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Home My WebLink AboutMiscellaneous - 111 CHRISTIAN WAY 4/30/2018 (2) 111 CHRISTIAN WAY 210/104.13-0130-0000.0 APPLICANT: Ae. a°j� • PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: January 17, 2018 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D-Box Repair of On-Site Sewage Disposal System By: Todd Bateson — Bateson Enterprises, Inc. At: 111 Christian Way Map 104.D Lot 130 North Andover, MA 01845 Thi Issuance of this cert' ate not be construed as a guarantee that the system will function satisfactorily. M1. chele E. Grant Public Health Inspector 120 Main St.,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.9542 Web www.northandoverma.gov North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 111 Christian Way MAP: 104.D LOT: 0130 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: January 17, 2018 D-Box Only INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base [� H-20 D-Box Inlet tee (if pumped or >0.08'/foot) L-d Hydraulic cement around inlet & outlets Observed even distribution NSpeed levelers provided (not required) Schedule 40 PVC Pipe r C - Comments: 016D �� SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN f CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib.to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot.Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lr v r 111 Christian Way T01,494 OF '07-q I P,'I CJVIR Property Address HLALIi' Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 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, �J use only the tab 1. Inspector: key to move your cursor-do not Neil J. Bateson use key.the return Name of Inspector 1 es �� Bateson Enterprises Inc. lifts ILS Company Name 111 Argilla Road pill oeo� Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI-15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 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 El Needs Fu er EvalLption by the Local Approving Authority r ; 12-27-2017 Inspec o s Si nature 41Date 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 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.doc•rev.6116 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 111 Christian Way Property Address Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is North Andover MA 01845 12-27-2017 required for every page. Cityrrown 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 page. Cityrrown 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: Outet tee in septic tank&d-box needs to be replaced. Install riser on d-box. 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 '/day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is North Andover MA 01845 12-27-2017 required for every page. Citylrown 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 laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 page. Citylrown 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 C] ® Were any of the system components pumped out in the previous two weeks? E ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is North Andover MA 01845 12-27-2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 ears usage Yes g ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 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 111 Christian Way Property Address Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 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: Pumped 2017, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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): 15ins.doc•rev.6116 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 111 Christian Way Property Address Robert Parker Owner Owner's Name information is North Andover MA 01845 12-27-2017 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 30 years old, 8-5-1987, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below rade: 1,6 p g feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 0.5 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: 10'x 5'x 4' Sludge depth: 1" t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is North Andover MA 01845 12-27-2017 required for every page. City/Town 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 N/A Scum thickness 0" Distance from top of scum to top of outlet tee or baffle N/A = outlet tee off Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee corroded off. Needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. 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: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 page. Cityfrown 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.doc•rev.6/16 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 111 Christian Way Property Address Robert Parker Owner Owner's Name information is North Andover MA 01845 12-27-2017 required for every page. Cityrrown 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 level &distribution equal. Corrosion around liquid level. D-box need to be replaced. No evidence of leakage. Evidence of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 page. Cityrrown 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: 1 field 20' x 40' ❑ 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.): Snow cover yard, No evidence of ponding to surface, . Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 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.): 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.doc-rev.6/16 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 111 Christian Way Property Address Robert Parker Owner Owner's Name information is North Andover MA 01845 12-27-2017 required for every 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 t� ID-Px _ � � if � � y t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is North Andover MA 01845 12-27-2017 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 3 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: 8-23-1984 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: Test pits on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts -- . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Christian Way Property Address Robert Parker Owner Owner's Name information is required for every North Andover MA 01845 12-27-2017 page. Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ouuuumy y narm.naniun eyo Town of North Andover Tax Map # 210+1044D-0130-0000.0 Parcel Id 16816 111 CHRISTIAN WAY PARKER, ROBERT 111 CHRISTIAN WAY N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1.Residential Zoning3 1 Residential Size Total 1.1.Acres FY 2018 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until PARKER,ROBERT Payor 111 CHRISTIAN WAY N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17763.0-111 CHRISTIAN WAY Last Billing Date 10/10/2017 3170427 03 Cycle 03 Active UB Services Maint. Account No.3170427 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 64.60 /1 UB Meter Maintenance Account No.3170427 Serial No Status Location Brand Type Size YTD Cons 36185597 a Active ERT HH b Badger w Water 0.63 0.63 664 Date Reading Code Consumption Posted Date Variance 9/12/2017 664 a Actual 17 10/18/2017 130% 6/8/2017 647 a Actual 7 7/25/2017 15% 3/9/2017 640 a Actual 6 4/12/2017 -22% 12/9/2016 634 a Actual 8 1/23/2017 -89% 9/7/2016 626 a Actual 66 10/24/2016 324% 6/13/2016 560 a Actual 17 8/2/2016 177% 3/11/2016 543 a Actual 6 4/22/2016 -50% 12/10/2015 537 a Actual 12 1/20/2016 -68% 9/9/2015 525 a Actual 37 10/16/2015 70% 6/10/2015 488 a Actual 22 7/24/2015 251% 3/10/2015 466 a Actual 6 4/28/2015 -21% 12/12/2014 460 aActual 8 1/15/2015 -86% 9/10/2014 452 a Actual 59 10/15/2014 6146/o 6/9/2014 393 a Actual 8 7/16/2014 32% 3/11/2014 385 aAct ual 6 4/11/2014 -32% 12/12/2013 379 aActual 9 1/17/2014 -69% 9/12/2013 370 a Actual 29 10/15/2013 222% 6/13/2013 341 a Actual 9 7/24/2013 14% 3/14/2013 332 a Actual 8 4/22/2013 -53% 12/12/2012 324 aActual 17 1/9/2013 -77% 9/12/2012 307 a Actual 74 10/15/2012 307% 6/12/2012 233 a Actual 18 7/16/2012 127% 3/13/2012 215 a Actual 8 4/14/2012 -35% 12/12/2011 207 a Actual 12 1/17/2012 -66% 9/13/2011 195 a Actual 38 10/13/2011 174% 6/7/2011 157 a Actual 13 7/20/2011 57% 3/7/2011 144 a Actual 8 4/13/2011 -19% 12/8/2010 136 aActual 10 1/12/2011 -89% 9/9/2010 126 a Actual 94 10/15/2010 200% µ0111H tJ � � C Of 4.10 �ry0 • O Town of North Andover `�,'•_,,,,,.:' r HEALTH DEPARTMENT ,SSACNUStS CHECK#: /7.)—O DATE: s 20/?/LOCATION: C� V/ H/O NAME: CONTRACTOR NAME: &,6_ son Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTICSystems : ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector 1 $ Sn Title 5 Report Co d 0/10J $� ❑ Other. (Indicate) 55 $ 1�?10 IhWiiAgent Initials White-Applicant Yellow-Health Pink-Treasurer C4 r CAHME D 7-ate . 8„ Commonwealth of Massachusetts Map-Block-Lot 104.D0130 BOARD OF HEALTH ----------------------- Permit No North Andover -BHP-2018-0002---------------- ------ P.I. FEE F.I. $175.00 IF,* ---- —....I---- --- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Bateson Enterprises to(Construct)an Individual Sewage Disposal System. at No 111 CHRISTIAN WAY ----------------------------------------------------------------------------------------------------------- -- ----------------------- --------------- as shown on the application for Disposal Works Construction Permit No. BHP-2 Dat Ja 2018 ------------- '---------- Issued On:Jan-17-2018 BOARD OF HEALTH Application for S:•e°ptic Disposal System Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $280:00—Full Repair $425.00-Component _Application is hereby made for a Permit to: Q Construct a new on-site sewage disposal system' ❑Repair or replace an existingon-site sewage disposal'system' M'fepair or replace an existing system component—What? A. Facility information Address or Lot# JA 16 2018 Citylrown .D do �G2 /"1 vf•4- TOWN OF NORTH ANDOVER 2.-*TYPE OF SEP IC SYSTEM*: A []Pump cavity(choose one) HEALTH DEPARTMENT ' if pump sys m attach copy of electrical permit to application"' onventional System(pipe and stone system) ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is theModcAy 2. Owner Information Name 11r Ch��sf,yrr. lv,E.Y Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information I INC; Name Nam;o ompa�y 'i 1 T ARGILLA ROAD ��/ g,(�✓F ANDOVER,MA C1810 Address Cityfrown• State Zip Code I Telephone Number(Cell Phone#if possible please) 4. Desi.Qnerinformation Name Name of Company Address City/Town Z State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit.Page 1 of 2 4 ApplicaUg.n..for- septic Disaosal Xstern , Str"adflon Permit -TO" T �'� ' TODAY'S DATE ��4 '� • +� _R .'�.y�+ 0' j��VER4 ,M�`phr x:250.00�Full Repair Oil i iV 1 "A .03'iZ5 00:-Compbn.ent PAGE 2 OF 2 A. Facility.anformatton conflnued �1 .... S. Type'ofBuildfnq:. esidential,Dwellin9 or❑Commercial B. Agreement Me undersigned agrees to ensure the construction and maintenance of the afore.descrfbed on-site sewage disposal system,In accordance with the.provls/ons of Title 5 of the Environmental Code,as.well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to p/ace.the system fn operation.until a Certificate of Complla tco has been lssue y this Board of Health. 6Z /-A Name Date tion pprov Bo rd of He re eat t t/ve ms f � I ` Date Application Disapproved.for the following reasons--- For easons:"For Office Use Only: 1 "FeeAttschcd?: Yes L/ No 2.• ProjectJfadager Oftgradon Form Attached? Ycs No - 31: rirn System? Ifsoi Attach copy or wtdc11 Petmrt. Xcs No 4. FouadatlonAs.Bu&p(hew Consfructlonron!}r): Yes No (Same state as approvedplaa) A FloorRws?(hew coristmt6on'only): �'es No_ J yA,ppifcatldn'i. .p�sposat 5yateri5: onstracfiuri Permit:Pace 2 rii SF.P' `IC st• ' , io, 'M ►-GG '0BrrAos As fie-Nq tffiAuduvarZmAedltianllrt fcsF t$C b ihtx�edgn fps t?se�eptic�t fat.the lsetty at; (Adm ot,ep*Sri) "~. F'�pUm by gime a Acid dUod Dtttd ' A Z /Y ' (loaars A vft r9vidow da P-4n rc;�f: date) I uaderataad the following obligations fat to agem=t O Shia projcm 1. As the ion I�ts.ablig�ttrdta obtain.aIIper�atr mdl�oxrd of Hc�h approves p�a�� . �pet6oaaiag sap.'ap�c (ft a enter 3. h:&o imttallnj.,= =U fov anp and d*Vmdom I£ pl..Oject=,M t,as An oOhcrpat =not*qoc W ed�my 6ompiapr I'mlaapec#m sad the�t�is notneady,th,3. Y 'Item ab�b�st�spl�stble. .. ''. 4 A x im. d to h�v►c the�y wo :psio� the applt�tb�e iRt3peckgA3 stsa tltauyd Y+ �1 p� px:las them ss rct�raiug hictr oar+ r� t a iii`sp=wm 104 doietilot have to be pr if i b. _ _Wtstit o 'i�rsbrit OK"(or a msll.tnr ba ftibiuitfed•tc>�hc.Botad•ofHax&�,ate'' .,� � -• the etf�ttara must 6eptx:ffit<fctr x�aP dtur."haatrtlter irilist eavao .�, t d caY c lc�a f be seWy ad able to oa to bebwgtr- •—�sttiller sit� aaP.earoa abed�fl$�edfn�•�+cntrtpltte: I,asm}iei does not 4. ! lie inatAltr;'I u d that only F g titil* atltirt6a�r Da igcaopiete.thyt altut of t�e:pe r san) i re�tiircd d � lioa: . 4 5., A�thniaaetlle�Y derstaa I sr fit a n:d�3 ib�pAte :66 act flf dF i fc,Iiomut&camsto sm Via: Dept rrrikd c0AL-tears '' . - A .laspe�ofa�ofthe'>�ad�eadst�ex�Y�eoeab rr�se�cbe� a Pia:l�aa ��yBo�la��Taitt�r�d�orc+Qa�uh��. d .&atdtllatlart aft�aak,} - �Daae,s� PSP bei& v wgUsntl other, �: :�d..�3IIdt1'LICA...�� 'k��YY^'"'"...�,��"lrl�r+•�..•.:��....� � �i� y. .. VT At NOR7 ,� 6 B Town of North Andover HEALTH DEPARTMENT ,sS4CHU5f� CHECK#: /7 s / DATE: /- /7,-/g LOCATION: /// ri s�iu.n "U H/O NAME: ID,,,-4e� CONTRACTOR NAME: 6-,_fP_So/� Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ 1 Septic Disposal Works Construction(DWC) $ 7 S— ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ He Agent Initials White-Applicant Yellow-Health Pink-Treasurer BURR op Is N o{�TH Ati l?�V EI�, NLQ, P�1 CAIv wA�E� sc�Pl'1,7 Q T6wrJ ❑ Wfuz P our"D D4rC WrIC S'yST �Ppjf�ovt-v DAr�' 4PR�Ovw6 AuThoi�iTy DES+ G'vCl� ►�QPPRQVEp CoIOoltIO�J5 ; R�45oNS t rf rI c SY6T67M 1 J STA U-. 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Action -- De artment - --------- ----------- Board of Appeals — Board of Heal h Planning Board _ Cans ervatiion Commission — Bui6ding Deportrrie�-t �_— Town of North Andover, Massachusetts Form No. 1 NORTHA BOARD OF HEALTH O�tT`ED '6 41 19 APPLICATION FOR SITE TESTING/INSPECTION ADRATED PPp\�y ACHUSEt Applicant ' NAME ADDRESS TELEPHONE Site Location - 4t �5 Engineer - NAME ADDRESS TELEPHONE Test/Inspection Date and Time i CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. � D.W.C. No. 3q C.C. Date Plbg. Permit No. � 1�v { 1I l to t l e L T l� LFA0 } u t � � 4 � ELISTfi k) 1 w OV � Gf-i�IS rlAti wAr {, 5%, Tr l ...., r+1_.I.. L � .w+I'J. N n i. .•r i ti' 'I ilk SL RI AC�- i j" 1 .lrl'( y Id� � .�ST -Z],0, C 1.JY 4_,T LFT I J. �y_ �- �� Ci!:icc I �� YYI 1`�\v\`V� _ f� � 1 " �" �,/�i'/ v �