Loading...
HomeMy WebLinkAboutMiscellaneous - 107 ROCKY BROOK ROAD 4/30/2018 (2) - -- 107 Rocky Brook Rd. 1 r t C A` �,, A v r ;'f :•h +L„`..p.lr`y�"�l ”tt .'`-s 1t 'y � ,,q 6Sa;".'Y����'�r���+E��r.. snie - 5': t t F � } y J y tics , > ,,,,pp *"`�L ',,. fr •" .s r ,P �'`r�i� �as „��,f'�,✓t r..° .�i ? tr�7 } �� t.,F. MAP # /�I ' ''i` � ' LOT # PARCEL. # :3 STREETL �O.NSTRUC_TIp.N A.PPROVA.L� HAS PLAN REVIEW FEE .BEEN PAID? YES NO PLAN APPROVAL: DATES APP. BY --- DESIGNER: PLAN DACE. CONDITIONS WATER S PLY: TOWN WELL WELL PERMIT-,-- DRILLER WELL TESTS: CHEMICAL DAIS APPROVED B RIA I DA I E /1PNROVED BACTERIA II DATE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSULYES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION A P P R 0 V A L YES NO OTHER ' YES NU ANY VARIANCE. NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:.9/_Lfµ/_7G • S • �E=Q_3) EM— .NSI_a4Llal- QN ,�Rr•. •v;l '{' , f r 11.:z>;..1 '7. ... '♦"'• iI •. T 'A. '.,^, It` t _\ �.^ 1 1.,' y, .. 'THE' INSTALLER LICENSED? yet YE NO TYPE. OF CONSTRUCTION: ?' - _ - a NEW REPAIR' NEW CONSTRUCTION:' CERTIFIED PLOT PLAN REVIEW NO t = CONDITIONS OF. ..APPROVAL YES NO (FROM .FORM U) `.,ISSUANCE OF DWC PERMIT' ` YES NO - 1;DWC PERMIT N0. r - INSTALLER: �eZ �'��) " BEGIN INSPECTION YES 0 _ t :EXCAVATION , INSPECTION: ; NEEDED: •t1 - � S 1/ L ',fit.' . .....,PASSEDqw BY CONSTRUCTION INSPECTION:, . , ;= NEEDED: AS BUILT PLAN SATISFACTORY: , YES: - .APPROVAL. TO BACKFILL: 4z DATE: HY " ' .< FINAL . GRADING APPROVAL: DATE I�9`f� BY FINAL CONSTRUCTION APPROVAL: 3f/ � BY 40 DATE. Commonwealth of Massachusetts �fCr:4 _ City/Town of North Andover System PumpingRecord S ': Form 4 �w+�o> �. A, # � :h 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 he Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility information Important:When filling out forms 1. System Location: on the computer, `` use only the tab Id-7 &Ck `y C ©(�/� key to move your Address cursor-do not North Andover Ma 01886 use the return key. City/Town State Zip Code 2. System Owner: cS'��r IoG/l Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record s 1. Date of Pumping Date _ 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ( Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ .No if Yes,!was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date I t5form4.doa 03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of No Andover System Pumping Record DT 7 2013 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT + yee e DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not No Andover Ma use the return key. City/Town State Zip Code 2. System Owner: Whet, Gc Name relun Address(if different from location) Citylrown State I Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: ed:Date 1vol� Gallons 3. Type of system: ❑ Cesspool(s) � Septic Tank Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filterresent? p ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pump 4 Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 i X Commonwealth th of Massachusetts ; � ����, � W City/Town of No Andover W° System Pumping Record SEP .i 2 2013 y` Form 4 G„ TOWN OF NORTH ANDOVER P MENT DEP has provided this form for use by local Boards of Healt ff&ZA% RT y�ie Tse , but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 107 RocN Brook key to move your Address cursor-do not use the return No Andover . Ma key. City/Town State Zip Code 2. System Owner: Sherlock Name nnan 1 I Address(if different from location) Cityrrown State Zip Code Telephone,Number B. Pumping Record 1. Date of Pumping pate 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: C �d� el �I I 6. System Pumped By: i tamAe Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01,835 Sign t e of Hal Date i I Si ature of Receiving Facility Date i t5forrn4.doc•03/06 System Pumping Record•Page 1 of 1 Town of North Andover, Massachusetts Form No.2 ,tORTff BOARD OF HEALTH F w 9 * • c� • �'' DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM ApplicantTest No. Site Location 1 Reference Plans and Specs- ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH J° pl Fee Site System Permit No. 0 le Form No.3 : Town of North Andover, Massachusetts BOARD OF HEALTH (� MORTN ./� •Q �9 �t 4t Ll0 'L'O �1 /. .� • 3j e:T. ..,,,.a oc O p 71 DISPOSAL WORKS CONSTRUCTION PERMIT ,S'V CMtJSEt Applicant AME L ADDRESS TELEPHONE Site Location (V Perm Permission is hereby granted to Construct ' or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. • EA T F D.W.C. No. Fee i Dad Schedule hof Inverts Plan O f L on d in ROC Br R Invert @ Foundc'1on = 124.77' Rocky - VV-de)� Sep tic Tank In = 123.88' North A�do ver, Mass. (Privcte — 5� Septic lank Out = 123.66' showing D—Box In = 123. 16' "As—Built Sanitary Disposal System " D—Box Out = 122.97' Lot �,3B — Rocky Brook Road ' Invert @ Sys tem In = 122.97' Invert @ System End = 122.66' Prepared For Ogun q ul t Homan es, Inc. Sc ale: 1 " = 4 0' Da t e.- April 23, 1996 0 Schedule of Tie Ds t a n ces / hereby certify that / have inspected the construction of this disposal system and that the construction and final grading has AS = 16.6' A' = 101.9' been in accordance with the designer's intent CG = 83.5' and that the materials used conform to the 6-4-4", - ' AD = ..38.9' plan specifications and 310 CMR 15.00. CD = 45.5' AH = 110.6' CH = 84.5' Existing AE = 75.3' Concrete Top of Foundation This plan has been prepared for the purpose - - - - - - - - - - - _ _ _ - - _ - - - - 62.0' Foundation Elevation = 130.42' CE _ ,34.6' Al = 89.9 of showing the "As—Built" conditions of the C B A AF = 6J.5' Cl = 43.6 sanitary disoosol was installed hon the D—Box , premises. All in the �03 CF = 35.8' AJ = 119.9' construction limitations expected for a job CJ = 87.0' of this type. E F D \\\ TOWN OF NORTH ANDOVER/ BOARD OF---HEA TH ��,�tN OF ,*,,�� P2 1500 Gallon � Sep tic Tank E'cya PA JA 23 + N , P1 (3) 50' L ong, 4' Wide, 2' Deep o ° J H G L each Trenches Desi E P.E. 0 Thomas E. Neve Associates, Inc. 447 Old Boston Road — U.S. Route 1 Engineers — Surveyors — Land Use Planners Topsfield, Massachusetts 01983 (887-8586) Job No. 550— 138 Septic System Information 107 ROCKY BROOK ROAD Printed On:Friday, May 18, 2007 u System ID: BHS-2003-0011 General System Information Latest Permit Information Calcaluted Design Flow. Test Pits Septic Tank Disposal Trench k. Design Flow. One Two Capacity. Number. Design Flow Provided: Minutes per inch: Width: Width: Total Flow. Depth: Length: Length: Seasonal: No No Depth to Water. Diameter. Leaching: Grinder. No No Soil Type: Depth: j Laundry: No No Inspections: Inspected: Expires: Inspector. Status: 05/10/2007 Neil J. Bateson Passes Comments: Title 5 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 r r, rt ,0RTM F p Town of North Andover HEALTH DEPARTMENT S4CHU+ CHECK#: ` DATE: ✓/ Q� LOCATION: Al D H/O NAME: CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ O Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 pector $ itle 5 Report $ c37. ❑ Other. (Indicate) $ 2432 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer COMMONWEALTH OF MASSACHUSETTS 7, /�/� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS G. d DEPARTMENT OF ENVIRONMENTAL PROTECTION IA_M by! '9 MAY 15 2007 TOWN OF NORTH ANDOVER TITLE 5 HEALTH DEPARTMENT OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_107 Rocky Brook Road- -North oad__North Andover_ Owner's Name: Huntley Myrie _ Owner's Address:_107 Rocky Brook Road_ _North Andover,MA 01845_ Date of Inspection:_5/10/2007 Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,MA 01810 Telephone Number:_(978)4754786_ 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: X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails ktaInspector's Signature: Date: _5/10/2007_ 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: I ****This report only describes conditions at the time of inspection and ander 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. I Page 2 pf 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_107 Rocky Brook Road- - North Andover_ Owner:_Myrie_ Date of Inspection:_5/10/2007_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 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. 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 pf i 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_107 Rocky Brook Road- -North Andover— Owner: Myrie_ Date of Inspection:_5/10/2007_ 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. i 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: i Page 4 pf 11 . , OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_107 Rocky Brook Road- -North Andover— Owner: Myrie Date of Inspection:_5/10/2007_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: — _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'/z day flow. _No7 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 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.] 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:_107 Rocky Brook Road_ _North Andover_ Owner:_Myrie_ Date of Inspection:_5/10/2007 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? 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? I The size and location of the Soil Absorption System(SAS)on the site has been determined based on: i Yes No _Yes_ — Existing information. _Yes_ — 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 l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_107 Rocky Brook Road_ _North Andover– Owner: Myrie_ Date of Inspection: 5/10/2007_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_600_ Number of current residents:_5 Does residence have a garbage grinder(yes or no): No_ Is laundry on a separate sewage system(yes or no): No_ Laundry system inspected(yes or no): _ Seasonal use: (yes or no): No Water meter reading:_Yes_ Sump pump(yes or no):_No_ Last date of occupancy:_Current_ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sgft,etc.):_ Grease trap present(yes or no):, Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2003,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 forum in : Inspect tank&tees P P g _ P _ 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_11 years old,4/23/1996, As built plan_ I Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_107 Rocky Brook Road_ _North Andover_ Owner: Myrie Date of Inspection:_5/10/2007 BUILDING SEWER_X_ (locate on site plan) Depth below grade:_36"_ Materials of construction: _X_cast iron _X_40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"Cast iron thru wall,3"PVC in house. No leaks visible SEPTIC TANK: X Depth below grade:_24"_ 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 depth4"_ Distance from top of sludge to bottom of outlet tee or baffle: 21"_ Scum thickness:_6" 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: 15" 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 septic tank leaking._ 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.): i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_107 Rocky Brook Road- -North Andover— Owner: Myrie Date of Inspection:_5/10/2007 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: I 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 (locate on site plan) Depth below grade _18"_ 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.Evidence of light carryover,pumped d-box to clean No evidence of leakage._ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_107 Rocky Brook Road_ _North Andover_ Owner: Myrie_ Date of Inspection:_5/10/2007_ 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: X leaching trench,number,length:—3 trenches 50'long_ _ leaching field,number,dimensions: overflow cesspool,number: innovative/alternative system Typetname 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: Number and configuration: Depth—top of liquid to inlet invert:_ Depth of sludge 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 Property Address:_107 Rocky Brook Road_ _North Andover Owner: Myrie_ Date of Inspection:_5/10/2007 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 feet.Locate where public water supply enters the building Driveway Water Meter House C Porch Deck B 1 SeptiTank D- Boz A to Tank=3818" B to Tank=37' B to D-Boz=2216" C to D-Boz=3416" Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_107 Rocky Brook Road_ _North Andover— Owner: Myrie Date of Inspection:_5/10/2007_ SITE EXAM Slope_No_ Surface water_No_ Check cellar _Dry_ Shallow wells_No_ Estimated depth to ground water_4'_ 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:_10/24/1995_ 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_ Commonwealth of Massachusetts City/Town of System Pumping Record F 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 Important: When filling out 1. System Location: forms on the (-\ � Q v computer,use ll only the tab key Address to move your cursor-do not City/Town state Zip Code use the return key. 2. System Owner. Name Address(if different from location) CityfTown State Zip Code i Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was,it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped L;k i Pia t Natn Vehicle license Number Company 7. Location where conte is were disposed: 777 auler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 I VYYI1 VI I YVI Ll 1111 MA VV%.,I Tax Map # 210-090.A-0053-0000.0 107 ROCKY BROOK ROAD HUNTLEY& CAROLYN MYRIE 107 ROCKY BROOK ROAD NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1.05 Acres FY 2007 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until HUNTLEY&CAROLYN MYRIE Owner 107 ROCKY BROOK ROAD NORTH ANDOVER,MA 01845 GALVAGNA,ANTHONY Previous Customer Inactive 11/9/2004 FAZZI,JENNIFER 107 ROCKY BROOK ROAD NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18068.0-107 ROCKY BROOK ROAD Last Billing Date 4/2/2007 3180096 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/ WTR WATER 01 ALL METER SIZE 76.37 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 13306724 a Active 00 METE METE w Water 1 1 0 Date Reading Code Consumption Posted Date Variance 3/16/2007 564 a Actual 23 4/16/2007 -25% 12/13/2006 541 a Actual 28 1/19/2007 -38% 9/19/2006 513 a Actual 48 10/20/2006 52% 6/20/2006 465 a Actual 32 7/10/2006 47% 3/20/2006 433 a Actual 18 4/17/2006 -48% 1/3/2006 415 a Actual 50 1/17/2006 -73% 9/15/2005 365 a Actual 155 10/14/2005 650% Trouble Code:03 6/14/2005 210 a Actual 18 7/15/2005 17% 3/25/2005 192 a Actual 19 4/5/2005 0% 12/15/2004 173 a Actual 7 1/14/2005 -2% 11/8/2004 166 f Final Bill 10 11/8/2004 -82% 9/17/2004 156 a Actual 103 10/8/2004 38% 6/14/2004 53 a Actual 41 7/30/2004 19% 4/23/2004 12 c Correction 81 5/17/2004 0% C/O 69+ERT 12=81 12/23/2003 1010 n New Meter 0 12/23/2003 0% r b 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 Ins ection Report � p i i Property Address: 107 Rocky Brook Road, North Andover Owner: Myrie Date of Inspection: 5/10/2007 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. Nei J. Ba)eson Bateson Enterprises, Inc. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Y p d DEPARTMENT OF ENVIRONMENTAL PROTECTION r V TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION601-1r ��Sf Q,14��6 4�6'�T4•�f�2S'lY'°+�1 Yell/�°e 7' OFIKI Property Address:_107 Rocky Brook Road- -North oad__North Andover_ Owner's Name:_Karl Pearson_ APR 1 4 Owner's Address: 107 Rocky Brook Road_ n North Andover,MA 01845_ Date of Inspection:_4/4/2003_ 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Jails 4/4/2003 Inspector's Signature: � � Date: _ _ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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:_107 Rocky Brook Road- -North oad__North Andover— Owner: Pearson Date of Inspection:_4/4/2003_ Inspection Summary: Check A,B,C D or E/ALWAYS complete all of Section D A. System Passes: _X_ 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 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. 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_107 Rocky Brook Road- -North oad__North Andover— Owner: Pearson Date of Inspection: 4/4/2003 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. , Systemwill 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:_107 Rocky Brook Road- -North oad__North Andover— Owner: Pearson Date of Inspection:_4/4/2003_ 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— — — tili q SAS or cesspool _ _No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z 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 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.] 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:_107 Rocky Brook Road_ _North Andover_ Owner: Pearson Date of Inspection:_4/4/2003_ i 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) i _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:_107 Rocky Brook Road_ _North Andover— Owner: Pearson Date of Inspection: 4/4/2003_ 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#off bedrooms):_660_ Number of current residents:_5 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: Yes_ Sump pump(yes or no): No_ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gnd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped two years ago,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) hmovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 7 Years old. 4/23/1996. As built plan_ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_107 Rocky Brook Road- -North oad__North Andover— Owner: Pearson Date of Inspection:_4/4/2003 BUILDING SEWER(locate on siteplan)X Depth below grade:_24" Materials of construction —X—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"Cast iron thru wall. 4"PVC to 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:—3"_ Distance from top of sludge to bottom of outlet tee or battle: 24"_ Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle:_19" How were dimensions determined:_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. g ):_ Depth of P P 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:_107 Rocky Brook Road_ North Andover_ Owner• Pearson Date of Inspection: 4/4/2003_ 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_107 Rocky Brook Road_ _North Andover— Owner:_Pearson Date of Inspection:_4/4/2003_ 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: X leaching trenches,number,length:_3 trenches 50'long_ leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):'Soil ok.Vegetation ok.No sign of ponding to surface. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth'of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes 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:_107 Rocky Brook Road- -North oad__North Andover_ Owner: Pearson Date of Inspection: 4/4/2003 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 feet.Locate where public water supply enters the building. Drive House C Porch Deck B Septic Tank D- Box A to Tank=3818" 50' B to Tank=37' B to D-Bos=22'6" C to D-Box=34'6" Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_107 Rocky Brook Road- -North oad__North Andover_ Owner: Pearson Date of Inspection: 4/4/2003_ 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:_10/24/1995_ 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 CO y' .a Y _ .. ._ ..._ J r` '_:.J�:o� � - %i"%i�: t'j-i ai':f ti~i•- ��-' ::3'i. - - .e..•w G • _ . .a���-:.�. ::- �•-.: : tic - ;q.-t3 �::':�_�• : I�. .n,s,_ •- G :. ���- �GZ;�SSb]le.§- .�i�V11�V�P�Q�'�� ;!�:7}y1 •�� � `�':° �< ;,{ E ;�33ti58_ t�`+ •Tar j' '?'{, � � _ � =i'-: .;Sr_:i`• - °A-:(-_ - .±F 3':-- .-i^ ,�..Y'_"a. - _ Fi�-- _ : 'C -�,t •,r-�'j -3_,j��r �.� _ g i ak- `���3'-.-._: - - q .y, Y' d''� _ °N• <:>`J�j {'r { i S `•i�: 's_Y &:,r3~ry/•.'i3:�sF _ �. ' �t ••z...z T� --... '1aYY � .�• ;'�•:- 3.14 >J•ij�!�• �, - __ .:4-`-•:'•�z'�'..-'' •=•:J�> ' >t .�1--- :-dpi"� ` `t Q�((? s:i�- .•s,=,:i,.`°.z;,, � -- _ •`tri- .f - • ,� - ..3Sc :3c� - ,3 . -.$ �I�':3�•,; :' , iieiEET'' _ E+( suc y' t.-•.,�` A�oinEiE.� '.:FyY�e/r .f- .r !� Fy=�i�� }T ` 1 tfr'> mill cv IF WATER BILLING HISTORY 816009 R DelI 07 7Gp�ioi# `- iot �---- - #; ROCKY�= BROOK�-� METER 111'•' 3180096'. u ' - • 0 CYCLE SERVICE- MOR CURRE _ WIRYEtt SEWER FEES TOtit- did AL 2 1999-130 05/15/1999 x`0.04 QO' 0:00 WA ' . ;:. .,,.- - 0.00 0.00 0_00 `- f r '=tnternle =`: ,pd� 3 1999=169 02/06/1499 0-0 =R 0r 24-57 0.00 0.00 24.57 4 7999-190 12/29/1998 . 3,28 0.00 O.AO 3.28.' 5 2000-13 10/01/1999 450 540 90 245.70 0.08 0.00 245.7 s ; r 6 2009-23 09/11/2000 540 550 10 27.3© 0.00 0.00 2T.3 1' �' �EkCU�O 7 .2000-33 03/29/2000 550 S60 - 10' 27.30 0_00 0_00- Es -. R.ecy, 8 2000-43 06/15f2000 560 580 20. S4.6p 0.00 0.00 54.60 - 9 2001-13 09/26/2000 ' _ 580 640 60 163.80 0.00 14_30 178.7 70 2001-23 12/12/2©00 60 650 1® 27.30 0.00 14.30 41.6 s x r� 11 2001-33 04/02/2001 .650 670 20 54_60 0.00 14.30 68640. R' ..•Y . . OtaRj---k 12 2001-43 06/19/2001 670 730 60 163.80 0.00 14.30 178.10 ' Ly } irsis'' 13 2002-13 09/04/2001 739 790 60 '193.62 0,00 6.21 199.21 14 2002-23 02/08/2802 790 830 40 102.1.b 0.00, 6.21 108_3T t -r 11S 2002-33 04/10/2002 830 840 10 2410 0.00 6.21 .30.91: ?c?) 16 2002-43 06/26/2002 840 850 10 24.70 0.00 6.21 20.91 17 2003-13 09/17/2002 050 . 909 50 161..60 0.00 6.68 168.28 � 4dei$;lrjg '^ =_`.9YC4.•�-_.., $18 2003-23 :.12/17/2002 900 920 20 47.60 0.00 6.68 54.28: r NEUIEW CHOICE 0 or <ENTEO� MORE HISTORYc -3S r . - _Y;:,, <7i ca.•?-sc;.__•f'1.��.�: = �ti[-.�:.s��_�.�_:c _.a-'� _ - :-yl ,s_ -;�_�;�t:'^,sJ - ' - Rip - � .. - ...3;-�.' --Lar::..�;e.1Jc;:L•,i!' - po, so.:. 'atm' co; mu s. Ii•'�p T7•z� ._:.. �� _zv t t�!4 d '{ T ']'•{•i(t.t i'z, i `� � ' ,p�jjt_ ? .��y.��.� + -}4 9 p� - .L:: '-+-i .t%:i's;}fz3�.n':' 's iia,..•i� ' _ __ s�. - F+_, '?t -?` --j-•�I3'Esr•__ -� _�__-r,.�___..t�Y:�'•>� .,`.-7i�: � �.. •s�se f�_"':�3 i+yr= '•��i �.qz._- .tz 7 4 - -r41. .= :_:.. -.i}'??s_ Ys��a, ,�--� -:.:�' •.;i>.o..a(�a,��: !:s..sr-'�:}.•' '.�it{,.�..a��r ,=F:'•.:�ii;.'t�p � iv��V�' H'=T.hl•� i`.'�,.:�_J�.- _ �=;!_•:. _ -.•�«r...:i •Y-`=IZ-+C'r _ =y:_2y_'i�'• 7 i1. � ..1. y,: - ,) •-• i�,"1��'�"t► - - � a :� - �Lr��f-::t; ,;:. _ 'iti'_':: eii - __ �j�,{�, :-Y "#i.iYa,.•:�::.#[.z::ti"sy'i-•�i� a` f - Nt ZZ.. - f� 1 �n-:'3••: ♦,r.• y�:i.i: e' •!GYggr. } y t-'+'• .:j�,�J� f Qr$�o,(�` r.:.5j }, '< -. �y - 1��,-_r J,`SFr _:�. '. -i.y�' __ - J fgt�. .i,��f_ SSi f�f9•f, ! _ •1 .� -��.: i:`'':�• E. .4e t.t •j of MY.i. - -.Lsc+�a`J-'3 ��•r=. sflPi - �- Y4t_lt i LS - _i : ,. 0 ._i:a�,:'! ga' 3rin `!:' .=�i.•a�ia:....i% _ _ r•-.•,'• ..t � - _Ki hsci ir_ti.-. ♦ :��:;...y_ c> �7 -_—. _: i.'Q'� yjYtkit�a -- a>-�"-'' -�•.- <''.v.%iYFf �"_ .e"T' 1 Q'3. :D ........� WATER BILLING HISTORY 5180096-PEA 0�1rKAR �� - '"` '� -- : stir ----- t7Es 01. 9180096 _ y; Meir' -------- ---- RES-RE 07' ROCKY BROOK; RQ 0 CYCLE SERVICE PRIOR CUR U R SEWER FEES TOTAL 1 2003-33 ,-, 03/17/2003 920 930 10 � 68�`';• = r;. 23 80 O Od 6'. . 3®.48 °iriir1 ; •: ' '� ••cc ss��,. s a .r s- +5�3:i .. S 7,+,n A. Rei i.r .r. ,,"•+ _ - -.i fm. :' :fit 2"? 1. 13 ft •itti�Y i f � � .n Y r is C s w t�s'i i .,t;3 !t'. 'moi}•-,,� .. a , �: : ":� .; . .. - r• t # +� to-ry ,� p.� r "" �, S-�Yx� x'a sw' fi�tt ' L. , ;BEU I EW CHOICE 0 or <ENTER> .M AE HISTORY: ;_moi_}• ":;i'-''',ii ��,i.. _• _._f. .� � _ '- 7 - _ ••yir��'•t"-�-? _ .zii-- r's• z: wn ffid '� � =•5.=i'- �����r:rtd '��; •.- ._,s� -i -r t' ._ 7: _ �w' row,.:"` �v'� t:,.__ '�._ _ _ _ __ _ _}_`'t . 'ts 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: 107 Rocky Brook Road, North Andover Owner: Pearson Date of Inspection: 4/4/2003 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septicY p s stem. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. B eson Bateson Enterprises, Inc. i TOWN OF 0 do tfifL SYSTEM PUMPING RECORD DATE: APR 142003 L 2003 . SYSTEM OWNER& ADDRESS SYSTEM LOCATION--.----,�,.�_j (example:left front of house) ptc((�Ovk- I b 'Roc &ov �- ack DATE OF PUMPING: QUANTITY PUMPED: O-D GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: i CONTENTS TRANSFERRED TO: ' J 2411 R.C.P. __ \ � .D.M.F-I•. � .— �� 5= 0.008 / , Dwelfu 5A ,, L Mon TP1.41 N _ , Rocky`,Brook Rs r `'`--- 122 T?ust , -- ---- 1 �16 122' 1 20 13 n 1 1 1 , •'+��'"�` .v � � '-�`� \�`� \`, 1 � �, � `125'� l i Food Rood \I , 12 2 N 41 ` V 12 rc / ® 4, A �. 4 mom-0 0— Rock Br o Realty u rf"s � ` ♦ , I' r' I . a . O 1 - - 1 12 T O I� O �1��"�9 Qt ►'�.i..3 nn oc i. c�Nd o VI' 3cm .4o 72 h a 3 1ip��c'nv� fill FORD U - LOT RELEASE FORM INSTRUCT- - 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 f is out this section*****,*✓*********�*a* APPLICANT: -•'"" Phone _( C� LOCATION: Assessor's Map Number _ Parcel _ Subdivision A Lot(s) Street 14 ,a tpi 4 St. Number ************************Official Use Only************************ RECO TO DA I S AGENTS: 7z /, Date Approved /v �2/ Conservation Administrator Date Rejected i Comments J }' Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected a Date Approved Septic Inspector-Health Date Rejected Comments I Public Works - /water connect'ons v - driveway permi-12t Fire Department �\ Q v Received by Building Inspector Date Io ,now­ _ THOMAS E. NEVE ASSOCIATES, INC. Engineers • Land Surveyors 9 Land Use Planners 447 Boston Street US #1 R� TOPSFIELD, MASSACHUSETTS 01983 0�NORT P`r Mpg NO. (508) 887-8586 tOW 8�,�,Ro of 11 too�9� FAX (508) 887-3480 TTE TION , _ I� TO S 1C>2pt STAB Q. e.s. Nps 161 RE: m s eocr_ tiyp�'C4� P�D�V�, MR WE ARE SENDING YOU Attached ❑ Under separate cover via the following items: ❑ Shop+drawings Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION 4 v �v� Sri►-.�-ta,� tS S`Mrrr Y1 -t.o'T t3b. ��K�+C tt l t51� (08�- PPS P "nA-b A f4'5- e. t-Ae'JI L-_ ASsorAP S t ` py.• OIG a V>CzkE orm- tomo' WETt.Ass>r� 2x��-F�— a i THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted Resubmit 4" copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS Dom- - '`�.fl"�: IASE �l► �� EA��LJpS£t�4 P'21tyTj C��Rr- I�E�.!lSE~r7 -�tA¢34 !>-fS-Venn fW- -nA-C. AScwq!s� Ite- fa��CAzIlP LST. Prt--� puE-�SE FleW0t -rVVC- WC-*T _SIPS- AL-Sd, V4 csrE IIW*l-1- A J, kCX:>t-ttorvq.A. Sic�1 Yvt�R 8rn+*2- 8�6-� aon� f -rH is m MArt.tL_ t5 CA n,rk r -tc -WAc- 5�� TFN�-� -�}1� e?rsE Pt?� v tcx aSu-{ t PEsv'Ttfaf�- .(cxJ W fit A_. At�,S.o MCSLCE. -n4fVC" JIWL._ t=t r�ai St=-1 C�G1Rt _ h�1t93 � At� +E�p dtEye_ 0-�1� - Tb E4-t vt1.t rc 1(�j'� rt�� +�E:E-� F� qt, �c_CS�S G�t►�n�E� t F WE G+PW" BE; OF Pt=� 1.' S 44ec-'%1 c�riJ�-. "i'�-►'�*��- '�2c� �c� `#'ole t2. �f't rnn E. t r� �V t E�.i t uta � t�4 f�'r-e�L. COPY TO RECYCLED PAPER: SIGN A` 4 - -n C— Contents:40%Pre-Consumer•10%Post-Consumer If enclosures are not as noted,kindly notify us at once. NORTH F Town of Z!� y. V No. .594 odover, Mass., 140y cml(e 2z 19` s* C OC NI C ME N�ICH DRATED 5 BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT...06 141x1_1...... 6M .4,.... ....... .................................................. ......... oundation has permission to erect.. .... W.? W_ buildings on Ab_1...4..� .. l- Q0....... .. U+ ou h to be occupied as lL bh .... '�4fY1f� ~1pU Yi .......%jal.....1.CC�....G Q4C.M......." l provided that the arson accepting this arm shall in eve resect c*form to the terms of the application on file in --� P P P 9 P every JI' Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover.. PERMIT FOR FOUNDATION ONLY PLUMBING INSPECTOR C B 8-S. . . J VIOLATION of the Zoning or Building Regulations Voids this Permit. REGULATED BY PARA. 114. hc, .2— q— 4 e- PERMIT EXPIRE N S__ FEE PAID IW -' y� t(tt�� ELECTIAC4 INSPECT R UNLESS CON O T a ou FRAME/BUILDING T � PERMIT FOR FRAM service .... .. . .. ..... . ........ ........ .... .. ......... .......... .. BUILDING INS CT R Fin DATE: `' fEE AID• i��' �CCupancy Permit Required to Occupy Building GAS INSPECTOR Rough -Dis la in a -Conspicuous Place on the Premises - Do Not RemovC � -Display Final 4, No Lathing or Dry Wall To Be Done FIRE DEPA ENT Until Inspected and Approved by the Building Inspec dr. w Burner 'S,��� Street No. �. 01 Smoke Det. 44�'1 L r I. - - - - - V i Plan o f L and 1 _ A IBOPR° O \gg� /n or th Andover, Mass. Sho wing �. "As—Built " Foundation Location 0 �o ° Lot 13 A — Rocky Brook Road 7' Prepared For O o un ui t Homes, Inc. PQ Lot 13 A Sca/e: 1" = 40' Date: November 27, 1995 �..R 45,560 S.F. 1.05 AC Zoning District: R- 1 (Residence 1) (Subdivision Previously Approved �� �`�� Under R-2 Zoning) - •cr_ 6�` `9s= Note. Property line data token from o plan by Lot Neve Assoc.,Inc,dated du/y 11, 1995. Ogunqui t Homes, Inc. Epsting In my opinion, this foundation is not in a Flood ron rete Hazard Zone as shown on the U.S.D.H.U.D. Flood Fou Hazard Boundary Mops. e (Community Panel No. 250098 0007 C) OP � Top of Foundation l hereby certify that the foundation on this property ,-62' �� Elevation 130.42' - - - is located cs shown on plops and complies with the 1 zoning requirements of the Town of North Andover, Mosscchuse t is 82.00 Lot Profe veyor r 14 A $0.6� Ogunquit Homes, Inc. Tbomas E. Neve Associates, Inc. Engineers — Surveyors — Land Use Planners 447 Old Boston Road — U.S. Route 1 550 To sfield, Massachusetts 01983 887-8586 P PLAN REVIEW CHECKLIST ADDRESS..,Z./,3 QC YrBPMe ENGINEER C 1✓(� GENERAL 3 COPIES r/ STAMP �/ LOCUS L-� NORTH ARROW SCALE r✓ CONTOURS ✓ PROFILEL-✓ SECTION BENCHMARKS SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED? DRIVEWAY ✓(Elev) WATER LINE Pte' FDN DRAIN,/', SCH40 C/' TESTS CURRENT? L/ SOIL EVAL :5_ ,7 �U� �S, 5,r SEPTIC TANK MIN 150OG ✓ . 17 INVERT DROP �� GARB . GRINDER(+200% EDF) 25 ' TO CELLAR-L-""' MANHOLEZ ELEV GW # COMPS . D-BOX SIZE # LINES FIRST 2 ' LEVEL STATEMENT INLETIA3 - OUTLET_)-J, = 'y (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 ✓/ 4 ' TO S . H.GW t/ (5 ' >2M/IN) 35 ' TO FND & INTRCPTR DRAINS L,� 325 ' TO SURFACE H2O SUPP i 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVERFILL? ✓( ' if above natural elev; 101if below) BREAKOUT MET? ./.- I I TRENCHES MIN 660 gpd L"-/ SLOPE (min . 005 or 6"/ 100 ' ) ✓ SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ) (/ RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10 ' MIN . ✓ 4" PEA STONE? -t✓VENT? (>3 ' COVER; LINES >501 ) BOT 6�0C) + SIDE tP01 X LDNG = TOT 7,Z 7�e-,d (L x W x #) (DXLX2x#) (G/ft2) Copyright cj 1995 by S.L.'Swrr `'«4 ✓+fS� ` 1 At +.tl"S "}. .w. NpL ST LfjWl w� .�>y,.'•4., kb E* 01 s,tlr J r d °M . tt Na. a a*a 4•. � � �v '° t ix£ ^ , , P.! Y���; � � � ��• *. � tom. #.. so 4t a i L'd'f O. . crf� .,�, �r�' s • . �X t 14#x``, 2T`E' ' A '` •a S >t b4 wMEN �1 rte} � ,.��,� r • IIIIn11in111111111 } �Olti �Inlllllll s � . 111 , HIM r .31 11111111 3 # 111l�l11t d. , 1111111111 Ill�.ie - fi n .Il�ri�llllllilll , fr• ;t a �x� � : ,`: 11[7!11 �iONE Ilc)/ic� . •n IIIIn�111111Ql- '��} syr t` , , Y � s . - � «.1 nllll � , �• .m i�. 11111111 1111 • .1l��1innllll � .� � : • ._ - _ 11111111 `� _ Inillll _ PEWS I II IIIIII�n11 11111111 � 1 111111 1mill nlllill 111111111111 nlllnl 1111!11 n 1111 1 111111/1 1 11111 n III ON 111 mill 1 4hF Ir l ��t •.� ifi F m; AMY all EMINEIIII INIME FAR mm CK MMMMMMMMMMMMMml IMES FT . well rim MMMIIIEIIMMEImdlillmoll" �����►L M� �iEll ����I�IINMErINEENIMA� -------------------- 8 Pr /77 = a: ' - .cam. - .�-• j t. - { i' F YY�IOYYYYYiiiY�lYYiiYYYY�.1Y �i�i!!J'li l. � ii►� .. I�►�7E7�7�� ��YiiiYYiOiY-� � Y ��YYYIY11�'a% Em I= RM �Y�1YY��RJ�YIL�T..L'a�l�lYYdt� •1f�i�YY v�\YYYYiYips PIWO , k YYiYYE:1!>■YYI�I�l�1: ` ►� YYYYrYMM� !YY\AYE`IYYi�i{�!l�l�Y�I�YYY�I�YYl1'i YYYiY1i �4 Y Yi►�tliYii�' Yii� �YYYY�iY�i�i iii► M�MMMMYYY YYYYY M !YYiYiiiiYOYYY �/YYYYii`l�►`iiiiM_iiiiii iSW/=YYYiYi\RMiiiMliiYiiiit� . ii/iiYYYYYY�1YiI�1�IiiiOl�1.A�7L'�►i �� - - - - .� i�IiYYYYYYYi►�Y � .��IYYYYYi'i1►aYtVr YI/iYY• + `7 l�Y��RI ►. ►f7iiiYYiil►� '11�i N, -.. _;�• , Y��YYYYY�1►�IY�1r!!1117YYiYYYYYI ��>■� I�JIM M ►����L'L��•�IAS��YYYY�r�• .. � YLY•iYft MwnM "r, M 71 I�ir 1�,fvYOYYil�lili, r$a;'.• ::.:rry:'ia:[ ___--��� Y�JinWUNYYYiiMMM iiaYYY tFj , All a �.C:' a y� to la 1 E. a w�. .j , c 1 ilk ]r if PLAN REVIEW CHECKLIST ADDRESS ��/3aG�y ENGINEER GENERAL 3 COPIES STAMP c/ LOCUS/ NORTH ARROW SCALE �--�. (C CONTOURS PROFILE . SECTION BENCHMARK D SOIL & PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS & WETLAN `-✓ WATERSHED? DRIVEWAY �(Elev) WATER LINE L� FDN DRAIN v SCH40 TESTS CURRENT? I SEPTIC TANK MIN 150OG � . 17 INVERT DROP GARB. GRINDER_(+200% EDF) 251 TO CELLAR L/ MANHOLE TO GRADE L/ ELEV GW D-BOX SIZE # LINES FIRST 21 LEVEL STATEMENT INLET/ZZ o 7 - OUTLET 9 = , / (211 OR . 17 FT) TEE REQ'D?� LEACHING / / / MIN 660 GPD? �/ RESERVE AREA (/ 41 FROM PRIMARY? `- 2% SLOPE 1001 TO WETLANDSti/ 1001 TO WELLSc-� 41 TO S.H.GW 351 TO FND & INTRCPTR DRAINS i/LL3251 TO SURFACE H2O SUPP 41 PERM. SOIL BELOW FACILITY ✓ MIN 1211 COVER ✓ FILL? (2,51 if above natural elev; 1011 below) BREAKOUT MET? TRENCHES MIN 660 gpdL-"---SLOPE (min . 005 or 611/1001 ) 1'�z>31COVER?-VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) � IS RESERVE BETWEEN TRENCHES? L---' IN FILL? MUST BE 101 MIN. t, 411 PEA STONE? BOT J,6 1 X LDNG jl$ + SIDE -'%60 X LDNG 490 = TOT 7 (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) Copyright O 1993 by S.L.Starr 96 .i DO& 000\ IN, 1 IN • _ : 1 Al\ oil 0t CL 77 ti Cb �80'p ro n \ 1 0 tIX ' \ �� n—lt1'/� 3i,�j:• / �„/, ,'�• ..�3n�dn �le� Oy 3n'1dn 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD j DATE: SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED y�C''�J GALLONS • v, CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COYER HEAVY GREASE BAFFLES''IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: Ana0ver j COMMENTS: CONTENTS TRANSFERRED TO: Commonwealth of Massachusetts Mused, but D City/Town of 1W System Pumping Record 07 Form 4 DOVER ENT DEP has provided this form for use by local Boards of Health. Other forms 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 Important: When fining out 1. System Location: forms on the (y 0 us-'ecomputer,use t only the tab key Address to move your t 011 A B;GrjVZ_ cursor.-do not City/Town state Zip Code use the return key. 2. System Owner. Name �m Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record �- 10-0r7 1 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ light Tank I� ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped t N Vehicle License Number Company 7. Location where conte],ts were disposed: Sid.Ka6ler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 'y' ', 4:��• b0V T"-, • ,4v1'v lyy�,,llr�l,�,�ly���'y�yllr,y,.,,•f'•� I';r (� ' Q✓'P.fl�r DrpYldlf(J 'ir•Yl.i�/�' DEC � g 209 1It(I Iprmlo, `1Q �„ r / 1 119d1Io V1r Ioc11 Bc+rl; 7 oulln';o! 8oe cl pr /,ua :^ (I. A' F 7�1 ty I (.o rr1 I I o R T�V WOP WOR-TH ANQOVER DEPARTMENT ti . 1 ,1 . $y Ism l Uon; :4 ''/�•1,'1�,%''1.1�'I Q Idl(r,yf '' ,,, , �' $1111 '•r,l !, ,1(11 •I, �,'li�;s �.I�.m Own�er'�''''r•' -., ��_.. v ' �lyi i 1,�1,1,r�•� r�r11 `1.1, v i„L.ry/��''y,,!,' 11 lik'11',I�v ••. ,,,�' '.;, �/ ' r a;.y;,,r,1 ��rl,1,ll'.,; r',:� V���"'C / 111n1 inn bV.Vvn Ang; ,, Q,q , . �, ' rl,l v' I.•i;{1'''k1114n 11:�Ir1 � ,• - !' 0010 01 Pvmping f' 2 ;' '�'t ', , ', r 01;1 7 ��•d�'�. . •!• '1.'...,1• .'1'1";;I,1�•�:, - S9D1!C r8n� � Oer(deyc�ib0' r��, ;d. I I�r4 1'{I.r'•r' r"( aanr7 �,4r4�'1,,;,� 11 roe. nes I, c Bane �, ., :1^•j;,r'' III�IC�II�(, n'Q�a�p �SL;rinrt'i.'�'. � _". r! ! I y11�!ryl9 tl I 7 ,1•r•„ly'�'>7'iU l i��!',�11'.I•Ir4 �1'i� 1 1 6,c) ', .,'1�7�1r�11'1' �1''7' •11 r��. .i� I ),l Ir 1 I�r!/!'''l,l�"�, ' �'(1�'• ( 'i(i i c ul Jc4nl I n'',Tvll "�, ;��� �i'.,, ' • :,.:fa• ,.;.;,,,'r'� •,r:11�,.�q.� 1. .I 1',,I r 11.1 .0 0 109m: '•,' r II' li.l',•b.1 .11ui�rY,, l '1 i, ''I �' I'i''1 � �' . '�, ;,';" �,,', :` • ,'!Sri/,I �1..�,1,`;,.,,•i i m� ' •' rV4(�y�' /,1,.',,,1.1.. e .por/d0p1y010i/iPPWO Olorma,r,;�,�1. Commonwealth of Massachusetts ACMEIVIED W City/Town of North Andover System Pumping Record OUT 18 2191 ^M Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Otherorms may be used, bute information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the /0-7 computer,use only the tab key Address to move your No.Andover Ma 01845 cursor-do not use the return City/Town State Zip Code key. I 2. System Own V rab1 � I /� Name 'e"tl7 Address(if different from location) City/Town State Zip Code I Telephone Number B. Pumping Record Wit 1. Date of Pumping / 0 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) LL Wtic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4 Effluent Tee Filter resent. Yes No I p ❑ ❑ fY es, was it cleaned? ❑ Yes E] No 5. Condition of System: ond y < 6. System Pumped By: Name 'Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: St 's Pre-treatmignt Plant, 20 So. Mi-1114dford, Ma 01835 /I. au r Date 19(!: q•%- Signature of Receiving Facility Date I t5form4.doc•03/06 System Pumping Record•Page 1 of 1 i