�RZ V °o Q LQ D Z ti O A be M N \J Q 04� O J � Q 44 Q J W 4u 0 0 to Q Q w a vQ OOC•c v N u 14 All �p ydi 'C w a tea, a Q '44 OOC•c v N u 0 0 v Q1 7' z U IN Q 6 C '8 I c R o_ Q tv 0 u o G 0 m U) c. L a L y � CL 4 U CL C O E C N = }0� R O G7 GCQ Q) F- O t Q 0 0 c, 0 0 Z is a) E L- ro n. c m c 0 N E E 0 u c 0 L Q) C: O U I O m c C (Fl d I m 2 u - O to O CO I Q) O_ O_ Q O 0 m O n SOIL PROFILE & PERCOLATION TEST DATA North And 1,.3ss. No.&Street`�/:�� Loc./Subdiv.� ,� Plan Owner Investigator�1 Observer y SOIL PROFILES -DATE 1' Elev. ?' Elev. 3' Elev. 0 0 0 0 1 1 I 1 2 2 2 2 3 3 3 3 4 ' 4 4 4 5 5 5 S 6 6 6 6 7 7 7 7 8 8 8 8 9 _. 9 9 9 10 10 10 10 Benchmark Elevation Location Datum Percolation Tests -Date U--7,-7 '? t 4. Elev. 4 Ties to Test Pits Pit Number 1 2 3 4 S Start Saturation; Soak -Mins." tt; Start Test -Time ,ov Drop of 3" -Time Dry of 6" -Tine I;inS lst 3"Dro bins . 2nd 3"Drop Votes & Sketches on Back / Board of Health North Angbver:Maae. { FAIL OK J r/ �_r i easonsi BEPTIC SISTEi INSTALLATION CHECK LIST Ox", /la 3 oyC LOT j AVATION OK FAIL I. Distance Tot a. Wetlands b. Drains 2. Water Line Location 3• No PVC Pipe 4. Septic Tank a. _Tess -_Length & To Clean Ont Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts C. No Back Flow 6.- Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits' a. ions b. a Depth c. lash Pads d. Tees Ceaent Pipe to Pit - Both Sides f. Clean Double Washed Stone 8, No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table R Reg Bo d Of Health North Andover,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # APPROVED DATE DISAPPROVED DATE!„ Provided: Reasons: � 1�3 Title V Reg 2.5 Reg 6 Reg 10.2 Reg 10.1 fhe submitted plan must show as a adnimum: a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation gles-distance to ties c" location and results percolation tests -distance to ties design calculations & calculations showing required leaching area e) location and dimensions of system -including reserve area f` e3dsting and proposed contours g) location any wet areas within 1001 of sewage disposal system or ,. disclaimer -check wetlands mapping h) surface and subsurface drains within 100' of sewage disposal system or disclaimer i) location any drainage easements within 1001 of�sewage disposal system or disclaimer -Planning Board files j) known sources of water supply vithin 2001 of sewage disposal / system or disclaimer k) location of arq proposed well to serve lot -100' from leaching facilit; 1)'location of water lines on property -10, from leaching facility m) location of benchmark n) driveways o` garbage disposals p no PVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations r) maadmum ground water elevation in area sewage disposal system s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans S22tic Tanks a) capacities -150.% of flow, water table, tees., depth of tees, access, pumping b) cleanout c) 10t from cellar wall or inground swimming pool d) 25+ from subsurface drains .Distribution Boxes a) slope greater ME 0.08 ,b) sump Reg 15.1 15.4 15.8 3.7 Reg 14.1 14.3 14.4 1.4.6 14.7 14.10 Reg 9.1 9.6 esiga C� List FAIL OX E- Leaching Pits 2 Leaching pits are preferred where the installation is possible calculati� of leaching area -rd nimam 500 sq ft spacing surface drainage 2% cover material llTAN splash pad 14e at elbow no bends in pipe from d -box to pipe Leaching Fields no greater than 20 minutes/inch area -minimum 900 sq ft construction of field surface drainage 2 % 201 from cellar wall or inground swimming pool as-` ooeaching area-mda 500 eq ft ft min 6 ft with reserve between drainage 2% Dounhill Slope a) slope -y x ---T& be shown b) y/x X 150 a (to be shown) PurflPs a) approval b) stand-by power . Commonwealth. of Massachusetts tity/Town of • NORTH ANDOVER MASSAC -S. stem Pumping Record �-1/ED F Y. p 9 Form 4 WV 1 3 2006 DEP. has provided this form for use by local Boards of Health. The 9p�t IP �nq ftrd must be submitted to the local Board of Health or other approving auth HEALTH DEPARTMENT A. Facility Information Important: When filling out 1. System Location: forms on the computer, use only the tab key Address to move your , cursor - do not City/Town State Zip Code use the return key.. 2. System Owner: y l� Name Address (if different from location) City/Town State Zip Code 97P7 c.;�(f Telephone Number ------------ B. Pumping Record /7 1. Date of Pumping2. Quantity Pumped: -` Date Gallons Type of system: ❑ ❑ Other (describe): Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: A If yes, was it cleaned? ❑ Yes ❑ No Sy em Pumped By: Name Vehicle License Number s�. rw.Gc�.t.Q, S+. ad1d J rna Company 7. Location where contents were disposed: Signature of Hauler . http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect `�z �l . Date �— t5fomA.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. "ILEI Commonwealth of Massachusetts City/Town of NORTH ANDOVER. System Pumping Record Form 4 L OG15 ITS 20io TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. The to be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: / Address I ✓` -/\./ • 1 1 1 1\ Cityrrown 2. System Owner: I Name Address (if different from location) Citylrown State Telephone Number Zip Code Zip Code B. Pumping RecordW17 / . �0 1. Date of Pumping Date 2. Quantity dumped. Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. tem Pu ped V _ me Vehicle License Number Company 1--rIgnature of Hauler gov/deptwater/approvals/t5forms.htm#inspect t5fonn4.doa 06/03 System Pumping Record •Page 1 of 1