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HomeMy WebLinkAboutMiscellaneous - 1090 TURNPIKE STREET 4/30/2018 (3)U � 0o m o m (D (D rt MAP# LOT #_— ................................................................................. PARCEL # STREET-____-, ...... ........... CONSTRUCTION APPR HAS PLAN REVIEW FEE BEEN PAID? 3— PDYESPNO I o PLAN APPROVAL: DATE A P. BY . . .... I ............. DESIGNER: PLAN Dn I -E 17-3 ... ... COND I T I ONS. WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER.-.... .............. . .. .. .. .... ... . ... .. WELL TESTS: ----CHEM I CAL DAIE APPROVED BACTERIA --I DAIE (11"PROVED BACTERIA II COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE NO __171// �.._©Y__—___ . _.. .. _ DATE ISSUED CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL No SEPTIC SYSTEM CONSTRUCTION APPROVAL CVf_-_, NO OTHER NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:._.._ BY: �E��GY�Z�M�NSIfl4l��TjjQ�I� •� ' i k: l i. .i„'•- T7 e�•:, w:l ti" {-�-•�.itse".wb z'`� is.,.7 v =i. t ♦::r e`i'rj(� ''. i 1H aY- H :s 9 ` S•'i 't" "T � �,,,, � '�.,,,, , P i y ,>:�,� •� �• �ry '- i y,c IS THE MINSTALLER LICENSED? �; _ }�r �� ` ' '�Y �, YE NO r TYPE OF CONSTRUCTION: a! ; _ ti ;�� r :` NEW j REPAIR , I ' NEW CONSTRUCTION:_, -_.'CERTIFIED PLOT PLAN REVIEW NO y _r CONDITIONS OF:. APPROVAL YES NO (FROM .FORM U) x:f r •` �ISSUANCE OF DWC yPERMIT NO fDWC PERMIT N0. # f�" ," ; f ' INSTALLER:��,. ,'1. `Y 3A` t, -G ! . - _ 1. '.` -• • _ - i,. :BEGIN INSPECTION -BA-o: EXCAVATION, t EXCAVATION INSPECTION: NEEDED: T A, SASSED Iz J �Y if :.:'CONSTRUCTION INSPECTION: NEEDED: AS BUILT'PLAN SATISFACTORY:. YESs J ' t . APPROVAL TO BACKFILL. DATE. BY �FINAL.GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: DATE: ��� BY140 -/ ji�r i �- � FOR S/ CZ-*'4a"A �DATE TTI �E / P. M. nn — LCA/ L-L•� T �N` �C.6 v' /CJ / PHONE AREA CODE NUMBER 48003 NOTE 1KI 4�e D-BOX=20L4,Zg h 11 72 *2 = Z03, RS' A�I15s T. M )4.(eTz) X3.3' .3S� D -sox 61.0' E*Kjt T, #I q6, 0' 11 -7.2 ' -y2QPI F=E—::- AS E AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATEDIN ANDOVER, MA - AS PREPARED FOR, MARSHA T�LESETS ky DATE:. APRILS 1995 SCALE: I"• X10' LOT 'k5 7-v2N RI K STREET MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS. 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (6706) 475.3555, 373-5721 A� SCN., �o P. S '� 2to d�44 u `\� 11 DoT' M.14C«� 3S . 3 ` o 3S' OuI D X- C f V Z 61-0, -- . p. 13.i. ►� �, �, ,, Ov r6 D- BOK =Foq• l 1. SCN 140 . PE2F= P, �, ►, ►, ►� ►� 72 0-2 s Zo3, RS y2� P► k E s�Z�T' AS BUILT PLAN OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN AS PREPARED FOR- e -IA R S RA T5LESE-rs k -y DATE_:._.APR11.,.5,1_gq,� SCALE: I.'°.qO _- 1_oT "'5- Tu�1�i P KF'— STREET" MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS. 66 PARK STREET 0 ANDOVER, MASSACHUSETTS 01810 0 TEL. (6b@) 475-3555,373-5721 AS -BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations__ House Tank IN Tank OUT 74 D -box IN D -box OUT� Trench Inverts Line 1 Line 2 Line 3 Line 4 0 As -Built Elevation Bottom of Exc. Stone OK? D -box checked? Pipes cemented? Town of North Andover, Massachusetts Form No. 3 HORTFI BOARD OF HEALTH • s DISPOSAL WORKS CONSTRUCTION PERMIT SSA us Applicant NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct .i -k or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 4. Fee A. ' CHAIRMAN, BOARD OF HEALTH D.W.C. No. TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 Sandra Starr Public Health Director August 6, 2001 Michael Putnam 1080 Turnpike Street North Andover, MA 01845 Re: Conceptual plan —1080 Turnpike addition Dear Mr. Putnam: Telephone (978) 688-9540 FAX (978) 688-9542 After looking at your fax I have the following general comments relating to your proposed project: • It appears there are no additional rooms proposed for the site. The addition of even one more room could necessitate the evaluation of the size of your septic system to determine if a larger leach area would be needed. However, your project seems to indicate that the number of rooms remains the same so a full evaluation would likely not be required. • There is a reference to a pool on the plan; the probability of being asked if there is a pool on the site and its location is high. • With a 30'X30'X30' addition, you would more than likely be required to move the septic tank or decrease the size of the addition. • It would probably be considered a good idea to investigate the state of the septic system by having an inspection done by a licensed Title 5 inspector. • Chances are very high that you would be asked for a plot plan with a scale of no less than 1 "=40' showing the existing house, the proposed addition, the existing septic system location, and pool if there is one. The wetlands line would probably be needed by the Conservation Commission as well. I hope these general comments will help you as you design your project. While I have tried to make my comments address all possible requirements, there may be additional concerns if/when you make an actual application for a building permit. At that time all comments will be official and based on your applicaiont. Sincerely, _.>d�0JA---) Sandra Starr, RR, C.H.O. Public Health Director Cc: Building File r p_J• 6'•7• 1'•J )'•Y ' {'•�• ' I p -O• ♦•''m• J'.Y r.)• r' -f• I'.S ' I i• -p• I 9EJC44 SEAT, I j OFMCNAL i I i STEPS TOI I I j �lo STEPS TOGRADE I GRADE \ i I DECK I • !j I j� r— \ i r -la• Iru is�� T ® x o 3® o DiLL; BREAKFAST \ROO DINING E II I �DINING KiTC:;L=*! I I / ! •.u..l C• !41 �l mI// ILA 5AT14 '2 a/ �------ a• .• �G-REAT ROOM W al 9j j ! e•o ea •%r.owr.o►=miler LIVI ROO " JT I ! of —r i, ''/ I 0+�� F;ALLC\ I I I I STAiRI I I f I STCRAGC :i ;Ila •Heal FOYER'.I r, . L'e — O ZZ if 71. Il iD. 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Pane 7'•7' UP 0 i 4'-71/2' RNC 4 Z ° b °4-k ac. 3 g ad •nom i� o' WO sApz 0 $ �2 p � R O s^�"g km lb f n 0 3 � 'moo= g > FIELDER KE51DENCE m A TURNPIKE ROAD n �^ NORTH ANDOVER, MA m z C' i y � v n A m b mm p A Q A P < b 8 ss(A z 3 � i• F > ; o m y c a s v E ° n am �3i g > FIELDER KE51DENCE m A TURNPIKE ROAD n �^ NORTH ANDOVER, MA m z C' i y � v n A m b mm p A Q A P ,NSTRIUCTIONS: This form is used to verify that all necessary approvals/permits from Beards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. PLICANT FELLS OUT THIS SECTION APPLICANTPHONE �L'i7 (r✓�7 `/f`�i- Cj- r �f L,�G�.•�S ��/�r• .�, ter, /T� LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET �O jO /Ur.� /� +! t ii` ST. NUMBER USE REGOMMENDA T IONS OF TOWN AGENTS: /CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPE TOR- LTH DATE APPROVED DATE REJECTED IC I PECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS S�r M PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9197 jm DATE 08SL-99Z-t09 3NOHd • 58091 X09 •0'd O r� !0 13 so Ni '1�311HO�d "83Nd8dO .d 41dN04 GLZ OH H� ¢ I cc lo nd laL, o^wzo¢� Q ► i���o¢- -�---- �c-c.�T3�� A••a O 1 .r' ' I II �\ r•-"��` ,5� .� � '� � Vii'-J.�' � mac— ^Y ' :i•.t: p ' ci .r I r--- lll I \ I Ln `1 Q —41 /* La Via,, II! W III 'I '! I I � {.} —•' - —� � � . •l//l�'� �(n�(yy� III i I � 1I •I 1 VV I I~I \rI I I I II f ' 1 1..�0 � L C ��.1 � Q: .0•.T ...T '1 ` .T1 I �I QI {I cl �` lu p I I I ' II � i/• I�� mI �� 1 � I I I �' I �! 111 sl, I $ .55•e • �� £IF'.c .r.t 1 —J O ' 1i .ml•A I , -^ L--- --- o U \ ULU\ C 0 r•.t ,� I � I ID \ \ 0 W�,ym�aQ BZW � W KWO�UWJ~q�LLC>Ur g Urd- LL t��.. U-JU�-qLL�:' U z w�°° / '✓�,v �/� S/ c 12.3. /Z 1 Nc P�4Y Ct C IFY i 0 TYC T/T�c /l/S!/CD O 1 177C B�Nt' T%/yi Tfic �a-E G/u6 /S LGYA: �� D 7 �r / cJ O AS S.svey-v A.vp Ti G4T� p lY/T.1 T;/c CC t/FGlP�/ —,12— ✓ ' OF c: 1 ^o ter/ 20 vi vG �EGvLAT b vS �/�/ FU,�Tii�C,P CE.�: /FY T.Si.4T T.s�/,s O.v'E.:L/iY6 /S " �T'�• � �� �. %- _ �/OT /AI T//E FEOEPAG /:� Ss ntY A.t/ODYcT �1.4SSAC,�U�` TI �����- FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: APPLICANT: _ i�f7��� ��C_S�i ILS Phone LOCATION: Assessor's Map Number %y %' C Parcel,JJ Subdivision Lot(s) J� Street ��t '4 ' J tl �l�K S1—' St. Number D �� ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Conservation Administrator Comments Coe l Town Planner Comments Food Inspector -Health Septic Inspector -Health Comments Date Approved lil Date Rejected VC -10 semi 1e1?0s7`— Aeml T �167 s unV. Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date Approved - 1 %L Date Rejected Date Approved D tc Da, c -.ted Date Approved /957 - Date Rejected Date DATE !�LXd Sheet----./- of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # 210 DATE RECEIVED APPLICANT �/,t %1�'SCS,C}/ ASSESSOR'S MAP 9q L.c7/LLOc2� v% �` 7 ADDRESS G�/��45/�I , /1%/� D�CSCd PARCEL # LOT # .STREET ENGINEER ADDRESS PLAN DATE Nov, ,3,z 19'q-3 REVISION DATE CONDITIONS OF APPROVAL:—/.) 0, 1oZZ).p- /A/ 9 1 61,�I-o ep APPROVED DISAPPROVED v / 94.6v -,,* - -- . 72 ' - ' T�iev•�/.�E" ST.2Ec"-T �.2ouTE" //�, . .S .yEREBY IE.CT/Fy TO Tif�E T/TLE /,�/SU.COiC.Q,t/p RL or /QN TT% T/�.'E B,4 N.t' Tyg7' T,yE O�rELG/.�K' /S �GtC'ATEp O•V T�/E GoT .lS .S.fGI►'.V AND 7,4647'/7'oGCS .t.0, ANLb ✓eR ZON/NGroof r XV/ -f Af LOG4TEG /y Tzile ., E0E AG A400.0 hXZ.4 OSA.PE Or Sryew�! OSS/ Ft`M•�' e,:2 P. ,V .1H OF Ewe EY oATE �'fiy NOT FO.P Boavo.Py !aE �/ BDII.VOA.E'Y /.f/FO.P�•l- �E.P.P/�t1�4G� E'.1/GidEE,P�.�/6 s'E•PY��'�'s S.S,4G.fi!/SE'7 --: Marsha Telesetsky 99 Willow St. Condo 7 Chelsea, MA 02150 February 9, 1993 To Whom It May Concern : I would like to reserve a date with the Town of North Andover Board of Health where the Health Inspector will be available to come to the site regarding Soil Tests. The site in question is in North Andover on Turnpike Street (RT 114). The lot area is 46,172 SF and is parcel 107C - 107 . I will be represented by Merrimack Engineering Services, Inc. The president of the firm whom I have talked to is Stephen Stapinski. He can be contacted at 1-508-475-3555. Otherwise, you can contact me at either of the following phone numbers: Home: 1 -617-884-6568 or Work :1-617-693-4406. Sincerely, Marsha Telesetsky A5 T 5 v.3 UVEA OL Q �- F - �rIiyE 3 14'A w- 0 kAVec 1-1E1yIL V MOTlL �j G 2-�1� �; z o Ct u .c.j / - 4CJ, y 6 F -3S &k tle Town of North Andover, Massachusetts BOARD OF HEALTH LED X64 �\ lr Ly °f;4 VA APPLICATION FOR SITE TESTING/INSPECTION Form No. 1 19 Applicant N'y\rl-k cl,_ •�,"n _ 1 __ n 'A 5.._�.__, NAME ADDRESS j TELEPHONE Site Location Engineer NAME ADDRESS t TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee c,j Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. vJ J� 1� �J m PAUL FERRAGAMO 419 HIGHLAND AVENUE SALEM, MASSACHUSETTS 01970 (617) 595-3010 May 3, 1994 Ms. Sandra Starr c/o Board of Health Dept. Town of North Andover North Andover Town Hall 170 Main Street North Andover, MA 01845 Re: Turnpike Street, North Andover, Massachusetts Dear Ms. Starr: Pursuant to our telephone communication, I, Paul Ferragamo, of Salem, Massachusetts, being the owner of Lots 4 and 6, Turnpike Street, North Andover, Massachusetts, hereby grant a permanent construction easement unto Marsha Telasetsky of Chelsea, Massachusetts, as owner of Lot 5, Turnpike Street, North Andover, Massachusetts, for the purposes of placing soil on an approximately twenty foot by fifty foot area of Lot 6 in order that the said Marsha Telasetsky may construct a septic system and leaching field. Ver my yours, Paul erragal cc: Marsha Telasetsky 99 Willow Street Chelsea, MA 02150 PLAN REVIEW CHECKLIST ADDRESS-/,, 72-1q pl e/ f-" S,; ENGINEER GENERAL 3 COPIES f/ STAMP .C./ LOCUS C----' NORTH ARROW SCALE �---� CONTOURS(/ PROFILE SECTION Lr-- BENCHMARK SOIL & PERC INFO 6 ELEVATIONS / WETS. DISCLAIMER L--' WELLS & WETLANDS b,-'WATERSHED?/V,0 DRIVEWAY -t--(Elev) WATER LINE -� FDN DRAIN SCH40 L� TESTS CURRENT? I99 3 SEPTIC TANK MIN 1500G ✓ .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR �� MANHOLE TO GRADE ✓ ELEV 04 GW V'L D -BOX SIZE B # LINES FIRST 2' LEVEL STATEMENT INLET,L4,'7 - OUTLET,/64 g-©_ . % % ( 2" OR .17 FT) TEE REQ' D? VO LEACHING MIN 660 GPD? RESERVE AREA �' FROM PRIMARY? --2% SLOPE 100' TO WETLANDS L✓100' TO WELLSy" 4' TO S . H. GW r..� 35' TO FND & INTRCPTR DRAINS L% 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY C/ MIN 12" COVER "-'--FILL? 25' if above natural elev; 101if below) BREAKOUT MET? TRENCHES MIN 660 gpd t,.,/ SLOPE (min .005 or 6"/1001) >31COVER?-VENT — SIDEWALL DIST. 2X EFF. W OR D (MIN 61) y IS RESERVE BETWEEN TRENCHES? 'L,""' IN FILL? L ---"MUST BE 10' MIN. ✓ 4" PEA STONE? 4 ---- BOT c3% 0Z X LDNG ad3�'!" + SIDE ;� og X LDNG-�/16 = TOT (L x W x #) (G/ft2) (DxLx2x#) (G/f t2) Copyright O 1993 by S.L. Starr f NORT1y O ' L F A Y ; ♦ s sSACHUSEt Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant m A -O � �L S ka Nest No. Site Location � b T S - Reference Plans and Specs GINEE DESIGN Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. nn 0 Fee UV CHAIRMAN, BOARD OF HEALTH Site System Permit No. (Ve `t PETER F. REILLY 136 ANDOVER STREET ANDOVER, MA 01810 (978) 375-3750 TITLE V OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION Property Address: Name of Owner: Address of Owner: Name of Inspector: Company Name: Mailing Address: Telephone Number: 1090 Turnpike Street, North Andover, MA 01845 Mark and Marsha Fielder r same Peter F. Reilly same 136 Andover Street, Andover, MA 01810 (978) 375-3750 CERTIFICATION STATEMENT RECEIVED JAN 2 8 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTME I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) The system: ✓ Passes N/A Conditionally Passes N/A Needs Further Evaluati N/A Fails // Inspector's Signature: F. -Reilly the Local Approving Authority Date: January 22, 2005 The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty (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 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 a the time of inspection and under 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 (See attached Disclaimer). OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 INSPECTION SUMMARY: A. SYSTEM PASSES: Check A, B, C, D, or E / ALWAYS complete all of Section D ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: The system met the Pass Criteria of Title V. B. SYSTEM CONDITIONALLY PASSES: N/A 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). Describe basis of determination in all instances. If"not determined", explain why not) N The septic tank is metal, and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a 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: N Observation of a sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): N/A broken pipe(s) are replaced N/A obstruction is removed N/A 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): N/A broken pipe(s) are replaced N/A obstruction is removed OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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: N/A Cesspool of privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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: N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply well. N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from a private water supply well.**Method used to determine distance N/A This system passes if the water well water analysis, performed at a certified DEP 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. A copy of the analysis must be attached to this form. Other N/A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART A - CERTIFICATION (continued) Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 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 an 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. N/A Liquid depth in cesspool less than 6" below invert or available volume <'h 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: once No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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 laboratory, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form). N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310 CMR 15.303, therefore the system fails. The property owner should contact the Board of Health should be contacted to determine what will be necessary to correct the failure. E. Large Systems: Tobe 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 a large system in addition to the criteria above) N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No N/A The system is within 400 feet of a surface drinking water supply N/A The system is within 200 feet of a tributary to a surface drinking water supply N/A The system is located in a nitrogen sensitive area (Interim Wellhead 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 such 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. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART B - CHECKLIST Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 Check if the following have been done. You must indicate either "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 flow 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 available note as N/A) Yes Was the facility or dwelling was inspected for signs of sewage backup ? Yes Was the site was inspected for signs of breakout ? Yes Were all system components, excluding the SAS, located on the site ? Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum? Yes Was the facility owner (and occupants of if different from the owner) provided information on the proper maintenance of subsurface sewerage 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. N/A Determined in the field if any of the failure criteria related to Part C is at issue (approximation of distance is unacceptable) [15.302(3)(b)]. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 FLOW CONDITIONS RESIDENTIAL: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms: Number of Current residents: Does the residence have a garbage grinder (yes or no): Is the laundry on a separate sewerage system (yes or no): Laundry system inspected (yes or no): Seasonal use (yes or no): Water meter readings, if available (last 2 years usage [gpd]) Sump Pump (yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of Establishment: Design Flow gpd (based on 15.203): Basis of Design Flow (seats/persons/sq.ft., 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) PUMPING RECORDS 4 4 660 gallons 5 no no (if yes, separate inspection required) N/A no about 250 gpd no current N/A N/A N/A N/A N/A N/A N/A N/A N/A GENERAL INFORMATION Source of Information: owner (about once each year) Was system pumped as part of inspection (yes or no): no if yes, volume pumped (gallons): N/A How was quantity pumped determined ? N/A Reason for pumping: N/A TYPE OF SYSTEM ✓ Septic tank/distribution box, soil absorption system Single cesspool Overflow cesspool Privy NO Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative / Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from the 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: original system installed in 1995. Were sewerage odors detected when arriving at the site (yes of no): no OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 BUILDING SEWER: (locate on site plan) Depth below grade: about 12"-14" Materials of construction: cast iron ✓ 40 PVC other (explain) Distance from private water supply well or suction line N/A Diameter: 4" Comments: Condition of joints, venting, evidence of leakage, etc.) Building sewer was watertight and appeared sound at foundation. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: about 4"-6" Material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain) If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle How dimensions were determined: Rectangular - 1,500 gallons (per plan) <1" 28" <111 8" 16" observation Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid level as related to outlet invert, evidence of leakage, etc.) Tank was watertight and appeared to be functioning properly. GREASE TRAP: N/A (locate on site plan) Depth below grade: material of construction: concrete metal FRP other (explain) Dimensions: N/A Scum thickness: N/A Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A Date of Last Pumping: N/A Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid level as related to outlet invert, evidence of leakage, etc.) M_1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: N/A material of construction: concrete metal Fiberglass Polyethylene other (explain) Dimensions: Capacity: Design Flow: Alarm Present (yes or no): Alarm level: Alarm in working order (yes or no) Date of last pumping: N/A N/A gallons N/A gallons per day N/A N/A N/A N/A Comments: (condition of alarm and float switches, etc.) N/A DISTRIBUTION BOX: ✓ (locate on site plan) 0" depth of liquid above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) D -box was level. Two lines leading to SAS were accepting effluent evenly. D -box was 20" - 22" below surface. No solids carryover evident. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order (yes or no) N/A Alarms in working order (yes or no) N/A Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) not applicable OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required) If SAS not located, explain why: Type leaching pits, number leaching chambers and number leaching galleries and number ✓ leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number alternative system (name of technology) N/A N/A N/A 2 trenches per "As -Built" Plan N/A N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Soils in area of SAS appeared normal, no signs of breakout. CESSPOOLS: N/A (locate on site plan) Number and configuration N/A Depth -top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow (cesspool must be pumped as part of inspection) N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable PRIVY: N/A (locate on site plan) Materials of construction Dimensions Depth of solids N/A N/A N/A Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc.) not applicable OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100'. Locate where public water supply enters the building. SEPTIC TANK TIES: A to Inlet (1) N/A B to Inlet N/A A to Center (C) 2210" B to Center 366" C to Outlet (0) 2610" D to Outlet 3918" D -BOX TIES: A to Box 4418" B to Box 6110" NOTE: The system is in the front yard. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 1090 Turnpike Street, North Andover Owner's Name: Fielder Date of Inspection: 1/22/2005 SITE EXAM Slope flat in area of system Surface water none observed Check cellar dry Shallow wells none observed Estimated Depth to Groundwater >4' (below bottom of SAS) Please indicate (check) all methods used to determine the high ground water elevation: Y Obtained from Design Plans on record - if checked, date of design plan reviewed: 1999 Y Observed site (abutting property, observation hole within 150 feet of SAS) Y Check with Local Board of Health - explain: information on file Y Check local excavators, installers - (attach documentation) N Accessed USGS Database - explain: website too complicated You must describe how you established the high ground water elevation.* 1995 design plan indicates adequate separation. The soils and grade changes in the area indicate no groundwater in the SAS. However, the precise groundwater elevation cannot be determined for certain without a soil evaluation test. *Inspector's Note: Soil Evaluation is the currently recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaluator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified subsurface disposal system inspector. (see attached Disclaimer) P DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwaterfor this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. January 22, 2005 FORM U -LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANTJ'' '' 1 T -f fs-4 PHONE T 7 -7!` 7 LOCATION: Assessor's Map Number /0 7 PARCEL_ SUBDIVISION LOT (S) --� STREET 10'x'0 ( ST. NUMBER /W OFFICIAL USE ONL RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD I SP CTOR-HEALTH DATE APPROVED -, 2, DATE REJECTED .2 S PSPE�CR -HEALTH DATE APPROVED DATE REJECTED iv PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE RevhW 9197 Jm �;I S sI0N - C,,�y� : NO CONE RATION NEEDED F, S59€-90 00S) ...A3dO 13V0 3SV31d `SW3190dd NJ 'ON '131 9NIMAN03 9662—Zf 9 P Iglu Qu MR1 TO 39vj �co7 .� ! S1N3WW00 .04 0� /✓Y (ARS END JNIGM)NI } c? : SBVd 30 # 39Vd MOD 311WISOVJ 8M -Rt (809) : S3Id003131 SSSE-9Lt (809) OT810 A `b3AOQNb 133ts AVd 99 SDIUM 9NA33NION3 NOW MW SNd3S9dN9N3%lDVWI J3W G� : 31VO /{ SbbT.SLbOkS ZZ:OZ " 02/17/1993 10:22 n ti �q a [1 N d 5084751448 ON t+9ER I MA CKENGHFGSEPVS PAGE 02 N 41 i Ire 0, •t V C S it t� 0 jab it • 1� � A jt �t rn _ I � I, D N ASSACHUSETTS..I.- 1;. .1-1.11, aw I.y 1. 7 EPhai Ordiidid thls form for us0 byd_QcAl of 7Hwealth. The System Pumping Record mus,, be submitted to thi.10CA1,13 oard of Health or other approvidg authority, A.- Facility inforth'a TOWN OF NORTH - p,� , I,)(;VER 1:; System .L= on:r. ",v,ENT out. =npu um D % (ST Address 04 the tab key to move you[:; . `/��` ��o�'�`�� do. -not �::..,U" return State ZIP Code ,:, 2 System ner, 8 em U4, Name different rom tate., zj Cod ...... Telephone Number umptg Rekord' a W; of Pumping' ..:.-, Date 2, Quanflty Pumped: Cesspool( system: 3) Septic Tank❑ Tight Tank J .0ther(descilt .�';"--Effldent Te'e Flltet'orii6nt?. [3 'Ye's 0. It yes, was It cleaned? C Yes ❑ No on 9,,:. t '1 711 SAW U d B C.) jq� j 7 IA p . cent Nunter AA C 0 W re.dipposed: Date mass.gov/dep!wafer/approva)s/t5forms,htm#Inspect I httpJM%& as�.goWdeo4v vAjs/t5forms,htm#Inspect Owner NU V 54/ L System Pumping Re f 00rd, Page I of