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Miscellaneous - 101 CROSSBOW LANE 4/30/2018
i Lot &Street 1-10-��ilf� Map/Parcel X660 v'( CONSTRUCTION APPROVAL Has plan review fee been paid�-,�Y E S f NO Permit# Plan Approval: Date:1 Approved by: Designer: Ili - Plan Date: 71 D� Conditions: Water Supply: To ell r Well Permit: riller: Well Tests: Chemical , Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing Sign -Off: Wiring Sign -off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By.- Conditions: y:Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? YES NO Type of Construction: NEW REPAIR New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: YES NO DWC Permit Paid? YES NO PWC Permit # Installer: Begin Inspection: YES NO Excavation Inspection: Needed: Passed: Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: Final Grading Approval: Date: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: North Andover Board of Assessors Public Access I' NO OTM �,SS�cNug t� Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial . Page 1 of 1 iproperty Record Card Location: 101 CROSSBOW LANE Owner Name: PAQUETTE, ANDRE & JENNIFER Owner Address: 101 CROSSBOW LANE City: NORTH ANDOVER State: MA Zip: 01845 eighborhood: 7 - 7 Land Area: 1.00 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2870 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 539,300 570,100 Building Value: 313,200 345,100 Land Value: 226,100 225,000 Market Land Value: 226,100 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1519079&town=NandoverPubAcc 6/16/2010 ° 0 u Commonwealth of Massachusetts Map -Block -Lot 106.60206 Board of Health --------------------` +� Permit No North Andover BHP -2010-0610 P.I. FEE �S��Mu�Ei F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson ---------------------------------------------------------------------------------------------------- to (Repair -DISTRIBUTION BOX ONLY) an Individual Sewage Disposal System. at No --101---------------CROSSBOW--------------LANE --------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. B_ - 1 CD_ated June 02,2010 FIL y----------------------- Issued On: Jun -02-2010 -------------------------------------------- -------------------------------------------------------------------------- Board of Health 030 j,�R� 4��°c Commonwealth of Massachusetts Map -Block -Lot 106.B0206 Board of Health --------------------- North Andover b,..�a •�''� i;«CERTIFICATE OF COMPLIANCE �ssust� THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -DISTRIBUTION BOX by Todd Bateson --------------------------- Installer at No 101 CROSSBOW LANE 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. -BH-P-201-0-06 1 Dated --- June -O;,_2010 Printed On: Jun -15-2010 -- ------ ------ ---------------- - -- - --- -------------------------------------------------- Board of Health �eh t 1 5067 a Town of North Andover �.;s ;>.•�� HEALTH DEPARTMENT SCHUSt CHECK #: 5:%Sa DATE: /49 LOCATION: %o/ H/O NAME: 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 Systems: ❑ Septic - Soil Testing $ ❑0 /Septic -Design Approval $ e Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Y. Important When filling out forms on the computer, use only, the tab key to move your cursor - do not use the return key. 151, M Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* 6-01-/0 TODAY'S DATE $ 250.00 Full Repair $925.00 - Component ❑ Repair or replace an existing on-site sewage disposal system* tepair or replace an existing system component — What? A. Facility Information JB / e 'ross & w Address or Lot # IVO r A4 A1,4 - Cityfrown 2.- *TYPEOF SEPTIC SYSTEM*: ❑ Pump 21ravity (choose one) ***If pump system, attach copy of electrical permit to Conventional System (pipe and stone system) JUN 22010 TOWN OF NORTH ❑ 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. Name /10/ 6-1-V5'j-8 , L� Address (if drfferent from above) Cdyfrown 3. Installer Information odd 4P '1Z ✓ Name 4. Address dyfrown Name Cityfrown State _--- Q IOV Zp Code _ Telephone Number otSo- _. 70 Name of Co N=1111 ENTEgpRISES, INC. !t! Aiir�u r --M-'Ak-_ . --- -,wow State Zip Code _jOZ Telephone Number (Cell Phone # H pole please) Name of Company State Zip Code Telephone Number (Best # to Reach) Apprrcatlon for Disposal System Construction Permit • page 1 of 2 V r - y SEPTIC SYSTEM. INSTALLPR PROJECT :MANAGEMENT` OBLIGATIONS As the North Andover licensed ;installer for the .construction: for the septic system for the property at: (Address of septic system) Relative to the application of (Installer's name) Dated 6 —a )v o a s ate For plans by (Engineer) And dated (Original date). With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. Asl the installer, I am .obligated to obtainall permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the pemut'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 .tlie.necessary work. completed mior to the .applicable inspections as indicated below .I.iinderstand that rec�uestingan inspection, without comnletion:.of the.iterns in a��nY.dnim a:. Bottom of Bed Generally, this: is the first (Is), inspection unless.,there is :i ietaining wall, which should be done:first. The installer must request the inspection but doesnot have to be present. . b. Final: Construction Inspection — Engineer must first, do thein inspection for elevations; ties, 'etc. As -built of verbal OK (or e-mail to: healdidmt@townofnorthandover com) from the engineer must be submitted to :the Board of Health, after which instaler .calls for an inspection time. Installer must be present for this.inspection,./ith a pump system, all electrical work:must be ready and able to cause pump .to -work and alarm :to function. c. :FinahGrade — Installer must arequest inspection when. grading is complete. Installer does not have to be on=site. 4. As the installer, I understand that only I 'Mayperform the work (tither than :nrVle- -e. xcavation) and I am required to complete the installation of the system identified in the attached application for installation: ':I further :. understand: that work done li others unlicensed to' install se c s stems :in North Andover can constitute reasons for denial of the s' stem and or:revocaton or sus 'ensaori of m. license too erste iii. the Tbwn.of North Andover significant fines to alliersons involved are also possible 5...As the.installer, .I understand that I mustbe on-site during the.performance'of the following construction steps: a. Determination that.the proper elevation ofthe excavation has been reached. A Inspection ofthe sand and stork to be used. c. Final inspection by Board ofHealth staffot consultant. d. Installation.oftank , D Box, pipes, stone, vent,primp charimtber, retaining waUancl other components. 6. As the* I understand that I.an, soldres orisible for the installation of the s stem as er the aw2roved olans. _ or'an .other: ersons shall-absol me of this obli tion. Undersigned IAcensed Septic Installer: (Today's Date) i a APP cation for Septic Disposal System ' Construction Permit - TOWN OF PAGE 2OF2 A. Facility. Information continued.... TODAY'S DATE $.250.00 - Full Repair $125.00 - Component 5. Type of Building: sidential Dwelling or ❑Commercial B. Agreement y� The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has bAlissu this Board of Health. Na Date Application pproved By (Board of Health Representative) Name Date A plication Disapproved for the following reasons: For Office Use Only: I. Fee Atiachedp 2. ProfectManager ObEgation Form Attached. 3. Rum S sv tem; Ifso; Attach copv ofElecaical Petmit 4. Foundation As -Built. (new construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Yes No Application for Disposal System Construction Permit - Page 2 of 2 �rT �.'�� rit f ,�? �A.�fn R• S �.. ......�....�,..�....___ � _.w.._ .�, .� _......_. _ � ,._ . _�....�., �T,,. _....._........_Wyk_.. _...�._...._..... 13 0 _ ow.._ f3 ! }.__x'11 relS,S • f7NCha VICAR AI14-.5..-..._ 9—//—g . vR.r_ dc'A , T "�n�,�r ��r t t r • sc !� s� �R _�7 ttc�� .l L1. • .'� l._y J r L� ��a.�._��.i.I - I � r • �. t r t 0I • � /� 111.E � �__F1.c�_.tL_a' - �t �• is - r,,. io WLI pORTH O�,�ZLEo 16 OL O `T 'q LOCM CMCWKK PUBLIC HEALTH DEPARTMENT (ommunity Development Division C`�1�7I�'ICA�I'E OF CO�I�i�LIANC`� As of: June 30, 2010 This is to cert that the individuaCsu6surface dTsposa(system received a SAVS(FAC7oRT IMT EMOX of the: ft&cement of a Component: Distri6ution Box Tor an On Site Sewage1DisposaCSystem By: ToddBateson 101 Cross6ow Gane Wap -106. B; ParceC-206 J1 Forth Andover, 90 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com C TOWN OF NORTH ANDOVER a+ NORrN q Office of COMMUNITY DEVELOPMENT AND SERVICES 3 -.41"o SOL . *a o HEALTH. DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS Public Health Director O A �9SSNCNUs���h 978.688.9540 — Phone 978.688.8476 — FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: /D / Jl MAP: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: D `/° -74 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK LOT: ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer ❑Topography not appreciably altered . LN 0 ❑D Bottom of tank hole has 6" stone base Weep hole plugged 1500 gallon tank has been installed H-10 loading Monolithic construction Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) Inlet tee installed, centered under access port Outlet tee (gas baffle or effluent filter)'installed, centered under access port 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 g TOWN OF NORTH ANDOVER p4 NpRTk q p Office of COMMUNITY DEVELOPMENT AND SERVICES a ,,�,a 2 a�:.e .,.*a HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 ALHUSE Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 —FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Comments: Wastewater System Documentation — Feb 2006 Page 2 of 6 A TOWN OF NORTH ANDOVER f NORTH q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS Public Health Director D -BOX Comments: SOIL ABSORPTION SYSTEM 11 Comments: O �. T 9e �9SSACHUSQt�h 978.688.9540 — Phone 978.688.8476 - FAX Installed on stable stone base Inlet tee (if pumped or >0.087foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Bottom of SAS excavated down to soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 Y2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed Laterals installed and ends connected to header Laterals vented if impervious material above Orifices @ 5 & 7 o'clock positions Gravel -less disposal systems: type, number and location as per plan Elevations- of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan Wastewater System Documentation — Feb 2006 Page 3 of 6 F� o TOWN OF NORTH ANDOVERE „oRT„ Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH. DEPARTMENT p 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 X98 44— .•�<ty SAcHus Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION ❑ -- inch manifold ❑ laterals installed with end sweeps size: material: ❑ Squirt test ft in height ❑ Equal distribution to all laterals ❑ orifice size inch as per plan Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation — Feb 2006 Page 4 of 6 EW TOWN OF NORTH ANDOVER Noark Office of COMMUNITY DEVELOPMENT AND SERVICES p��b"N�a�"°�°aA HEALTH DEPARTMENT 1600 OSGOOD STREET; Building 2-36 NORTH ANDOVER MASSACHUSETTS 01845s�'`<�y S4cHU5 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 . Page 5 of 6 Tank SAS Sewer ❑ Property line 10 10 -- El Cellar wall 10 20 ElInground pool.. 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 101 ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑' Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Bank' 75 100 1:11 Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 . 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 . Page 5 of 6 N Y e A TOWN OF NORTH ANDOVER F IORTH q Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT41 A 1600 OSGOOD STREET; Building 2-36 : NORTH ANDOVER, MASSACHUSETTS 01845 �qs q•rrn .P� �y SICHUS Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 ,0 I+aRTH Commonwealth of Massachusetts Map -Block -Lot �a, "mO 'a,a44a 106.B0206 I p Board of Health Permit No BHP -2010-0610 North Andover ----------------------- 'q°«ti P.I. FEE �ssycm F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bateson to (Repair -DISTRIBUTION BOX ONLY) an Individual Sewage Disposal System. at No 101 CROSSBOW LANE as shown on the application for Disposal Works Construction Permit No. BHP -2010-061 Dated June 02, 2010 ------------------- ------ Issued On: Jun -02-2010 Board of Health naR rh Map -Block -Lot oa .,,SO ,« t� Commonwealth of Massachusetts 1 ` � °4 106.60206 Board of Health ----------------------- - North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY That the Individual Sewage Disposal System (Repair -DISTRIBUTION BOX by Todd Bateson ----------------------------------------------- ---------------------------------- --------------------------------------------------------------------------- Installer at No101 CROSSBOW LANE - ------------------------------------------------------------------------------------------------------------------------------------------------------ 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 -2010-061 Dated -_. June 0;,_2010 -_______ Printed On: Jun -16-2010 ----------------------- - - -------------------------------------- Board of Health I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority JAN 6/5/2010 Inspecto s gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts MOVED\j Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Ass ssmei��o 101 Crossbow Lane TOWN OF NORTH ANDOVER Property Address HEALTH DEPARTMENT Jennifer Paquette Owner Owner's Name information is required for North Andover MA 01845 6/5/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. A General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor - do not use the return Name of Inspector key. Bateson Enterprises Inc. Company Name . 111 Argilla Road Company Address Andover Ma 01810 City/Town State Zip Code 978-475-4786 SI15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority JAN 6/5/2010 Inspecto s gnature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �r 101 Crossbow Lane Property Address Jennifer Paquette Owner Owner's Name information is required for North Andover MA 01845 6/5/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D. A) System Passes: ® 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: After permit from B.O.H., install new d -box with riser, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _ I- 41 Commonwealth of Massachusetts G ` Titley Officials Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessnts� 20 ��� 101 Crossbow Lane Property Address HEALTH DEPARTMENT R Jennifer Paquette Owner's Name North Andover MA 01845 5/20/2010 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. r A. General Information l�-� IWO- 1. Inspector: 0-"4, Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Cityrrown 978-475-4786 Telephone Number B. Certification Ma State S115 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑N d Furth r Evaluation by the Local Approving Authority r 5/20/2010 InspecVrs ignatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 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 101 Crossbow Lane Property Address Jennifer Paquette Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 5/20/2010 Date of Inspection 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 exMtration 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Crossbow Lane Property Address Jennifer Paquette Owner's Name North Andover MA 01845 5/20/2010 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 ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Crossbow Lane Property Address Jennifer Paquette Owner Owner's Name information is required for North Andover MA 01845 5/20/2010 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D -box needs to be replaced , has corrosion holes. 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 - 09/08 Title 5 Official Inspection form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Crossbow Lane Property Address Jennifer Paquette Owner Owner's Name information is required for North Andover MA 01845 5/20/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El® 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. El® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El® Any portion of a cesspool or privy is within a Zone 1 of a public well. 1:1® Any portion of a cesspool or privy is within 50 feet of a private water supply well. 1:1® 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. 1 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 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 101 Crossbow Lane Property Address Jennifer Paquette Owner's Name North Andover MA 01845 5/20/2010 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): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 09/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts u u Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Crossbow Lane Owner information is required for every page. t5ins - 09108 Property Address Jennifer Paquette Owner's Name North Andover Cityfrown D. System Information Description: MA 01845 State Zip Code 5/20/2010 Date of Inspection Number of current residents: 5 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 9 ( Y g (gpd))� Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Crossbow Lane Property Address Jennifer Paquette Owner Owner's Name information is required for North Andover MA 01845 5/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped 2008, owner 1500 gallons Measured tank Inspect tank & tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 101 Crossbow Lane D. System Information (cont.) 5/20/2010 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 27 Years old. 9/11/1983. as built Dian Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron thru wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2 feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: a ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System, • Page 9 of 17 Property Address Jennifer Paquette Owner Owners Name information is required for North Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) 5/20/2010 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 27 Years old. 9/11/1983. as built Dian Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 3 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron thru wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 2 feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: a ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System, • Page 9 of 17 Owner information is required for every page. t5ins - 09/08 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Crossbow Lane Property Address Jennifer Paquf Owner's Name North Andover Cityrrown D. System Information (cont.) MA State 01845 5/20/2010 Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 25" 6" 811 1211 How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: 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 101 Crossbow Lane Property Address Jennifer Paquette Owner Owner's Name information is required for North Andover MA 01845 5/20/2010 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 Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): 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 - 09/08 1 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 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 101 Crossbow Lane Property Address Jennifer Paquette Owners Name North Andover MA 01845 5/20/2010 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box has corrosion holes at water line. D -box level & distribution equal. Evidence of leakage. Evidence of carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Crossbow Lane Property Address Jennifer Paquette Owner Owner's Name information is required for North Andover MA 01845 5/20/2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 1 Field 25'x 36' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 09/08 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 101 Crossbow Lane Property Address Jennifer Paquette Owner Owner's Name information is required for North Andover MA 01845 5/20/2010 every page. City(rown State Zip Code Date of Inspection L). aysiem inrormation (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 - 09108 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 101 Crossbow Lane Property Address Jennifer Paquette Owner's Name North Andover MA 01845 5/20/2010 Cityrrown 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 0 w Mt 9� k Ar g O t 01 -Trru"1`` a t 4'J.Q D e" D -S' Ip" P � it RAto l 3 a g4J t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 15 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 101 Crossbow Lane Property Address Jennifer Paquette Owner's Name North Andover Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 5/20/2010 State Zip Code Date of Inspection Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/10/1983 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Original plans ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 Crossbow Lane Property Address Jennifer Paquette Owner Owner's Name information is required r North Andover MA 01845 5/20/2010 fo every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 17 of 17 i �L\ Commonwealth of :Massachusetts = City/Town of w System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, Left rear of hou ,rear of hous . Left rear of building. Right rear of building. Address i� City/Towh 2. System Owner: Name Aaaress (it aitterent from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) State P�- t UO-jue. Zip Code 5tattD � _ �v Zip Code L/� Telephone Number — 2. Quantity Pumped ETITe—p—tic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes E No If yes, was it cleaned? ❑ Yes ❑ No 5. Con Iti n of System: ��. I 1 V\,- �� �r C � 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: �. LfjS. D�n Lowell Waste Water Of t5form4.doc• 06/03 F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 Summary Record Card generated on 5/14/2010 3:03:50 PM by Karen Hanlon Town of North Andover Tax Map # 210-1063-0206-0000.0 Parcel Id 17601 101 CROSSBOW LANE ANDRE PAQUETTE 101 CROSSBOW LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Size Total 1 Acres FY 2010 UB Mailina Index Name/Address ANDRE PAQUETTE 101 CROSSBOW LANE NORTH ANDOVER, MA 01845 BRAKELEY, HARRY 101 CROSSBOW LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 17577.0 -101 CROSSBOW LANE 3170247 03 Cycle 03 UB Services Maint. Account No. 3170247 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3170247 Serial No Status Brand 29955835 a Active YTD Cons Date Reading 3/10/2010 875 12/10/2009 854 9/10/2009 831 6/9/2009 810 MSG -8% 3/13/2009 750 12/9/2008 725 9/10/2008 700 6/5/2008 633 3/11/2008 573 12/10/2007 551 9/5/2007 506 6/18/2007 429 3/13/2007 360 12/12/2006 335 9/12/2006 311 6/14/2006 291 3/8/2006 267 12/22/2005 246 9/21/2005 223 Trouble Code:03 -49% 6/27/2005 100 3/23/2005 15 Type Loan Number Owner Previous Customer Property Type Active/Inact. From Inactive 9/24/2004 Occupant Name Active/Inactive Last Billing Date 4/2/2010 Active Rate Charge Multiplier/Users 0.635/8 7,82 1/ 01 ALL METER SIZE 81.55 /1 Page 1 1 Residential Until Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.63 0.63 302 Code Consumption Posted Date Variance a Actual 21 4/14/2010 -8% a Actual 23 1/12/2010 12% a Actual 21 10/15/2009 -67% m Manual estimate 60 7/20/2009 156% a Actual 25 4/29/2009 -4% a Actual 25 1/20/2009 -60% a Actual 67 10/10/2008 -1% a Actual 60 7/16/2008 192% a Actual 22 4/11/2008 -49% a Actual 45 1/22/2008 -52% a Actual 77 10/12/2007 37% a Actual 69 7/20/2007 159% a Actual 25 4/16/2007 4% a Actual 24 1/19/2007 19% a Actual 20 10/20/2006 -9% a Actual 24 7/10/2006 -11% a Actual 21 4/17/2006 11% a Actual 23 1/17/2006 -83% a Actual 123 10/14/2005 62% a Actual 85 7/15/2005 260% a Actual 15 4/5/2005 -100% William F. Weld Governor Trudy Coxe Secretary, EOEA David B. Struhs Commissioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION I Property Address: /01 C(us5 6XA; � Address of Owner: Date of Inspection: (..-7—�11 (If different) Name of Inspector: —BOARD OF HEALt n i� 14 l9% Company Name, Address and Telephone Number: 13eat lA,1a i'�naC ti�� CERTIFICATION STATEMENT ,, t-rr�oc% � Ma. 01815- I 181- 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: T( -,,-,Q -7t 1 �4� I Z -1 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspect on. 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 repo.^. to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the �vstem owner ano copes sent to the uuyer, If apphcabie auu iiic opjAu„ ,& INSPECTION SUMMARY: Check A, B, C, or D A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. if "not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292-5500 \1� 4i Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property 6dId-_ress: 101 CC'C'&S'60 % Owner: •'Yek'r Date of Inspection: G — 7 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspoo! or privy is \N ithin 50 feet of a bordering vegetated wetland or a salt marsh. 2; SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE F',A IRON''siFN'T Thesysi't-m hasasepnc link and soil absorpsrort "M and is wttbin surface seater supply. _ The sten h,:• a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The s�sten, ha, a se(it!c tank and soil absorption system and is within 50 feet of a private water supply well. Tht?zz scp',.c tani, and so,! absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an 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. (revered 5/15/55; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: iOtC't`c5S�i:.i Owner: HaPPy (�:zake(ey Date of Inspection: (g—`t—W D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is v,•ithin 200 feet of a tributary to a surface drinking water supply _ the systern is loca!ed in a nitrogen sensitive area (Interim Wellhead Protection Area (IV%'PA) or a mapped Zone II of a public water supply well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 3 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �10 t C(CSS6U�; Owner:rt`y�eINY Date of Inspection: Check if the following have been done: /Pumping information was requested of the owner, occupant, and Board of Health. /None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /As built plans have been obtained and examined. Note if they are not available with N/A. _/The facility or dwelling was inspected for signs of sewage back-up. ✓ The system does not receive non -sanitary or industrial waste flow ZThe site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _ The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. f'nn' n\,:nP 'i \VPrp pro\,idPd \vith infnrmation on the proper maintenance of Sub Surface Disposal System. (revised 8/15/55) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . Property Address: I0I CrMTi., ,,, SYSTEM INFORMATION Owner: f�C Y �� ie Date of Inspection: RESID_ E_ NTIAL: FLOW CONDITIONS Design flow:(p-QQ_galIons�i�aur Number of bedrooms: Number of current residents: Garbage grinder (yes or no): -W, Laundry connected to system (yes or no):Yes Seasonal use (yes or no):, 0 Water meter readings, if available: 17 -:z. 1.1 I_ Last date of Occupancy: p nc}`:eA>-ly Oce, ptcy COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:___gallons/day 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) \Pater meter readings, if available: Last date of occupanc) OTHER: (Describe) Last date ofoccupan GENERAL INFORMATION: PUMPING RECOWS and sorurce of information:t_j , System pumped as pan of inspec . , �� If yes, volume pectron: yes or no) p,rmned __gallons Reason for pumping — TYP,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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) NO (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 i CtbSS6C Owner: t-lagy Rmke[ Date of Inspection: (,--7- q4 SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: 0 "L W 6,Q)( K Sludge depth: I/ !/ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I ii li Distance from top of scum to top of outlet tee or baffle: 11 Distance from bottom of scum to bottom of outlet tee or baffle:oZ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural . inteArityt evidence of lea kap, etc.) D to 15 1M Q�� 6rnP� ix-+� , , _ l � J-L�'� • eu? GREASE TRAP:_ (locate on site plan Depth belov, grade. Material of construction: _concrete _metal _FRP _other(explain; Dimensions: SLUM Distance from top of scum to top of outlet tee or baffle: D;; anre f• -)m ho!vn ", "w" t'. „nttr�m n, at tarn n. Comments: (recommendation for pump nc,. co d tior• of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakaee etc (revised 8/:5/55) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:t CCOSSk% Owner: Harry Bc k,e tH Date of Inspection: 6-7-40 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan` ' R�1C ¢� y � T Depth of liquid level above outlet invert: Cl�.� cv Nm' vt,, Comments: (IW'ie 11 IecCi GIIU U.i:-JG,UU , iy.l., t:116. 11i C: c"ildcrcc c; IeaksbC 0::; cf PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 101 CftvU 60uv Owner: j-�urc� j3c�.ciN Date of Inspecti n: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: 1 — q 0034 - overflow cesspool, number: 1 Comments: (note condition of soil, signs of hydraulic failurelevelof ponding, condition of vegetation,etc.) SoL'I c h vw Je Q Qr�� q-,, On S i s lit r (w rP Y Y1Q_4JDc' CESSPOOLS: _ (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: Materiel= of construction: inUCa;wlUl gtuUrlu'Nai�:- inflow (cesspool must be pumped as part of inspection) Comments: (note condit on of s61, 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.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 101 C=t Lo, o Owner: t- "v-/ g(t:,,kp ley Date of Inspection: 40 , �T _ A/"_ SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater: I feet v method of determination or approximation: i TO (revised 8/!5/95) 9 41— oaa COM jt�l Ic, �Z / it 4r w / .J 114 i 113 , uJ I to Z 110 ._._ G► 2q p E d (07 loo• a 61 _ 105 M w J l�il 7 QI UJ s Z Z SMUUB04A/CS/ND4/L017 TERMINAL NO: 052 TOWN OF NORTH ANDOVER CONSUMER METER F/M DATE: �6/04/96 TIME: 11:02:02 � Acct: 01-469100W0 BRAKELEY, HARRY 101 CROSSBOW LN Meter No: 1 Rev Mtr/#: N Book: 17 Page: 46910.00000 Meter Flg: 0 [1] Connector: ] Digits: 43 Dim Cd: A] Multiplier: ] Arb #: ] Manf Cd: ] Units: Pipe Site: ] Len: ] Type: ] Req: Inst: nc : C t Disc: Cd: @] Wrk Cd: ] Mt Code: ] Met Loc: ] In/Out: ] Notes: 5/8 TRI -10 ] Serial #: 0029220582 ] Bgn: / Cur: 1542 E Prev: 1503 A 2nd Prev: 1474 A [2] From: 02/08/96 To: 05/06/96 Cur2: Prev2: Next: Cns Cr: Mth Bill: 03 User: ] -------------------------- Consumption Information ----------------------------- ---------------------------- Fi st 12 Billing First Months ------[3] }------ Last Ig Billing Months -------[4] 06/96 39 E 12/94 35 A 106/93 1031,93 16 A 8 A ��@3/96 29 A Ju/12/95 09/94 89 ~~2N A A 112/92 ~��~ 30 A 30 A 06/94 09/95 59 A 03/94 31 E 109/92 4 A 06/95 �24 A 12/938 42 A 106/92 ~12 - A 03/95 2 A 09/93 51 A 103/92 ^ 25 A -�- Firs1^rotal: 471 } Last 12 Total: 154 (ESC} to Enter New Meter Number <M}odify, (D}elete or <N}ext TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr Public Health Director July 15, 2003 Ben Osgood, Jr. New England Engineering Services, Inc. 60 Beechwood Drive North Andover, MA 01845 Re:' 101 Crossbow Lane Dear Mr. Osgood: Telephone (978) 688-9540 FAX (978) 688-9542 The Health Department has reviewed the proposed plans dated November 15, 2002 for the repair of the septic system at 101 Crossbow Lane. Unfortunately, the plans cannot be approved as submitted. Please address the issues below with a revised plan. 1. The trench end section shows reserve between the primary leach trenches, however, the site plan does not reflect this. Also, there seems to be a stray reserve area shown as a field in the front of the dwelling. Please clarify. 2. The septic leach area is less than 50 feet from the diverter drain. 3. Vent not protected from precipitation and/or animal entry. (310 CMR 15.241(1)(b)) 4. The length of the trenches differs between the profile and the site plan. Please address. 5. There appears to be some of whether the percolation test was performed in the most restrictive soil layer. Please address. 6. Depth to groundwater is less than the 5 feet required for a 2 mpi perc test. If you have any questions, please do not hesitate to call the office. Sincerely, Sandra Starr, R.S., C.H.O. Public Health Director Cc: Owner BOH File 14 _I 1 0 011 A 00 s d 0 a b b o g v a 000 O ao 0 W wr 'Inn � W r W o z o b O C � a O � o �-+ 00 M'"•O'"'N`oC � 0 0 0 v zN O '3AB d' W x W O M O d' N y F7 0 a. .a 5 titig'A rh Q w Oa+ O ''^ y d A w z •o �; s. asp a 00 O O N O }�. O a, aC O aG:��CQaIV �Ao 0 011 A s d a b b o v a ao 0 W M W r W o z o .55 �-+ 00 M'"•O'"'N`oC � 0 0 0 v zN d' W W 0 .a rh Q w Oa+ O ''^ y M O N w NEW ENGLAND ENGINEERING SERVICES lk INC June 27, 2003 Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 101 Crossbow Lane, North Andover, Septic system design Dear Sandra: Enclosed are the following documents concerning the septic system design plans for the above referenced property. 1. 5 sets of design plans, one with an original stamp. 2. Draft copies of soil evaluator sheets. The final copies will be forwarded shortly. 3. Application for approval. 4. Fee to cover the review fee. This plan is being submitted for approval. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, Benjamin C. Osod, Jr., EITEL--- President 2003 ..----_._ A 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 i SEPTIC PLAN SUBMITTALS LOCATION: 1- 4AMap & Parcel 106 206 NEW PLANS: �Y�E: $225.00/Plan ✓ Check #: REVISED PLANS: YES $ 60.00/Plan Check #: SITE EVALUATION FORMS INCLUDED: C� NO LOCAL UPGRADE FORM INCLUDED: YES NO DATE:�I 27 �`� DATE TO CONSULTANT: DESIGN ENGINEER:_Telephone #: S 7 , ENC -k RwG— When the submission is complete (including check), date stamp plans, COPY for Conservation, and place in existing file with green Design Approval form. NEW ENGLAND ENGINEERING SERVICES INC Sandra Starr, Administrator North Andover Health Department Town Hall Annex 27 Charles Street North Andover, MA 01845 Re: 101 Crossbow Lane, North Andover, Septic system design Dear Sandra: June 18, 2003 TOWS! CF t iriTH Ai't.H/ EC ^.Pa, OF HEALTj I8 F Enclosed are revised septic system design plans for the above referenced property. The changes have addressed your comments as follows. ". The trench end section has been revised. The reserve areas have been deleted. The intent of the plan is to have the primary area at the rear of the lot and the reserve area in the front. I realize additional test pits will be needed in the reserve area and am prepared to perform the testing at your convenience. No definition of "diverter drain" can be found in title 5. If this is meant to be a subsurface drain that intercepts ground water, then the reviewer has mistaken the street drains for groundwater drains. The fact is these drains are not designed to intercept ground water and thus the required offset is 10 feet. �'3. The vent detail has been revised to indicate the installation of an isect screen/charcoal filter. 4. The length of the trench is labeled consistently in all locations on the plan. ,5. The percolation test was performed in one of the sand layers. All of the layers will obviously have a percolation rate of <2 min/inch. There is no question that the percolation test is indicative of all of the soil layers. 6. The depth to ground water has been increased to 5 feet. This plan is being submitted for approval. If you have any questions regarding the information submitted, please do not hesitate to contact this office. Sincerely, CS- C Benjamin C. Osgood, President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 CHECKLIST FOR NORTH ANDOVER SEPTIC SYSTEM PLANS Job The following is a checklist that incorporates all Title 5 and local regulations for septic plans. Name of Applicant:l/�,�/� 1 /L�ftlX Plan Date: % Revision Date: Name of Designer: / V L Date of Review: Property Address: d&---J,5A6 k) Map: /G6 Lot: BOH Reviewer: , 17—/'7 k Type of Plan (new or upgrade): Number of Bedrooms: f9 gpd) Garbage Disposal Allowed: /V0 General Information: N.A. = North Andover Septic Regulations Other numbers refer to Title 5 OK /Problem N/A �_� Street number and map/lot - 220(4)(u) Maximum scale of 1 "=40' for plot plan - 220(4) t/ Maximum scale of 1 "=20' for profile and component details - 220(4) Legal boundaries of the facility being served - 220(4)(a) / Names of abutters from recent tax map - NA 8.02j V,/ Number of bedrooms, design calcs., - NA 8.02i ✓ ,i Name & address of record owner & applicant - NA 8.02k Name & address of designer - NA 8.021 Holder and location of all easements - 220(4)(b) Date plan drawn & any revision date - NA 8.02m All dwellings and buildings, existing and proposed - 220(4)(c) Location of all existing or proposed impervious areas - 220(4)(d) All distances on site plan — NA 8.03a -c L,� Elevation of proposed driveway - NA 8.02t Location and elevation of foundation drain - NA 8.02y Location and dimensions of the system incl. reserve (new const.) - 220(4)(e) Limits of excavation of leach area on site plan - NA 8.02z Locus plan - 220(4)(t) (Not to scale) North arrow - 220(4)(g) 'Existing and proposed contours - 220(4)(g) Locations and logs of deep holes - 220(4)(h) Locations and logs of percolation tests - 220(4)(i) Date(s) of soil testing - 220(4)(h) & (i) V Existing grade elevation of each deep hole - 220(4)(h) Elevation of percolation tests — N.A. 8.02n Name of approving authority representative - 220(4)(h) & (i) Name of soil evaluator - 220(4)0) Soil logs and perc test logs match BOH records Locations of waterlines, drains, and subsurface utilities - 220(4)(m) Observed and adjusted g.w. elevation in the vicinity of the system - 220(4)(n) Complete profile of the system to scale - 220(4)(o), NA 8.02c Cross section of leaching facility - NA 8.02w (Not to scale) Location of benchmark(s) within 50-75 feet of facility - 220(4)(q) Note listing all variance requests with proper citations - 220(4)(p) '-� Local upgrade approval request form submitted - 403(1) Original R.S./P.E. stamp, signature & date - 220(1) & (2) P.E., discipline specified within stamp. MGL C. 112 s. 81M sfc. supplies (w/in 400'), pub. wells (w/in 250'), pvt. wells (w/in 150') - 220(4)( Location of watercourses, wetlands, wells, etc. w/in 150' of system — NA 8.02r Wetland disclaimer — NA 8.02s RLS plan reference & certification required (prop line setbacks) - 220(3) Plan contains designer's certification statement �✓ Use approvals / standards checked for I/A system - DEP docs., t/ Perc rate >30 MPI - not allowed for new, LUA for upgrade - 245(1)&('3) 1/ Perc rate > 60 MPI - must use modified tight tank or UA technology - 245(4) i ✓ Proposed system qualifies as "shared" system - 002 (definitions) Flow is over 2,000 gpd - No R.S. allowed - 220(1) Design flow was set in accordance with code - 203 Existing system location and note on proper abandonment - 354 Leaching facility at least 1' above Base Flood elevation — NA 9.05 All piping Sch 40 minimum — NA 10.01 Basement floor minimum 1' above groundwater elevation — NA 5.04 Foundation drain present with elevation — NA 8.02y On-site Soil and Groundwater Review OK/ Problem N/A Proper deep observation hole logs on plan - 220(4)(h) All deep holes and peres shown, including aborted tests — NA 8.02n t/ Soil evaluation forms submitted within 60 days of field work - 018(2) ✓/ Proper percolation test log - 220(4)(i) i� Ample deep observation holes in primary disposal area (minimum 2) - 102(2) Ample deep observation holes in secondary disposal area (minimum 2) - 102(2) Ample perc testing (one in each disposal area, 3 in prim. > 2,000 gpd) - 104(4) Deep hole testing conducted within two years — NA 7.05 ground elevation el. acceptable soil el. Il Leach facilitv invert el ground water el. Hole Identification Numbers: l refusal el. bottom of leach facility el. u� l�f thickness of acceptable soil before & after soil R&R separation to groundwater separation to refusal lb,Z, ZS soil class Hole Identification Numbers: l 2 2 9 .v 9 yZ lb,Z, ZS 2 2 3 perc rate • j loading rate 79 septic tank below g.w. table NO (yes or no) pump tank below g.w. table /¢ (yes or no) l.f in fill S -255(l) Setback Distances (Given in feet) 15.21 1 YES 0 OK Problem N/A 10 10 Cellar wall Is the lot in the Lake Cochiewick Watershed? NA 6.00 & 5.02 Septic Tank Leach Facility Property line 10 10 Cellar wall 10 20 Inground pool 10 5 10 10 10 Slab foundation 100 75 Deck, footings, .75 100 on etc. d/ 150 150 Waterline i L/ V Private drinking well Irrigation well L Wetlands t/ v Public well Wetlands bordering surface water Supply or trib. (in Watershed) Trib. To Surface Water supply Reservoirs V Tributaries to reservoirs L Drains (wat. supply/trib.) Drains (intercept g.w.) Foundation drains JDrains (Other) Drywells Downhill slope Septic Tank Leach Facility 10 10 10 20 10 20 10 10 5 10 10 10 75 100 75 100 .75 100 400 400 150 150 325 325 400 400 200 200 50 100 25 50 10 20 5 10 20 25 15' to 3: l slope L010 h G r !' 1er 3 4 w/o barrier Building Sewer OK Problem N/A Grease trap required for certain uses (check 230 for details) Pipe diameter listed (4" minimum) - 222(1) j " Pipe schedule listed - 222(3) 4 -, Pipe cast iron or Sch 40 PVC - NA 1.1.02 Watertight joints specified - 222(3) & (4) Pipe laid on compact, fin base - 222(5) ,Y/ Pipe laid on continuous grade in straight line - 222(7)@ Cleanouts precede all changes in alignment and grade - 222(8) Cleanout provided every 100 feet - 222(8) E/ Manhole at any 90 degree alignment change - 222(8) !� Invert elevation at building: ice: !a`� ✓ Invert elevation at septic tank: c/ Length of run: /0 / Slope: O )l— (minimum of 0.01 - 0.02 desired) - 222(6) 10' offset to private well or suction line - 222(2) Septic Tank OK / Problem N/A Tank is accessible - 228(3) No structures above tank - (228(3) j " Tank can accommodate both primary & reserve - NA 9.04 200% of flow (required & provided given. 1.500 min.) - 220(4)(f) & 223)(1)(a) 2-3" drop from inlet to outlet - 227(5) Minimum of 4' liquid depth - 223(2) i/ 3" air space above tees/baffles (minimum) - 227(4) 9"air space above flow line (minimum) - 227(4) Tees are not to be replaced by baffles - 227(1) Tees extend 6" above flow line - 227(1) Inlet tee extends 10" below flow line (minimum) - 227(6) Outlet tee extends 14" below flow line (more for deeper tanks) - 227(6) Gas baffle installed on outlet - 227(4) Access manhole cover above center of tank & each tee (except 2 compart) 228(2) 3-20" manholes - 228(2) '-� 1 childproof, 24" riser/manhole Win 6" of final grade if <1000gpd- 228(2) Inlet and outlet tees on center line - 227(1) Soil compaction below tank specified (if soil is non-native) - 221(2) 6" of <=3/4"stone beneath tank specified - 221(2) & 22 8(1) If > 1,000 gpd AND not a single fam. dwell. must be 2 tks or 2 comp. - 223(1)(b) ✓/ If plan specifies disposal must be 2 tanks in series or 2 compart. tank - 223(1)(c) —� Buoyancy calcs. required if tank at or below water table - 221(8) Tank is watertight - 221 (1) 9" of cover over tank (minimum) - 228(1) Vc H- 1 0 loading (min.) - H-20 if traffic - 226(3) Top of tank <=36" below grade - 221(7) All pumping to tank (if applies) in accordance with - 229 /� Tank is set to keep old system in service during install if possible Tight Tank (Check here if not present: ) OK Problem N/A 500% of design flow or 2000 gallons provided — 260(2)(a) 3- 20" manholes — 228(2) Soil compaction below tank specified (if soil non-native) — 221(2) 6" of <=3/4" stone beneath tank specified — 221(2) & 228(1) Buoyancy calcs. Required if tank at or below water table — 221(8) Tank is watertight — 221 (1) 9" of cover over tank specified (minimum) — 228(1) H-10 loading (min.) — H-20 if traffic — 226(3) Top of tank <= 36" below grade — 221(7) All pumping to tank (if applies) in accordance with — 229 AN alarm set at 3/5 tank capacity — 260(2)(c) Min. 1-24" frame w/cover at finished grade — 228(2)(f) Year round access for pumping — 228(2)(g) Distribution Box (Check here if not present: ) OK Problem N/A Inlet elevation: 2 f Outlet elevation: 101", 0.17' drop from inlet to outlet (minimum) - 232(3)(b) 6" sump (minimum) - 232(3)(e) All outlets at same elevation - 232(3)(b) Outlet pipes laid level for first 2 ft. - 232(3)(c) Pipe Sch 40 - NA 10.01 Number of outlets: Number of laterals: Size of outlets: q Inlet baffle/tee min. 1" over outlet invert for all d -boxes - 232(3)(a), Soil compaction below distribution box specified (if soil is non-native) - 221(2) 6" of stone beneath distribution box specified - 221(2) Box is watertight - 221 (1) Top of box <=36" below grade - 221(7) Buoyancy calculations required if box is at or below water table - 221(8) Pump Chamber (Check here if not present: ✓' ) OK Problem N/A Volume specified: 1 20(4)(r) Pump on elevation- 220(4)(r) Pump off elevation: 220(4)(r) Alarm on elevation: 220(4)(r) Number of cycles per day - 220(4)(r) (also 254(1)(d) if gravity from d -box) Minimum 2" delivery line to d -box if gravity - 254(1)( c) Pressure dosed Lf. if flow >= 2,000 gpd - 254(1)(a) & 254(2)(a) Cycles per day is consistent with chamber volume - 23 1 Volume calculations include flowback volume - 2') ] (2) 5 M 24 hour storage capacity above pump on elevation - 231(2) Number of pumps: 2 if system serves >2 dwelling units - 231(6) Capacity of pump(s) - gpm @ ' TDH - 220(4)(r) Pump can pass 1 1/4 "solids (minimum) - 231(7) Pump controls specified - 220(4)(r) Alarm equipment specified - 231(2) Alarm is in building and powered on separate circuit from pump - 2') 1(9) Pump sequence correct (off -lead on -lag on-alan-n on) - 231(8) Pump performance curves included - 220(4)(r) Manual operating switch - NA 12.01 Check valve, bleeder hole - NA 12.01 1 childproof, 24" riser/manhole to final grade - 2'31(5), Soil compaction beneath pump chamber specified (if soil is non-native) - 221(2) 6"of <=3/4"stone beneath chmbr. specified - 221(2) & 228(1), Buoyancy calculations if chamber is at or below water table - 221(8)@ 9" of cover over chamber (minimum) - 228(l) H- 10 loading (min.) - H-20 if traffic - 226(')), Chamber is watertight - 221 (1) Top of chamber <=36" below grade - 221(7) Leaching Facility (general - complete for all designs) OK Problem N/A Yl, t/ 50% larger if garbage disposal - 240(4) Trenches to be used whenever possible - 240(6) No vehicle or imperv. area above 11 unless unavoidable - 240(7); NA 13.02 Vented if under impervious cover - 241 (1) Vented through same pipes as distribution system - 241 (1)(a) Vent protected from precipitation/animal entry - 241 (1)(b) Vent is placed beyond traffic or impervious area - 24 1 (1)(c) All lines connected to vent if bed or trenches - 241(1)(d) 9" cover over peastone - 240(9) Reserve area provided (new construction) - 248(1) Reserve 4' from primary leach area — NA 9.04 4' (5' if perc rate <=2 MPI) separation to g.w. - 212(a) & (b) 4' (down to 2' with variance or I/A - upgrades only) of natural soil under 11 GW separation is adjusted to highest existing grade if facility cuts into a hillside Pipe slope minimum of 0.005 - 251(9) Require 5' removal and replacement if in fill - 255(5) Top of leach facility <= 36" below grade - 221(7) Final grade over 11 minimum 0.02 ft/ft -240(10) Surface & subsurface drainage away from l.f. - 240(1 1) & 245(5) Minimum design flow 440 gpd without deed restriction — NA 13.01 3:1 slope where grading required - 255(2) Toe of fill slope stops 5' from property line or Swale installed - 255(2) Impermeable barrier if < 3:1 slope or < 15 feet to—3:1slope - 255(2) Impermeable barrier/retaining wall poured concrete — NA 9.02 Retaining wall stamped by P.E. - 255(2)(b) Top of retaining wall >= top of peastone elevation - 255(2)(f) 10' offset from edge of leach facility to edge of ret. wall - 255(2)(g) Pere test(s) done in most restrictive layer - 104(2) Pere test 4' below leaching elevation — NA 7.06 Design flow listed and required/provided leach area given - 220(4)(f) Leach pipes SCH40 PVC — NA 10.01 Leach pipes minimum 4" diameter except for dosed system — NA 14.04 Leach lines capped, vented, or connected together - 251(9) Pressure dosing guidance followed if pressure distribution - 254(2)(c ), ✓ Pressure dosing required over 2,000 gpd or with I/A remedial use - 231(1) Leaching Trenches (Check here if not present: ) OK/ Problem N/A 3 Number of trenches: Minimum of 2 trenches - NA 9.01(2) ,, Depth of trenches (max eff. 2'): -247(l) Width of trenches (2' min., 4' max.): - 251 (1)(b) Length of trenches (100' max.): - 25 1 (1)(a) Trenches are vented (when > 50') - 251 (11) Trenches follow contour lines - 251(2) Trench spacing 3 times effective width or depth minimum- 251 (1)(d) In fill or reserve between trenches, 10' min. - NA 14.01& 1.4.03 Available leach area given (Min. 500 s.f.) - NA 9.01(2) Bottom = L x W x # — Sidewall=L x x# x2= Effective leach area given Loading factor: ! Effective area = total area s.f. x LTAR — Effective area is >= design flow of facility being served 2"of 1/8"- 1/2" 2x washed peastone.- 247(2) Trench depth of 3/4" to 1 1/2" double washed stone - 247(1) Leaching Pits (Check here if not present:) OK Problem N/A # of pits/pit systems: (dosing chamber if >1, 231 (1)) Dimensions of each pit or system: L W D _ Depth of pits (max eff. 2'): - 253(l)(a) Available leach area given Bottom = L x W x # of systems = Sidewall = L+ W x D x 2 x# of systems Total area = bottom + sidewall = Effective leach area given s.f. s. f. g/day s.f. s.f. s.f. Loading factor: Effective area = total area s.f. x LTAR = g/day Effective area is >= design flow of facility being served Minimum of 2 pits at least 13'X16' — NA 9.01(3) Distribution for galleries/chmbrs. in trench config. - pipe every 20' - 253(6) Distribution for galleries/chmbrs. in bed config.-ea.pipe serves <= 40 s.f.-253(6) Spacing - 2 times the effective width or depth (the greater) - 253(l)(c) 2"of 1/8"- 1 /2" 2x washed peastone.- 247(2) 3/4" to 1 1/2" double washed stone - 247(1) Each pit has at least one 20" access cover. 24" CI to grade over 2,000 gpd -253(3) Surrounding aggregate thickness between 1' (min.) and 4' (max.) - 253(1)(b) Vents, if necessary, extend under covers of pit(s) - 241 (e) Leach Fields (Check here if not present: OK Problem N/A Number of fields: (need dosing chamber if> 1, 231 (1)) 7 Length (100' max.): - 252 (2)(b) Width: Total area: L x W = s. f. Minimum 900 square feet - NA 9.01(1) Distribution lines connected with solid pipe — NA 15.01 Effective leach area given Loading factor: Effective area = total area s.f x LTAR = g/dav Effective area is >= design flow of facility being served Minimum of two distribution lines - 252(2)(a) 6' line separation (max.) - 252(2)(d) 4' maximum separation from edge of field to line - 252(2)(e) 10' minimum separation between adjacent leach fields - 252(2)(f) Between 6" and 1.2" of 3/4 - 1 1/2" stone beneath field - 252(2)(g) & 247(2) 2"of 1/8"-1/2" 2x washed peastone.- 247(2) )Final Grading OK Problem N/A Slope over leach area minimum of 0.02 feet/foot — 240(10) Grading shall divert drainage away from leach area — 240(l 1) Grading slopes away from dwelling 5/24/01 8 S �,o�iC � y � Tom/►-� U�t1 /J �� 5 i Z�1� 70 ,q/YI©U/Vi OF No �tiSP�"ciio�c.> of= s s z7S T"6 �U I�NG�/GU19Z171. S.S, �v�ti/�� z.uo F a -715' No siGti b cF �,P�� 121&19��i�, �L�G 7 � LC p 4/ Lb -VpKe y 39 co Pp N EEa 90 0 �> Cl) a r -t a CD -7 V) `` v) Q c� 0 UN --q rt m 0 -fi -n El Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH [<�� =t- i, DRAAPPLICATION FOR SITE TESTING/INSPECTION ATED PPR` '(� �SSACHUSE� Applicant AAa2 ��e��X NAME ADDRESS TELEPHONE Site Location �40,/ Z/i /VC30=b�� Engineer Test/Inspection Date and Time. 0'-'�"-� CHAIRMAN, BOARD OF HEALTH Fee Test No. " Zo S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. i L o c'n 101\I _•� `��9U Oi " /LSI I iV=S S. • �'• ��-COL=. i ION i =� i = =0.► i OIi'vl D;:::--7*-*OF i INIE T iNlE ,=. jiNlc .". i 'R.. T III/I. tiNl�,.i � .:. • OCT. 3.202 5:57PM P 1 FROM . . R.. C. TRNGARD PHOt-E tJO. : 701 334 0115 FORM I I - S011. EVAIXIATOR 1 OWN1 Page 2 of 3 i Location Address or Lot No. %' j 4l,, (fin -site Review Deep Hole Number Date:../ 1 Tima,.�.vu. Weather. ��%�'� � Location (identify on site plan) Land Use ......,l Slope (°h} Surface Stones 1�— Vegetation '_and!orm .. Position on landscape (sketch on the back) Distances frorn: open Water Body feet Drainage way :... feet Possible Wet Area feet Property Line .. feet Drinking Water Well feet Other. DEEP OBSERVATION HOLE LOG* � Depth from SjOace (.Inches} Soil Hcriton Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, Graven 10. -� a` �f - N AAM -� 40 -F-VI IMUM OF 2 KC-LE'J REQUIRED AT EVERY PROPOSED DI5PO5AL AREA parent Meteria; (geologic) _ Depthtolaedrol* Depth to Groundwater: StandiN Water in the Hole; ^ _ Weeping from Pit Face-_ Estimated Seasonal High around Water; DEP APPROVED FORM - 12107195 - - V V l . .�. GC.ICIG .J • .11Jf 1 1 L FROM.: R. C. TANGARD PHONE NO. 731.334 0115 FORM 11 • SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No, b !� `��&ev On-site Review Deep Hole Number Date:...:.:..:..� /�/ Time;. Weather � Location (identify on site plan) ✓ Slope M 1. Surface Stones Land Use ..... ,�- ... ...... : Vegetation Landform I Position on landscape (sketch on the back) f,..� .... Distances from: Open Water Body feet Dreinege way feet Possible Wet Area feet Property Line ......:.:.. feet Drinking Water Well ..:..... fee! other ....:.:...:,.....,v..,. DEEP OBSERVATION 'HOLE LOG' Depth from Sorf ace (inches) Soil Horizon Soil Texture (USDA) Soil Color (Mur i) Soil Mottling ` Other {Structure. Stones, Boulders, Consistency, Ok Gravel) 1� 7 Ft. 11- 7,,-q,i, 2,91 i wmriiuM wr L r1VLLJ nGu4 in ru MI ry Gn 1 rn Vrwocu u{arw,;)` L^ncM Parent Material Igeologle) Depthtosedroek: Depth to Ground walon Standing Water in the Hole:_ Weeping from Pit Face: __ ___-•- Eslimated Seasonal High Ground Water: UE!' APYR01'6D FORM - 12:07ro5 ' i, ,1 LOCA ICN: C G chi- NGIAV C 0 La. 710 N i = C ill_ A7r t� i TINIE T,6" saw i HM 1N EX i ---;",.Y i iN1` ,` BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR SOIL TESTS DATE: f ( 0 MAP & PARCEL: LOCATION OF SOIL TESTS: OWNER: H,4 ✓4 9 i2 y'Lr'� Et E TEL. NO.: ADDRESS: _i UI C 1>5 a h�N ENGINEER: )\)e --j ,u G�;rir �hy� e e�z; _ TEL. NO.: 7 8 G `v G 7 ',:5 CERTIFIED SOIL EVALUATOR: Intended Use of Land: Residential Subdivisiong e hamily Home Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $200.00 per lot for repairs or upgrades. (If time is not critical, fee for repairs is $75.00) GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be subnvtted'_to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. ' r t 2 LL I) Please Do Not Write Below This Line_ N.A. Conservation Commission Approval: D Date Received: Check Amount: Check Date: A . � , T . Board of Health No rt3::� dover, Yas s APPRWED DATE Provided' r P� 14 SUBSURFACE DISPOSAL DES GN CHWIK LIST LOT f 9 'CED'SS Sa � DISAPPROVED DATE Reasons s° 00*& 1Z4 70 v 17-&3 Title V Reg 2.5 Un) Reg 6 FAIL UL The submitted plan must show as a minimum: ' a) the lot to be served -area dimensions lot #,abutters � location and log deep observation hoes -distance to ties location and results percolation tests -distance to ties design calculations & calculations shOwi.ng required leaching area location and dimensions of system -including reserve area f) existing and proposed contours g) location any vet areas within IAO' 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 100' of stege disposal system or disclaiir—er-Planning Board fires () known sources of imter stipply within 2001 of sewage disposal e _ system or disclaimer location of any proposed well to serve lot -1001 from leaching facilit: location of water lines on property -101 from leaching facility (m) location of benchmark 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 Either elevations r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Eagineer or other professional authorized by law to prepare such plans Septic Tanks capacities -1507> of flog, water table, tees, depth of tees, access, pumping cleanout c) 101 from cellar -wall or inground sWlsn:ing P001 (d) 25' from subsurface drains / ✓ —A�a) I Reg 10.2I Distribution Foxes slope greater than 0.08 Reg 10.1 I b) sump •'110 Co�o�tz. M�41T SG �c� OF tv�,praps c%FCu�. w�""-„---. 1 �'W*N toa>` 10 r.>Q.A%*j C-0.--,ret.1E,q" Tile 4ewwMa -nAA#.a tem `ry —tb&A E1W.'1�3•z Ne 4 4E �NvE¢. vN1 ,s-a`►.e� ekev = 11'4.0 aa_ �-��t;C-v- 5'fL�YI lou F�aM DITZ 1,1 so ' ► ' . `t' I t Y of A ✓ u5--= fact> P: ::i = Chach List FII► M Leaching Pits Leaching pits are preferred where the installation is possible a) calculations of 1 hing area -minimum 500 sq ft b) spacing c) surface a 2% d) cover ma Tial e) 2'x21 0 splash pad f) at elbow bends in pipe from d -box to pipe Leaching Fields Wno greater than 20 minutes/inch W area -minimum 900 aq ft 0 construction of field A)'surface drainage 2 % e) 201 from cellar Wall or inground swimming pool L Leaching DMOdIles cilculatiopb of leaching area -min 500 sq ft snacine- ft min 6 ft with reserve between drainage 2% Downhill. Slo e a) slope Tx - TSo be shown) b) y/x Z 150 = (to be shown) ftms a) approval b) stand-by power SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No CF.0 Lot No (17 Loc/Subdiv. Tv (4 %1 S SC- Pland Owner's -M, 4 os(.too P Investigator (JIzu\e73 Observer y-") -%sM L-St7l 1 SOIL PROFILE DATES 1.'Elev 2.Elev 3.Elev 4.Elev T.pl P� eA 0 4 zo l v3 0 41 7.01 83 0 1 G I I-13t>%JS-t -70\ Benchmark Elevation 1 TS 1 TCS 1 2 1 2 3 2 3 3 ,� 3 4 Le -b.,4 E 1- v 4 � 4 5 5 3 5 6 d 3 6 6 7 7 LLaY 7 M ms.lst 3" drop / 8 Mins.2nd " Drop 8 8 9 9 9 10 . 10 10 Location Datum PERCO;,ATION TESTS DATES if/--) /e/ Ties P11%sTest 1- Ti,.)o pcf-(_5 faEfD64 7 - Nev-) FEc Pit Number 1 2 3 4 Start Saturation Soak -Minutes btart le 1 Drop of 3" -Time Drop of 6" -Time M ms.lst 3" drop / Mins.2nd " Drop Percolation 1 47 Board of Health North Anc_verxMaas Ow BSPT'IC SISTER / INSTALLATICK COOK LIST DI SUPRUMReaurast ~ 1. Distance Tos a. Wetlands b. Drains c. Well 2. Water Line Location r, ll S NpF 3. No PVC Pipe %. Septic Tank a. -Tess -_Length & To Clean flat Covers b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Bqual Amounts •_ 4* c. No Back Flow 6.- Leach Field or Trench a. Dimensions b. Stone Depth 5 , c. Capped Inds d. Clean Double -Washed Stone 7. LeXeh a.b.hc.s d.e.e 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 f I� a. Lot Location b. Dimensions of System c. Location with Aegard_to Pere Test d. Elevations e: Water Table LOTS s do r.J I Folui U . TOWN OF NORTIi ANDOVER LOT RELEASE FUM SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) 7 - PERMANENT PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET 1p l (fR06S &LU APPLICANT A� Sc n► PHONE DATE OF APPLICATION /p I0 g TOWN USE BELOW THIS LINE PLANNING BOARD DATE APPROVED TOWN PLANNER DATE REJECTED CONSERVATION.CO MI)SION CONSER ON ADMIN. )rBOARD OF HEALT l TAx i" DEPARTMENT OF PUBLIC WORKS DRIVEWAY PERMIT .SEWER/WATER; CONNECTIONS FIRE DEPT. RECEIVED BY BUILDING INSPECTION PATE APPROVED Lc 31/9/ DATE REJECTED DATE APPROVED DA'Z'E REJECTED DATE 1 : form shall be signed by the agents of the Planning and Health Boards, ,onservation Commission prior.to the issuance of any building permits ie subject lot. This form shall not releive the applicant from the ince of any applicable Town requirement.or Bylaw. f ` TO: FROM: NORTH ANDOVER, MASS �� 19 t'-.3 BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at 1 U % 9 C R oss idea '-� 1 N'F North Andover, Mass. SITE LOCATION The grades and construction are as specified my plans and specifications dated MAY C 19 9-!E3. A/E V' /9's /V6 -`c A5 j , L T 11-214 /Y