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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: _102 Wintergreen Drive_
_North Andover
Owner's Name: John Carney_ _
Owner's Address: 102 Wintergreen Drive_
North Andover, MA 01845_
Date of Inspection: _9/14/2002_
Name of Inspector: Neil J. Bateson
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: ate: _9/14/2002_
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _102 Wintergreen Drive_
_North Andover—
Owner: Carney
Date of Inspection: _9/14/2002
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.
Answer yes, no or not determined (Y,N,ND) in the 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 exfiltratiion 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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _102 Wintergreen Drive_
_North Andover—
Owner: Carney
Date of Inspection: 9/14/2002_
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
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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _102 Wintergreen Drive_
North Andover—
Owner: Carney
Date of Inspection: 9/14/2002_
D. System Failure Criteria applicable to all systems:
You must indicate `yes" or `no" to each of the following for all inspections:
Yes No
_No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
No Any portion of the SAS, cesspool or privy is below high ground water elevation.
No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
No Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ 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 certifned laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
_No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or `�no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _102 Wintergreen Drive_
_North Andover—
Owner: Carney
Date of Inspection: _9/14/2002_
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes _ Pumping information was provided by the owner, occupant, or Board of Health
No Were any of the system components pumped out in the previous two weeks ?
Yes _ Has the system received normal flows in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
_Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Yes _ Was the facility or dwelling inspected for signs of sewage back up ?
Yes_ _ Was the site inspected for signs of break out ?
Yes _ Were all system components, excluding the SAS, located on site ?
_Yes _ 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 ?
_Yes_ _ 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:
Yes no
_Yes _ Existing information. For example, a plan at the Board of Health.
_No_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [3 10 CMR 15.302(3)(b))
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _102 Wintergreen Drive_
_North Andover—
Owner: Carney
Date of Inspection: _9/14/2002_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _825
Number of current residents: _4
Does residence have a garbage grinder (yes or no): _No
Is laundry on a separate sewage system (yes or no): _No_ [if yes separate inspection required]
Laundry system inspected (yes or no): _
Seasonal use: (yes or no): _No_
Water meter readings: Jun 00 to Jun 02 = 69,400 Ft3 x 7.5 = 520,500 Gals./730 Days = 713 Gals./Day _
Sump pump (yes or no): _No * Has sprinkler system
Last date of occupancy: —
Current-C
OMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no): _
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped March 02, owner
Was system pumped as part of the inspection (yes or no): Yes_
If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank _
Reason for pumping: Inspect tank & tees
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information: _8 years old. Sept. 1,
1994 As built plan_
Were sewage odors detected when arriving at the site (yes or no): _No
A
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _102 Wintergreen Drive_
_North Andover—
Owner: Carney
Date of Inspection: 9/14/2002_
BUILDING SEWER (locate on site plan) X
Depth below grade: 24" .
Materials of construction: _cast iron _X_40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.): _4 ff PVC thru wall to septic tank 3" PVC
in house. No leaks.
SEPTIC TANK: X locate on site plan)
Depth below grade: _12"_
Material of construction: —X—concrete _metal _fiberglass polyethylene
_other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: _10' x 5' x 4'
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: _2011
_
How were dimensions determined: _Subtract scum & sludge depth to tee length. _
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 leakage. _
GREASE TRAP: _(locate on site plan)
Depth below grade: _
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 102 Wintergreen Drive_
North Andover
-
Owner: Carney
Date of Inspection: 9/14/2002_
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: _X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: _0_
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.): -D-box level & distribution equal. No evidence of leakage. Evidence of
carryover, pumped d -box to clean. _
PUMP CHAMBER: (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 1 i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _102 Wintergreen Drive_
_North Andover—
Owner: Carney
Date of Inspection: 9/14/2002_
SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
_X_ leaching fields, number, dimensions: _1 field 25' x 36'
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): _Soil oL Vegetation oL 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 or no):
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.):
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _102 Wintergreen Drive_
_North Andover_
Owner: Carney
Date of Inspection: 9/14/2002_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 fat. Locate where public water supply enters the building.
�W
A to Tank = 41'
B to Tank = 29'
B to D -Boz = 3616"
C to D -Boz = 54'
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _102 Wintergreen Drive_
_North Andover—
Owner: Carney
Date of Inspection: _9/14/2002_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 4 feet
Please indicate (check) all methods used to determine the high ground water elevation:
X Obtained from system design plans on record - If checked, date of design plan reviewed: _4/9/1986 _
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation: As per design plan_
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 102 Wintergreen Drive, North Andover
Owner: Carney
Date of Inspection: 9/14/2002
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system
Bateson Enterprises, Inc.
F
Date: _ t a -t 14 n_ -
Homeowner;
Street.
Phone .
AAl
TOWN OFAANDOVER
SEPTIC SYSTEM SERVICING
REPORT
Nature ��f S 2rvice: Routine
Emergency
Observat:.ion;; :
Descriptiot.. of Work:
Comments:
Pumper -��
Address:
Phone
Good Condition
Full to Coven
Baffles in Place
Leachfield Ru:iback
Excessive SOI. -ds
Heavy Grease
Roots
Other (Explain)
a
T � tW
I
No......................... FnR.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........TOW N ............. O F...........QATH....ANN.O.V49........................
Appliratiun for Di ipa�al Hitirkri Tunitrnrtiun Permit
Application is hereby Inade for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal
System at:
F.N...Dgi.vF.................................... .D.l......
o atio • A d es
1...1 ...................... ...6.7.1...�1��,���`f
Owner Address
....................................................................................................................................................................................................
Installer Address R
Type of Building Size Lot...4 .l Je�5..Sq. feet
Dwelling —No. of Bedrooms ............. .........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Btiildirlg ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures..........................................................................................
Design Flow .............. 8?1.1................ gallons per person ppr da�. Total daily gow............... �s............... gallons
Septic Tank .-- I..iquid capacitv�,OQgallolls I_ength.1Q.-.6.r.. Width.6.� .8.... Diameter ................ Depth....
Disposal --N, iF144. )..... Width..?,.S .......... Total t.ength......36.'
6C? 1...... Total leaching area..... 9%40...... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box (A ) Dosing tank
Percolation Test Results Performed by.....Cf'�k/STf,41S/ .�•(�({,/Gr--• Date.�R�U�?.I......(...1.........
Test Pit No. I ..... 2 ....... minutes per inch Depth of Test Pit ...... 78 .... Depth to ground water ..... .(PQ
Test Pit No. 2 ...... t?r.....minutes per Inch Depth of Test Pit .....4'h........ Depth to ground water ......(pq...........
.............................................................................................................................................................
Description of Soil ........0..'.. .4.11... %MPSI* (.....Aga.!Z!C....................................................
.......................................
..................................... ...... rr.••...............................................................................••---....---....................---.......
.................................................................................................................•-----............---••-------•--•-•--------...........................................
Nature of Repairs or Alterations — Answer when applicable................................................................................................
........................•---•----...........--------............................---•--•-•---•-•--.......---.....--•---..................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed......................................................................................................................
Date
ApplicationApproved By...............••---............................................................---...........---
Date
Application Disapproved for the following reasons: ................................................................................................................
..........................................................................................................---.................................................--••••....................---..............
Date
Permit No ......................................................... Issued ........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... O F ................................................. ....................................
AT
VWrtifiratr of Tuntliliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..........................•-•---•---...-•---•---.......................---•--..................................................----•--•----........................................................
Installer
at...............................................................................................................................
has been inst:filed in accordance with the provisiogs of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector......................--............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. I .................. ......... OF .....................................................................................
N0 ......................... FEE ........................
Di,qpuual IV urk!5 kTuluntradiun VerMit
Permissionis hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) :111 Inclivirinal Sem=agc Disposal System
atNo........................................................•-
...................................
Street
as shown on the application for Disposal Works Construction Permit No ..................... Dated ..........................................
....................................................... ..................................................
Board or Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
Town of North Andover, Massachusetts Form No. 3
Of NORTH 1 BOARD OF HEALTH -
l3 ��
O� 19
F 9 �-
} %
DISPOSAL WORKS CONSTRUCTION PERMIT
�,SSACHUSEt
Applicant "Tf, UL/ _
NAME ADDRESS TELEPHONE
Site Location (-V
Permission is hereby granted to Construcy�or Repair ( ) an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
i
CHAIR AN, BOARD OF HEALTH
Fee D.W.C. No.
Town of North Andover
Office of the Health Department
Community Development and Services Division
^9
27 Charles Street
North Andover, Massachusetts 01845 9SSACNuS%
Sandra Starr
Health Director
August 2, 2001
Mr. Jack Carney
102 Wintergreen Drive
North Andover, MA 01845
Re: Application for dining room, family room deck
Dear Mr. Carney:
Telephone (978) 688-9540
Fax (978) 688-9542
Your application for an addition at 102 Wintergreen Drive has been reviewed by the Health Department. The
application was denied on August 1, 2001 for the following reasons:
1. P Missing information
2. $/ Passing Title 5 inspection of septic system may be required
3. ❑ Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply:
a� Floor plan of existing and proposed addition
Certified plot plan showing house, septic system and proposed project in scale
If #2 is checked:
Have the septic system inspected by a certified Title 5 inspector to determine the size of the system
and whether it is operating properly:
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Sandra Starr, Health Director
Cc: Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section**************-***
APPLICANT:e-C`'�- Phone
LOCATION: Assessor's Map Number Parcel
/
Subdivision wrn -7&7L
& S 7_47_�� Lot(s)
Street St. Number /G L
************************Official Use Only************************
RECOMMENDATI NS OF T WN BENTS:
"` Date Approved
Conservation Administrator Date Rejected
Comments
61
i� 1-tc i t Date Approved
Town Planner Date Rejected
Comments
Food Inspector -Health
Septic Inspector -Health
Date Approved
Date Rejected
Date Approved _-3/v�7/"jCSr
Date Rejected
Comments 70 0&.
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector
Date
N/F Dorothy Arsenault
1
199.62
0
Lot 16
•N� Area = 4 , 568
Lot 17 N ;
Ezistin Foundation
SEPTic
UU1CH
'71CL:b
g5'7o SILT" ,4y_
90' To LEpx.,krIELb
N�
200.00,
WINTERGREEN
DRIVE
o.` OF G Location NORTH ANDOVER t MA.
a-
REDMOND rn Date _ June ?R, 1994 Scale: 1 inch = 40 feet
•e No. 31342
9a�A�Orsp��d� Deed and Plan Reference:
Deed Book Page Plan Book 1003 2 Page
-Certification is hereby made to: Stoneham
Savings Bonk
that the existing structures as shown are situated on the'lot
Commonwealth Engineering designated and are in compliance with the applicable Building and
Associates, Inc. Zoning By-laws of the municipality when constructed.
16 Old Post Road
E. Walpole, MA 02032 Certification 1i hereby'made that the structure shown on this plan.
IS NOT located within a Special Flood Hazard Area as delineated
Phone: (508) 668-5136 on the FIRM map of Community Number 250098 0007C
f-- '—r-- W^n% ^^- ..rte .. - ^ ^ e% -2
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FORM U -LOT RELEASE FORM
tUCTIONS: This form is used to verify that all necessary approvals/ r is from
s and -- partments having jurisdiction have been obtained. This does not relieve
,plicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION T
'PUCANT
✓LOCATION: Assessors Map Number.
SUBDIVISION
STREET l C) a (L IJ;
TIONS OF T
N ADMINISTRA
--PHONE 9 7 � ` i�I i I
*'"" ***OFFICIAL USE ONLY
AGENTS:
DATE APPROVED
DATE REJECTED_
vPARCEL___
LOT (S)
"T'. NUMBER
TOWN PLANNER
COMMENTS
DATE APPROVED
DATE REJECTED
FOOD IN4KCTOR-HEALTH DATE APPROVED
TH
DATE REJECTED
DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
FORM U - IAT FMZASu FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this sectio ***** * *********
//11114-'e-
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APPLICANT: C_J� 0e ,44-& G 114- 'e- ➢ `L Phone
LOCATION: Assessor's Map Number /0-/& Parcel i CI *7
Subdivision -sLots)
Street �%��':� <-P.✓ �`_ St. Number b Z
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved f
Conservation Administrator Date Rejected
Coir= eats F"< L91A1 -05 A-"Y2d
R
Cku±all _
Date
Approved k C Citet
Town
Planner
Date
1.
Rejected
Comments
Food Insrector-::ealth
Sent -'c Insrector-Health
Date Approved
Date Rejected l
Date Approved��7/
Date Rejected
Co=erts �.�L`;/t-"-"4�/L%i)�ee /
Public Works -- -'water connectionsml 1 - drivewav permit / �S�WSIWO'
V-
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Fare Decart:aent �4�u',y-�.. i9/'�^%'LCi��E'� .0�71e''LL�l�Cc'�'�
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Received by Building Insmector Date
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Town of North Andover, Massachusetts Form No.
`BOARD OF HEALTH
19�
ss� DESIGN APPROVAL FOR
sACNUS� SOIL ABSORPTION_ SEWAGE DISPOSAL SYSTEM
Applicant,
Test No
Site Location—Lb T--* j)i n V,
Reference Plans and
i-
_:i�
DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
s
Fee G
�)61
CHAIRMAN, BOARD OF HEALTH
Site System Permit No.
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``•'.1�. ihi•`.2L �lt_A<i.�b-t��S�.A�a.,� �.ti�4ui�:T:C��iX'i #'Y6h.1���¢43:�I'',:�vldc :\. �.�..! \�,� .t _, r) � .�.. -a .. ... _ .. .. .
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PLAN REVIEW CHECKLIST
ADDRESS/�//� j [%,E?:G�Ld ENGINEER
GENERAL
3 COPIESI STAMP'' LOCUS L---' NORTH ARROW SCALE
CONTOURS PROFILE SECTION t� BENCHMARK SOIL &
PERC INFO ✓ ELEVATIONS WETS. DISCLAIMER �� WELLS &
WETLANDS L,---'WATERSHED?� DRIVEWAY Elev) WATER LINE
FDN DRAIN SCH40 (/ TESTS CURRENT? 6 I
SEPTIC TANK
o
MIN 1500GZ
INVERT DROP GARB. GRINDER"!� ! (+200o EDF)
25' TO CELLAR MANHOLE TO GRADE ELEV GW
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET Zi - 3 7 - OUTLET J L . = r % (2" OR .17 FT) TEE REQ' D?
LEACHING
MIN 660 GPD? RESERVE AREA l/ 4' FROM PRIMARY? ` 2% SLOPE
100' TO WETLANDS ✓ 100' TO WELLS C---' 4' TO S.H.GW L----
35' TO FND & INTRCPTR DRAINS ✓ 325' TO SURFACE H2O SUPP
4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (25'
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 gpd SLOPE (min .005 or 6"/1001) >31COVER?-VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 6') IS RESERVE BETWEEN
TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE?
BOT X LDNG + SIDE X LDNG = TOT
(L x W x #) (G/ft2) (DxLx2x#) (G/ft2)
Copyright m 1993 by S.L. Starr
PITS
MIN 660 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT
GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE
BOT + SIDE x LOAD = TOTAL
(L x W x #) (2x(L+W)xD x #) (G/ft2)
CHAMBERS
MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT
MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005
BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT
BOT + SIDE X LOAD = TOTAL
(L x W x #) (2 x (L+W)xD x #) (G/ft2)
FIELDS
MIN 660 GPD900 ft2 BED PERC RATE FASTER THAN 20M/IN 4 --
GW MIN 4' BELOW BOTTOM OF FIELD`-' PIPE ENDS JOINED? Ob er077417
4" PEA STONE? G/ DIST LINE SLOPE .005? —J >3'COVER-VENT —
SCH 40 4,� MIN 12" COVER `--
RATER M //1) LDG /• O X 660 (906) ��-ir�3�= TOTAL qz}0 4(:T'
ft2/G REQ 'D (f t2) LXW
DOSING TANKS AND PUMPS
DIMENSIONS X X =
L W D Vol.
DISCHARGE SIZE
MANHOLES TO GRADE
inlet) HWL LWL
OP. SWITCH
Copyright 0 1993 by S.L. Starr
DISCHARGE RATE
ALARM SEP. CIRC.
CHECK VALVE
PUMP CAPACITY gpm
gpm
DISCHARGE TIME
GW (Min. 1' below
BLEEDER HOLE MANUAL
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FML APPROVAL
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