Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 109 RALEIGH TAVERN LANE 4/30/2018 (2)
10 9 y Ra l e ih 109 RALEIGH i AvtKN LANs g 210/107.A-01140000.0 a� i 1 J i' Lot & Street Mao/Parcel' C®tVSTRUCTiON APPROVAL Has plan review fee been paid: ES` NO Permit# ? Plan Approval: Date: Approved by: _Designer: bofl'Sh4. Plan.Date: - f f - _.. : Water Supply Town Well _ m r. =Well Permit. - r =- 4Well Tests Chemical _ Date Approved } s Bacteria l -Date Approved - Bacteria It Date Approved t r t Plumbing Sig"n Off - =_ Wiring Sign off:_ FComments: �. x s° Form "U" Approval~ Approval to Issue. YES. NO - Date Issued B , _. r Fina! Approval - - All Permits Paid? — NO Well Construction`Approval? YES NO - z h� Septic System Construction Approval? S NO _Certification? ; . . :':"_ S NO t Other? - s YES- NO AnyVariance-Needed? YES. NO 3z) FINAL BOARD OF HEALTH APPROVAL: DATE: Q — APPROVED BY: 7a_7<---) t r a y SEPTIC SYSTEM INSTALLATION , - CONDITI®NS r Y a _ r M� qA i Is,the installer licensed Type:of Construction - 5 r sNEW ' EPAIR •New Construction Cer<ifietl P1ot_F?lan:Review EYES k r. .� ,Y Floor Plan Review= v. `YES_ 4 N& ;Conditions of Approval fromYFormYU�' YES NQ 1 z Issuance_ofi DWC permit *T � ' �. � �` t ES ', � NO DWC Permit Paid? s }r 4� ' �. �. � ,. .,-N- .�� Y� t .�... YES � ..� NO�=� DWC Permit# _ nstaller �r -rte 47 L 1 h.r -4 Begin Inspection: - f �Y = YES ANO , Zr, Excavatiorilnspection. - r Needed. \ '� -° „ - --c- 'Pass"6d { §�� 7 A lit_ F6'yaez'.r Construction Inspection ,z� �S Needed17 .� �.. '� �2 _ S,:' ��`_: s-�—..�e+ u�^ s: ; d M", Satisfactory Y aT z * �.Appro-al'of Backfill 5 ;F�nalGrading Approval Date. FinalConstruction Approval:: Date By m 1 Certificate of Compliance: Approval �',`J Date: L Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c / 4 M 109 RALIEGH TAVERN LANE �. Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: RECEIVED j )_�qj key to move your l� cursor-do not John J. Soucys, a use the return Name of Inspector ',I, `" Lu key. Soucy's Sewer Service Inc. TOWN OF NORTH ANDOVER Company Name HEALTH DEPARTMENT 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑;es rther Evaluation by the Local Approving Authority �Z.i� 011516 nsature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO APPARENT LEAKS OR CLOGS Septic Tank(locate on site plan): Depth below grade: 15"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'X 10.5' Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owners Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owners Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 t Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified i laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis i and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual). 4 DESIGN flow based on 310 CMR 15.203 for example: 110 d x#of bedrooms): 9P ) ( P 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name - information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 i Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: SEE ATTACHED Sump pump? ❑ Yes ® No Last date of occupancy: DCaURRENT Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes E] No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G1M , 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Souc s Sewer Service Inc Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Gauge on truck Reason forpumping: Maintenance and Inspection Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness FRONT 14", REAR 4" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? TAPE & SLUDGE TOOL Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK IS STRUCTURALLY SOUND. NO APPARENT LEAKS. TEES IN PLACE. PUMP TANK ANNUALLY. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is N. ANDOVER MA 01845 011516 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: I ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D" BOX IS WATER TIGHT Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No" Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances etc.): PUMP AND ALARM TESTED GOOD * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20'X 45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately �z. lel.-7 g T.L Lr�N KI[�7(gcrM!� 0 IomaAt. PU"f-rA,&- o o Ia!p6.tL. hN 5�rr� r4N� Al 1 eQ��,Ga -raV"r t� UILDI T6'r_U4 A i 3G ' 13, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 3' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9/16/99 DUFRESNE/STAIR Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: DUG HOLE WITH AUGER REAR OF FIELD IN LOW DROP OFF, NO WATER AT 4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 109 RALIEGH TAVERN LANE Property Address EMILY GIRARD Owner Owner's Name information is required for every N. ANDOVER MA 01845 011516 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 111 52 01 6 10:22;35 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.A-0114-0000.0 Parcel Id 17939 109 RALEIGH TAVERN LANE SABASTIAN GERARD 109 RALEIGH TAVERN LANE NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.23Acres FY 2016 UB Mailina Index Name/Address Type Loan Number Activelinact From Until SABASTIAN GERARD Owner 109 RALEIGH TAVERN LANE NORTH ANDOVER MA 01845 DEPRIZIOI,DAVID Previous Customer Inactive 5/1112012 109 RALEIGH TAVERN LANE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 13321.0-109 RALEIGH TAVERN LANE Last Billing,Date 12/15/2015 2100120 02 Cycle 02 Active UB Services Maint. Account No.2100120 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 76.00 /1 UB Meter Maintenance Account No.2100120 Serial No Status Location Brand Type Size YTD Cons 16336694 a Active ERT METE METE w Water 0.63 0.63 645 Date Reading Code Consumption Posted Date Variance 11/212015 1264 a Actual 20 12/30/2015 20% 8/4/2015 1244 a Actual 17 9/14/2015 19% 5/412015 1227 a Actual 14 6/22/2015 -5% 2/3/2015 1213 a Actual 15 3/20/2015 -15% 11/312014 1198 aActual 18 12/15/2014 -16% 8/1/2014 1180 aActual 20 9/11/2014 9% 5/5/2014 1160 a Actual 19 6/12/2014 -27% 2/3/2014 1141 a Actual 27 3/17/2014 62% 10/31/2013 1114 a Actual 16 12/20/2013 -23% 8/1/2013 1098 aActual 21 9/1812013 35% 5/1/2013 1077 aActual 14 6/18/2013 -6% 2/7/2013 1063 aActual 18 3/13/2013 -11% 10130/2012 1045 aActual 18 12/13/2012 15% 8/2/2012 1027 a Actual 15 9/26/2012 185% 5/9/2012 1012 1 Final Bill 6 5/9/2012 -36% 2/2/2012 1006 a Actual 9 3/14/2012 -48% 11/1/2011 997 aActual 17 12/15/2011 -72% 8/1/2011 980 aActual 61 9/14/2011 1358% 5/2/2011 919 a Actual 4 6/13/2011 -27% 2/4/2011 915 a Actual 6 3/15/2011 -74% 11/1/2010 909 aActual 22 12/13/2010 -70% 8/3/2010 887 a Actual 76 9/13/2010 342% 5/3/2010 811 a Actual 17 6/9/2010 -29% 2/1/2010 794 aActual 24 3/11/2010 85% 11/2/2009 770 aActual 13 12/11/2009 -47% 8/3/2009 757 aActual 24 9/11/2009 46% Y I F I u - - _ _.._ , ���� �, � \\ � t C� j f _ � - 16 f UiLDI ES �cr r►F►��-r[o,,1 is 0 oT E[RB' �D rIJ. L 3G 1 A A t,`�,TBH . :VT 1s A eLcow OF 149 La nw Id Z3, AW E L e vArfloJ OF TWE el' K Na yY"b-1 COP PUC Li af-7 Av � 3 i I 8� -7 VF_or i I�LP('luwf) p o Iom�n1.. PL# _TA t&- 0 o 10W&LL. heY t � I 1 pr,�da��—--�--� r'"� OF 1 � DANIEL m i o KORAVOS s CIVIL SZ,ov No.37752 �"t.,t. , ru AS 1 T PLAN L OF SUBSUiRFACE DISPOSAL SYSTEM LOCATED IN 00 a.;T'� Q DD`s'e.W— AS PREPARED FOR �1 j� DATE: � .3-oma SCALE: I 4o, MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER. MASSACHUSETTS 01610 or TEL (617) 475-35S3, 3MS721 P I ,y S Commonwealth of Massachusetts , a Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments Property_Address 1�A vie, Dee Owner Owner's Name t information is required for every 6' State Zip Code Date of Inspection page City/Town Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. . Important:When A. General Information filling out forms on the computer, ` '' ¢ use only the tab 1. Inspector: key to move your r y cursor-do not F (1I , use the return Name f Insp ctor key. JL e- t C Company Name j Company ddre s rsrw lJ° - City/Town State Zip Code Telephone Number License Number G. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the.proper function and maintenance of on site sewage disposal systems. I am a DEP approved.system inspector pursuant to Section 15.340 of Title 5 {310 MR 15.000). The system: asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I 4 Lo /%ld 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. ****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 v :der the same or different conditions of use. 47 40 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t5ins 09/08 GL11 4- 1617 791 y6 -21 R A 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out o high static water level in the distribution box due to broken or obstructed pipe(s) or due to a b oken, settled or uneven distribution box. System will pass inspection if(with approval of Board Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is levele or replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ The system requir umping more than 4 times a year due to broken or obstructed pipe(s). The system will pass ' sp tion if(with approval of the Board of Health): ❑ broken ipe(s) a replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obst ction is rem ved ❑ Y ❑ N ❑ ND (Explain below): C) F rther Evaluation is Required by th oard of Health: ❑ Conditions exist which require further eval tion by the Board of Health in order to determine if the system is failing to protect public health, afety or the environment. 1. System will pass unless Board of Health et rmines in accordance with 310 CMR 15.303(1)(b)that the system is not functionin 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 t51ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d Ci rev e I'C' Property Address Owner Owner's Name ` information is or7"� �e���„ � 3/SC' required for every page City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [ Any portion of the SAS, cesspool or privy-is below high ground water elevation. ❑ ,�/ Any portion of cesspool or privy is within 100 feet of a surface water supply or u tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of,.a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform:bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. :��El criteria system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be.considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply . ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P Property Address Owner Owner's Name information is required for every [T page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ;'__�N Laundry system inspected? ❑ Yes �No Seasonal use? F-1Yes Water meter readings, if available last 2 years usage d r1 j78<1-4 Detail: Sump pump? ❑ Yes No 74o//�- Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal.System Form Not for Voluntary Assessments <^�M JS .• kL� Property Address Owner Owner's Name information is r Q A 3140 A•� required for every 11 �1 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: q— 3 Were sewage odors detected when arriving at the site? ❑ Yes No i j Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;,-�o El cast iron PVC ❑ other(explain): r Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Materi construction: I� concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) _ ✓cdOl �v� If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts rWW�I Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is JJ required for every ©�,r)y (fir _ o U page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 4 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i ('u)(fEG +C4V)zfh n Property Address Owner Owner's Name information is J required for every O �� G 8 l 3�� ��' - page. City/Town State Zip Code Date of Inspection D. System information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): C5;04 V--2 C Ie a , C4' �041 ),t� Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments i0C4 f`a�ei� � TCt c/%h, Property Address Owner Owner's Name information is �— required for every n Or page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate 7where blic water supply enters the building. Check one of the boxes below: I hand-sketch in the area below ❑ drawing attached separately ccvgrpt� scrrctice 4� 0 roof. C% vrP-v, L.4h -e, t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M io�c t-c41,eI61,, Property Address Owner Owner's Name information is J required for every �n/ o�^i L lil ove-it �Y✓/ J� 1� page. City/Town State Zip Code Date of Inspection E. Report Completeness p p Checklist nspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed i Syste Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 44 Commercial Street Raynham,MA 02767 Tel: (508)880-0233 Fax: (508)880-7232 March 25, 2008 — RECEIVED APR 0 912008 • North Andover Board of Health TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 1600 Osgood Street North Andover, MA 01845 Attention: Health Agent Reference: FAST° Wastewater Treatment System - Serial Number: 24277 Attached please find the Field Inspection & Service Report with field test results for services performed on 02/20/2008 at the property of David Wondolowski located at 100 Raleigh Tavern Lane-North Andover, MA. Please call if you have any questions or require additional information. Sincerely, Wastewater Treatment Services, Inc. Service Department Enclosures Copy to: David Wondolowski Massachusetts DEP LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems 9815 A. Installation Important: David Wondolowski When filling out Owner forms on the computer,use 100 Raleigh Tavern Lane only the tab key Facility Street Address to move your North Andover 01845 cursor-do not City Zip use the return key. Mailing address of owner, if different: _I 100 Raleigh Tavern Lane Street Address/PO Box: North Andover MA 01845 'eO1' City State Zip 617-821-1617 ext. Telephone Number B. Authorized Service Provider Wastewater Treatment Services, Inc. 08M Firm 44 Commercial Street Street Address Raynham MA 02767 City State Zip 508-880-0223 ext. Telephone Number Michael Dillen 11173 Certified Operator Name Certification Number C. Facility/System Information 24277 Bio-Microbics, Inc. MicroFAST .5 DEP ID Manufacturer ID Model Number 11/11/2004 Installation Date Start of Operation Approval Type: 0 General 0 Provisional Q Piloting ®Remedial Seasonal Residence—used less than 6 mo./year: 0 Yes ®No D. Operating Information 02/20/2008 Inspection Date Previous Inspection Date 12 Pumping Recommended 0 Yes ®No Sludge Level DEPMicroFASTnew.doc-3/25/08 Page t of 3 I Massachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form for Title 5 I/A Treatment and Disposal Systems 9815 E. Field Testing Field Inspection Color: Q gray Q brown Q clear Q turbid ' ®other(specify): N/A Odor: Q musty ®earthy Q moldy Q offensive Q turbid Effluent Solids: Ono Q some pH 7.0 SU DO 9.58 mg/L. Turbidity NTU 6 to 9 2 or greater 40 or less Should a Remedial or General Use system fail the Field Testing, effluent samples shall be collected per Standard Methods and analyzed for BOD and TSS. F. Sampling Information Samples Taken Q Influent Q Effluent Commercial systems or systems with a design flow of 2000 gpd and greater, and General Use nitrogen reducing systems: 440 gpd Parameters sampled: Q pH Q BOD Q CBOD Q TSS Q TN Q Other(list below) Other 1 Other 2 Other 3 G. Inspection and Maintenance Description of any maintenance performed since previous inspection and during this inspection Cleaned Filter, , , Checked Splash Recycle, Notes and Comments: Grassed over cover. DEPMicroFASTnew.doc•3125/08 Page 2 of 3 LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Title 5 DEP Approved Inspection and O&M Form.for Title 5 I/A Treatment and Disposal Systems 9815 H. Certification I certify: I have inspected the sewage treatment and disposal system at the address above, have conducted the required Field Testing and/or sample collection in accordance with Standard Methods, have completed this report and the attached technology operation and maintenance checklist, and the information reported is true, accurate, and complete as of the time of the inspection. I am a Massachusetts certified operator in accordance with 257 CMR 2.00. Michael Dillen 02/20/2008 Operator Signature Date System owner must submit this report, technology O&M checklist, and any required sampling results to the local board of health and DEP as follows for each inspection performed: Remedial Use—by January 31St of each year for the previous calendar year Piloting Use—within 45 days of inspection date Provisional Use—by March 31St of each year for the previous 12 months General Use—by September 30th of each year for the previous 12 months Send to: Department of Environmental Protection Attention: Title 5 Program One Winter Street, 6th Floor Boston, MA 02108 DEPMicroFASTnew.doc•3/25/08 Page 3 of 3 L I N C 0 8=PO 8 A T E 0 8450 Cole Parkway Shawnee, KS 66227 B Phone 913-422-0707 II Fax: 912-422-0808 9815 e-mail: onsite(ftiomicrobics.com a www.biomicrobics.com w 800-753-FAST(3278) FIELD INSPECTION & SERVICE REPORT For Bio-Microbics Single Home FAST® System -INSTALLATION AUTHORIZED SERVICE PROVIDER 100 Raleigh Tavern Lane Installation Address: North Andover,MA 01845 Name: Wastewater Treatment Services, Inc. Owner Name: David Wondolowski Mail Address: Mail Address: 44 Commercial Street 100 Raleigh Tavern Lane Raynham, MA 02767 North Andover,MA 01845 City State Zip 508-880-0233 508-880-7232 Phone: 617-821-1617 Fax e-mail Phone Fax e-mail INSTALLATION INFORMATION Model No. Serial No. Date of Installation Date of last pump out MicroFAST.5 24277 11/11/2004 EQUIPMENT YES NO MAINTENANCE PERFORMED AND COMMENTS Electrical Panel(s) Visual Alarm Operating X Audio Alarm Operating X if resent) Blower(s) Air Inlet Filter Clean X Blower Hood Vents Clear X Excessive Noise X Excessive Vibration X Treatment unit(s) Unusual Odor X Pum out Required: X Primary Settling Zone 12" Aerobic Treatment Zone 12" EFFLUENT(optional) LIMIT RESULT Estimated Daily Flow 440 gpd. H Standard Units Color Other Temperature 46.6 Odor Earth Comments: Grassed over cover. TECHNICIAN SERVICE DATE Michael Dillen 02/20/2008 Town of North Andover Office of the Health Department 0� Community Development and Services Division �a 27 Charles Street 9O�41e0 North Andover,Massachusetts 01845 cnuSEt Sandra Starr Telephone(978)688-9540 Public Health Director Fax(978)688-9542 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE OV22/03 This is to certify that the individual subsurface disposal system constructed O or repaired (X) by George Henderson at 109 Raleigh Tavern Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Bri j. LaGrasse Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The u dersigned hereby certify that the Sewage Disposal System ( ) constructed- ( repaired: by located at 109 nAI__E[C.1 s -� was installed in conformance with the North dov Board of Health approved plan, System Design Permit# / O dated l C/9 with an approved design flow of&k gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with theP rovisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: Engineer Representative Final inspection date: Engineer Representative Installer: Lic.#: Date: Design Engineer: j tlL Date: . BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# /p -2- LOCATION:LOCATION: LICENSE_ D INSTALLER: �- SIGNATURE: � ,,, , TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. 1 i Administrative Use Only 160.00 Fee Attached? Yes / l/ No Project Manager Ob. Yes No Foundation As-Built? Yes No �I Floor Plans? Yes No Approval Date: I PAGE 1 OF 5 Commonwealth of Massachusetts for c U er Application �_ Title 5, 310 CMR 15.000 DEP Approved form required by 310 CMR 15.403(1) To be submitted to Local Avuroving Authority/Board of Health: For the upgrade of a failed or nonconforming system with a design now of <10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or nonconforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full compliance, as defined in 310 CMR 15.404(1), is'not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 ibMR 15.000. 1) Facnitylsystem owner Name t)ea.s e 0nm6A I Address 1 Fxl "Alza 1 ra 0 Phone # oVF7 Address of facility_I cxi u t_g l r,14 �!�CWK l.0nJg - 2) Applicant'(if different from above) Name � 9 Address Phone 3) Type of fac' residential .—commercial _ school institutional (Specify) i 1999 DFP ArMOVID FORM-I2WM was.xa PAGE 2 OF 5 4) Type of existing system / _ ces _privy spools) ✓ conventional system Other (describe) Type of soil absorption system (trenches, chambers, pits,etc.) 1'L�I/b 5) Design flow based on 310 CMR 15.203 a) Design flow of existing system gpd Approved? _y✓ es approval date no why? b) Design flow of proposed upgraded system */v gpd c) Design flow of facilitygpd l 6) Proposed up rade of existing system is a) Voluntary Required by order, letter, etc. (attach copy) Required following inspection required by 310 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) b) .Describe the proposed upgrade to the system 60PI L451 c) Which of the following are applicable to the proposed upgrade? p Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) Percolation rate of 30-60 minutes per.inch (state actual perc rate) DFP APPROVED FORM-12/0786 I a PAGE 3 OF 5 Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) l�& Relocation of water supply well (identify well, describe relocation) Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the Code) System upgrades that cannot be performed in accordance with 310 CMR 15.404 & 15.405, or in full compliance with the requirements of 310-CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves.a reduction in the required separation between the bottom of the soil absorption system-and the-high groundwater elevation, an Approved Soil Evaluator must determine the-high ground water elevation pursuant to 310 CMR 15.405(1)(i)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater _ feet As determined by: Evaluator's name /w-����✓ < �� Evaluator's signature Date of evaluation 9 l6 9 DEP OMOVO FORM-1VV195 vw1 PAGE 4 OF 5 8) Notice to Abutters No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property or well is affected by certified mail at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the Department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the Department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. List of affected Abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): AIA a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible: AM, b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible: DO APPROVED FORM-U107195 PAGE 5OF5 dA c) a shared system is not feasible: VIA d) connection to a sewer is not feasible: 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? _yes 11) Certification ' " under nal of law that this document and all wrier, cerci I, the facility o certify penalty attachments to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." Fa ility ow 's signature Date Print Name l �jl LIQ �U �iJ� / 1-'I�CI-►ZIr'f�t�k, ��> �t 12W6 -5g: Name of preparer Date pre parer # & address of p p • CMR 15.403 4 requires,the system owner or operator to submit to the . Title 5 310 ( ), �N Y . NOTE , Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. DW APPROVED FORM-12W19S Town of North Andover- Of NI I. RTH OFFICE OF ° /6 ho COMMUNITY DEVELOPMENT AND SERVICES a A 27 Charles Street North Andover, Massachusetts 01845 WILLIAM J. SC_O_ TT sSACHus� Director (978)688-9531 Fax(978)688-9542 November 18, 1999 _ William Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 RE: 109 Raleigh Tavern Lane Dear Mr. Dufresne: This is to inform you that the proposed plans for the repair of the septic system located at 109 Raleigh Tavern Lane,North Andover, dated 11/2/99 have been approved. A variance-has been given for depth to groundwater to allow separation between the bottom of the soil absorption system and the groundwater to be 3 feet instead of the minimum of 4 feet. The property owner should be aware that there.can be no additional flow to the system with the granting of this variance, that is: there can be no additional rooms. If you have any questions, please feel free to contact the office at the number below. Sincerely, Sandra Starr,R.S. Health Administrator Cc: N. Ordman File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 AS-BUILT CHECKLIST JAN 2 l 2003 LOT NUMBER STREET 1' ET NAME ASSESSORS MAP& PARCEL NUMBER v __z LOT LINES & LOCATION OF DWELLINGS LOCATIONS & DIMENSIONS OF SYSTEM, / ua ✓ _�� TIES TO LOT LINES &DWELLING, WELLS d. FROM SEPTIC TANK b. FROM LEACH AREA ✓ LOCATIONS OF DEEP HOLES& PERC / TESTS ✓ ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION LOCATIONS OF WELLS,DRAINS, WATERCOURSES WITHIN ISO' OF SYSTEM LOCATION OF WATER,GAS,ELECTRIC LINES,CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX = ORIGINAL STAMP &SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW �' LOCATION&ELEVATIONS OF BENCHMARK USED .+VVIP" ' NW,�is�t� y,'4^ 4p�i� �k ` w d d r fi yah g r Cs fir i IV G Illllllllllllllln�� �1��J.� ►.. 1111 �� { ..��� � �4=b �� ° �,� "� Illllllllllllllli�.l ' -.!� k k Illlllllllllllllnllnlllllllllllll M , . , � E fi}} ,F � �„ h>��f� 1� X111111111111111111111111 ,; .� �x. � �t � - 1.►,�1�1� ' 1�� X111 A i Illln �,�nlllllllrinl 1111 � � � nll 11111 �� ` � 1 r thug 4.$ r � M1 � 1 11 1111 � :;t 1 111 ; s � 4 R 1 l i 11 11 1r :k t a 1 nl®Ilnl 1111111 I , - ` 11M. t,�3 nnIn111n1 •� Illnll :� k'� a � � � �F M��j� ����� , � � Illlllnnln Illnllll � w � 4 � TQ } Ilnll Ilnlllnl 111111 C V� f } L' - - _ F n A, l.� i r � r'�'�`•�{ ev� �'+'C. �"pr ir, ''�� k X2'3 } }c����i �. i R C - � �7' a •� � ,f� i-.t $-:P ks"% ice° i 2-- �K �{� anN � z'1. 4 ',y,�z e� �� aE.-,•a a ..r. ''+J'". .�,�y{� 3� ;.r�`*t-.r"'-� - �..a'�., �- C-.�� 4�,c* `++.;,, . i„ ,�N s� X"x`+ "'s .' LE{3';'. i.x �r.as.r BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: 40�--Zf4-9 �� LOCATION OF SOIL TESTS: Assessor's map & parcel number jo ��- OWNER: t7OMA.0 TEL. NO.: <o9 r ADDRESS:_ ENGINEER: 17io� �� TEL. NO.:. '� CERTIFIED SOIL EVALUATOR: �f {u Ff?� i e ed u of land: dentia) subdivision, single family home, commercial Repair tomg Undeveloped lot testing N. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of 1275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two,deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. NiZ. .WI A- JPLAtr0/106 ti AC.AAZ 17 4 AS Ar 725 J As"42. (12 2.d 31 AA 44 A.1%b. 16 3 iv Cv \tow lu 4 > NAAC-66 187 w a t22 ts"S\ V2 14 -T as Asb so, A\ C& Q A' A '* u M4 Or k G t21 AA .& Ah .to Irz I 1.—� 4:1 1— lrs %011 VI 16 EGD AA qao 45 sqa 'N 24 AA IZO AA- 6. SA Ui IYS Ik Uj C. 4r.2-7 kc. 27's ZG% V. 2 of A.11 120 1 -aF7 IA. ............I........................ ,, -rio . -- Nov-17-99 09: 26A Paul D. Turbide, PE/PLS 508-465-0313 P.03 November 17, 1999 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover, MA 01845 RE: Title V review for-109 Raleigh Tavern Lane Dear Sandra, 1 find that the design plans dated 11-2-99 adequately address the regulations. I make the following observations: There is a mistake in the buoyancy calculations. The water displaced is 140 CF, not 104. This makes the weight of the displaced water approximately equal to the weight of the empty tank. However, the fact that there is between 1 to 2 feet of cover over the tank, should be enough so that the tank will not float (the calculations should be redone by the design engineer to make sure that this is true). If you have any questions or comments please feel free to contact me. Sincerely "l /' Carlton At'Brown,PE/PLS Raleigh tavern 109.doc PORT ENGINEERING, Civil Engineers aS& Land Surveyura One Harris Street Newburyport,MA 01950 (978)465-8594 i FORM 11 - SOIL EVALUATOR FORhj Page 1 No. ................................... Date... .� Commonwealth of Massachusetts Massachusetts foil Suitability- Assessment for On-site SeH=M osal d�l..d�,GSj�Pi Performed By: �:.��... . ............... witnessed By: — _? — �. .................................................................__............................................................. tAoMm Add= AM=.wo LA I -71- New Construction ❑ Repair Cd" Office Review Published Soil Survey Available:ailable: No ❑ Yes L� f .Year Published . . Publication ScaleSoil Map Unit.... .�.. ` ................ Soil Umitations Y Drainage Class --- ...../..�.......Yes....................................._..�.__.__._._..:......:.. ... ........ Su g P rficial Geologic Report Available: No ice' ❑ Year Published ................. Publication Scale GeologicMaterial (Map Unit) .........................................................................................._.____........_................._................... Landform ........... ................................._..............................................._................................................................................................................ Flood Insurance Rate Map: ^ j Above 600 year flood boundary No ❑, / Yes Com' Within 600 year flood boundary No Lam' Yes ❑ Within 100 year flood boundary No L7 Yes ❑ Wetland Area: National Wetland Inventory Map (map unit).............:..............................._......._.... �__.._.__.._ ....�...._............._ Wetlands Conservancy Program Map (map unit).....................................................-......_..__� Current Water Resource Conditions (USGS): Month Range : Above Normal ❑ Normal ❑ Below-No(mal Other References Reviewed: VSez� QwWD. --�'� VORM 11 - SOIL EVALU TOR IKjltM Page Z Desp Hole Number._t'1 Oate:_ _ ..�q Time:_1 ..._....'�""` Weather Location (IdendfV on elte plant Land use - --------- filope(Al �=- Surface Stones ... .__ ------ Vegetation Landform position on landscape laketah on the backl Diatanoes from: ' Open Water 10ody ?deo feet Drainage way-ZL?e1 feet, Poselble Wet Area ` feet Property Una,_. "� feet Drinking Water Web 7../P =.. feet Other- ----.--...-.- w- pepq,`s6uttea sou 1latron soM Tia�• sots 1AaaunoOdw AM�•. rewoarr, . ar l0 yy/� qlq Parent Material IgeologiolDepth to Bedrock: Both to groundwater: Standing Water In the Hole: .1�' aaping from Pit Face: Y �i Estimated Seasonal High Ground Water: .7�6 f MRM 11 - SOIL EVALUATOR MRM Page Z On-site review ' Deep Nole Number --------Date:_... '���o�� Tlma:_ _..la.°` - Weather » Location pdentlfy on site plant ,�`• land Use `L =S� "'-��= Slope(%I `1.a Surface Stbnea .......— Vegetation __....._.........__..._.......... _.»__ tAwform position on landscape (sketch on the backl Distanced from: ' Open Water Body 7tfa fast Drainage way.:Zl feet, Possible Wpt Area feet Property Una, fast Drinking Water WON?1 .. feet Other DEEP OBSERVATION ROLE IA)- G D�Pthltr a6urfaa 6oY Norl:on 6oq TacWte fipM Dolor BoY f�A41ft l8tnbare�6 �aAAars. WSOA! ll�kinaaW f!t ve 4 , Parent Material(geologici -- _ _ -_ - = -- ---_....--.....--............. Depth to Bedrock: nen�th to Groundwater: Standing Water in the Hole: .X.1.7i.:--Weeping from Pit Face: .... 1 Eatimated Seasonal High Ground Water: ..Z�i FORM 11 - SOIL EVALUATOR VOR Page 3 nptpt'minn for SelwanM M Wader Tactile Method Used ❑ Depth observed standing in observation hole.. _ Inches ❑ Depth weeping from side of observation hole _ Inches t Depth to soil mottles .4�� .. Inches C, ❑ Ground water adjustment ..- feet Index Well Number .___.____-. Reading.Date Index well level Adjustment factor Adjusted ground water level nth-of Naturally Oocurdna Parva us Material Does at least four feet of naturally occurring pervious material exist Wall areas observed throughout the area proposed for the soil absorption system? If not what is the'de th of natural) occurring pervious material? P V �;$r�ifll��jQD II I certify that on S' datel I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 16.017. Signature/a _ ✓Qate f�1/- � FORM 12 - PERCOLATION QST COMMONWEALTH 'OF MASSACHUSETTS Massachusetts Percolation Test Date: Tune: Observation Hole # f Depth of Perc Start Pre-soak end Pre-sock Time at 12" ' Time at 9" Time at 6" Time W-6"1 . Ll (late Min./inch / Site Passed lJ Site Failed ❑ Performed By: , Witnessed By: Comments: .................................... BOARD OF HEALTH TEL. 688-9540 NORTH ANDOVER, MASS. 01845 rc APPLICATION FOR SOIL TESTS 0 1999 a DATE: 4�-?�-9 . LOCATION OF SOIL TESTS: VJ Lr jd,0 Assessor's map & parcel number. 10-7 /_''I [l OWNER: tl )ANE NWILjA0 TEL. NO.: ADDRESS:_ I I WALE IC W k j=[[ LAjJ ENGINEER: Eb�� ,Q; TEL. NO.: '�� I CERTIFIED SOIL EVALUATOR: �Of Ll— �FY. e ed u of land: re dential subdivision, single family home, commercial Repair to mg Undeveloped lot testing N. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of 1275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1'-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. SEPTIC PLAN SUBMITTAL FORM LOCATION: 10-1 YZAL.C16 N NEW PLANS: /Y�F $125.00/Plan �/ y REVISED PLANS: YES $ 60.00/Plan SITE EVALUATION FORMS INCLUDED: NO DATE: DESIGN ENGINEER: I�, �t, d,L��2 /r-t ,,��r�l,�e L 6N)6 ►ns2�ajQ DATE TO CONSULTANT: *If you want your plans expedited, please submit four plans and included a stamped envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place, route to the Health Secretary. Jr t 2 1999 ;a�;.Xx % IPLAT NO. 106 I to tiv. \ LAZ 44 rw of t7 AG As.".7 a r eaz 46'42. is 17 tt2 124 13t 16 AA tDe Di leb z AS L.-- AZ A, sy 123 IS Cits t39 m \µ466s2 187 122 Vilto \2 it \ jr t tAl 14 A&Abb Ob rDy S3, 'for, Its AA S-& vtiIt ob t. tlg Ail %elk %0 too o AA 14o 45568 ALA rl q zv S&e 4b' L a.,7�- ."k. 0." .0 2 39 2)0 . 0 o'er°v f 2mbz ec-0 US kc. v -e;t4 See P 2. N.011 7-7 k 278 2Zb 3,•74 rJ7 Ap Colo .20"1 r.A, In t r Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH O�"'E. "�"YO 3� h� a60� a / 19 � 0 K s A APPLICATION FOR SITE TESTING/INSPECTION 7aDHA TED �S.3 CHUS�S Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time C?Al�� CHAIRMAN,BOARD OF HEALTH Fee Y; Test No. f S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. : Town of North Andover, Massachusetts Form No.2 • pORTq BOARD OF HEALTH it 3:•_" , • oo ALI 9_ o � 40 w ��'' DESIGN APPROVAL FOR SACMUS t� • SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant Test No. : Site Location Reference Plans and Specs. • ENGINEER DESIGN DAT 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 rt Fee � `�'�� Site System Permit No. C) Town of North Andover, Massachusetts Form N°.3 BOARD OF HEALTH NORTH J f 110 Ot «a° �e'�4.0 - U�V O m DISPOSAL WORKS CONSTRUCTION PERMIT SgACH Applicant NAME ADDRESS TELEPHONE _ Site Location L`lflkik� IAVef/Q Permission is hereby granted to Construct ( ) or Repair an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH c Fee �� D.W.C. No.�'�=" Aj BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. � 1 �J � V-n Sv 1 s-o 1. NAMECuL DATE,__/ kv�l At 2. ADDRESS 16-1'• LOT NO. TEL. 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby ake application for a permit for a sewage disposal installation at 0 7 , �c �C f ,��i�� . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of o7-c-v lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by .similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the pert. Plot Plans must be submitted with application. DATE /2 G S gnature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE / - �� �7 O Sigffatur of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE D Signatur f Inspecting Officer Percolation Test_ i,,,,,.H.,_ Add Garbage Grinder Y c� BOARD OF HEALTH OF NORTH ANDOVER $ MASSACHUSETTS SEWAGE DISPOSAL DATE i 1 NAME OF APPLICANT . LOCATION Addres of lot no, BUILDING: Dwelling 'j'C Other SYSTEM: New Repai GENERAL DESCRIPTION OF LAND / SUBSOIL: Clay Lvel Sand PERCOLATION TEST minutes per inch, MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1 gallon capacity, LEACH FIELD `Z-0-0 lineal feet of drain pipe, William J. D ' scoll , E ginLker Board of Hea h `U1 APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby_62 make a lication for a permit for a sewage disposal installation at . I will install this system in ac- cordance with all the laws f the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of / >-T 6 in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe anc laid in a series of trenches, the bottom of which will pro- vide a minimum of ---.T lineal (square) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia. ) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion.of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit.� Plots Plans must be submitted with application. DATE /1 v -7/ 6 L gnature of Applic I hereby issue the above permit for the Board f Health of the Town of North Andover, Massachusetts. DATE �' Z' ' -71 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE Signature of Inspecting Officer Percolation Test Garbage Grinder BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. j ! -7 , P-7 1. NAME l6Ve-e �G �l''� �4-51 DATE 2. ADDRESS �/I � 'Vi S�v T NO. TEL. -:k 3. NO. OF BEDROOMS DEN YES NOy 4. GARBAGE GRINDER YES NO cl-I 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.