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HomeMy WebLinkAboutMiscellaneous - 115 CRICKET LANE 4/30/2018 115 Cricket Lane }� I f i y Lot & Street --'p7— 3 C�,�/C� r �� Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: NO Permit4 Plan Approval: Date: Approved by: Designer: 0,e/l>9Z2i Plan Date: - Conditions: (��/�D//UG �f� /t'1 �J✓ G®.el�C�n �'.�G . �o Water Supply: own _. WeII - Well Permit: _.Driller: Well Tests: Chemical Date Approved Bacteria I Date-Approved + Bacteria II Date-Approved Plumbing.Sign-Off: Winn Sign-Off: Comments: -- Foran"U ' Approv 1: Approval to-Issue:. YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Const pprov . NO Septic System Construction Approval? LYES 7 NO Certification? NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: j SEPTIC SYSTEM INSTALLATION Is the installer licensed? YE NO Type of Construction: REPAIR New Construction: . ._Certified Plot Plan Review YES NO –Floor Plan Review NO _— Conditions of Approval from Form U YES NO Issuance of DWC permit: – NO _DWC Permit Paid? � NO . --DWC-Permit#-- �j Vit!– Installer: TG M So 6,) Begin-Inspection:_ - — �E S NO Excavation Inspection: Needed: _Passed: By: .-Construction Inspection: Needed As-BuiltPlan Satisfactory: YES: Approval of Backfill: DaterZll�_5166 By: 0 --Final Grading Approval: Date: / By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w„ 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12 2016 required for every p page. Cityrrown 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive 11111`5,� A Company Name 58 South Kimball street Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 Telephone Number License NurriffURCEIVED MAY U � )�a 5 2016 B. Certification TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 ❑ Ne d urt r va ation b the Local Approving Authority I pector's Signature D e The system inspector sh I sub 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12,2016 required for every p page. Cityrrown 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12,2016 required for every P page. Cityfrown 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12,2016 required for every p 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12 2016 required for every _ P 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 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•3/13 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 ,M 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12 2016 required for every p 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El 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): 880 t5ins-3/13 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 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12,2016 required for every p page. City/Town 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied 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•3/13 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 M 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 April 12,2016 required for every p page. Cityrrown 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: Stewarts last pump 8/13/2015 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2000 gallons How was quantity pumped determined? Site guage on truck Reason for pumping: inspect tank 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 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12,2016 required for every p 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16"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.): Septic Tank(locate on site plan): Depth below grade: 4"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: Sludge depth: t5ins•3/13 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 M 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 12 2016 required for every -April 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 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape meause&sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles good no leakage liquid level good. 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 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 April 12 2016 required for every P page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12 2016 required for every p 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.): Equal dist no solids carryover Box level. 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.): Tested pump manually by lifting floats pump running at this time. Alarm waorking when lifting float. " 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-3/13 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 M 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12 2016 required for every p 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: 3-28 ❑ 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.): no hydraulic failure no ponding no damp soils. 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-3113 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 wM 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12,2016 required for every P 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12,2016 required for every P 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12,2016 required for every P page. City/Town 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: 48"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: 4/12/2000 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: pulled file ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Taken from design plan on file water @ elevation 188.5 bottom of trenches 202.0 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 115 Cricket lane Property Address Debra Simon Owner Owner's Name information is North Andover Ma 01866 Aril 12 2016 required for every p 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 � V/ (� elf (V 177.1 � C22 I m o Cp` NT 9 20 J nn «SO `` `! NqY&� q � «S�t�0°�9 pr v skrRfCfs& � G. iV v (�p�NCf �Ov AS- BUILT NOTE: THIS PLAN & CERTIFICATION IS NOT OF A WARRANTY OF THE SUBSURFACE DISPOSAL 0 SYSTEM. IT IS A RECORD OF THE LOCATION o SUBSURFACE DISPOSAL SYSTEAND ELEVATION OF THE EXISTING SYSTEM cn LOCATED IN COMPONENTS. NORTH ANDOVER, MA. AS PREPARED FOR " ' <- OPLEY DEVELOPMENT 4070 cl- 50 COPLEY DRIVE m METHUEN, MA. 0184 - . w SCALE: 1"=40' DATE: JULY 11 , 2000 TM#38 PAR. 38,44,45,&46 TM#107A PAR. 217 SUBDIVISION SUBDIVISION LOT #3 CRICKET LANECRICKET LANE MERRIMACK ENGINEERING SERVICES PROFESSIONAL ENGINEERS ® LAND SURVEYORS ® PLANNERS orf 66 PARK STREET ° ANDOVER, MASSACHUSETTS 01810 ° TEL. (978) 475-3555° FAX (978) 475-1448 INVERT ELEVATIONS BUILDING TIES 4" PIPE @ FDTN. = 198.45 BUILDING CORNER A B SEPTIC TANK IN = 198.08 SEPTIC TANK 22.8' 30.8' SEPTIC TANK OUT = 197.99 PUMP TANK 33.0 21.5' PUMP TANK IN = 197.95 PUMP TANK OUT = 198.14 DIST. BOX 63.5; 49. 0; DIST . BOX IN = 204.25 CORN. LEACH FIELD 1 47.3 67.3 DIST. BOX OUT = 204.10 CORN. LEACH FIELD 2 60.0' 70.0' END LEACH LINE 1 = 200.94 CORN. LEACH FIELD 3 74.2' 77.0' END LEACH LINE #2 = 202.46 END LEACH LINE #3 = 203.94 BENCHMARK X—CUT BOLT@ TOP FLANGE HYDRANT U.S.G.S., M.S.L. EL=200.60(N.G.V.D) _C15 N C16 �O a�X ls83' �� fl rnI C17 I S G! DGE OF 0,, Z Ni INEATED Cl�WET 010 l�:';:: :���. .j : .�-�- off'• ' ger gyp' '1!:c:rti:: (si:;�� � . IP`� I: G ..^D " "P. � . .. DRIVEWAY '; 1 ,� C20 �¢ APPROX. GAS LINE G V! W APPROX. WATER SERVICE �� A DRAINAGE^ I ��� f TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE: 7/24/00 This is to certify that the individual subsurface disposal system constructed (X) or repaired () by Tom Sawyer at 115 (Lot 3) Cricket 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. Board of Health Inspector //,c5 C_�'P- INVERT ELEVATIONS BUILDING TIES 4" PIPE ® FDTN. = 198.45 BUILDING CORNER A B SEPTIC TANK IN = 198.08 SEPTIC TANK 22.8' 30.8' SEPTIC TANK OUT = 197.99 PUMP TANK 33.0 21.5' PUMP TANK IN = 197.95 PUMP TANK OUT = 198.14 DIST. BOX 63.5' 49.0' CORN. LEACH FIELD #1 47.3' 67.3 DIST. BOX IN = 204.25DIST. BOX OUT = 204.10 CORN. LEACH FIELD 2 60.0' 70.0' END LEACH LINE 1 = 200.94 CORN. LEACH FIELD 3 74.2' 77.0' END LEACH LINE #2 = 202.46 END LEACH LINE #3 = 203.94 BENCHMARK X—CUT BOLT@ TOP FLANGE HYDRANT U.S.G.S., M.S.L. 1 EL=200.60(N.G.V.D) ~C15 N Ips e1 C16 8� � • g3 F i N cn o v� W C18 I W DGE OFINEATED O' 071 ' � E� WETLANDS C19 l C20 7 APPROX. GAS UNE G W �W O APPROX. WATER SERVICE A DRAINAGE �+ JA AND ACCESS I j O (p W EASEMENT a Y s (� j� C21 Cry m -BOX O O / � I / a O Az /\ C22 I � m N too T I t ® 6 Q v ,o cad J1, 'V M e N� sW � SSZOe9 Nkk v (�yp�NCf OyV/ �O AS- BUILT NOTE: THIS PLAN & CERTIFICATION IS NOT OF A WARRANTY OF THE SUBSURFACE DISPOSAL SYSTE . IT IS AOF THE SUBSURFACE DISPOSAL SYSTEM AND ELEVATION OF THHEDEXXISTING SYSTEM LOCATION co LOCATED IN COMPONENTS. < z4 w ��.' Vis\.� iii•inn l NORTH ANDOVER, MA. , , co C2 r AS PREPARED FOR " � .Jy COPLEY DEVELOPMENT R D_ a ui 50 COPLEY DRIVE m METHUEN MA. 01844 w Ll- - SCALE: 1"=40' DATE: JULY 11 , 2000 TM#38 PAR. 38,44,45,&46 TM#107A PAR. 217 SUBDIVISION LOT #3 CRICKET LANE MERRIMACK ENGINEERING SERVICES It PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL. (978) 475-3555• FAX (978) 475-1448 TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System constructed; ( )repaired; byy�,� "3 (2 i L £•7- LA-(nI4- located at _ w y>>,-A li,35� pz'))t\ was installed in conformance with the North Andover Board of Health approved plan, System Design Permit# , dated with an approved design flow of O gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions 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 Represe ative e7� 01 Final inspection date: > �? - Engineer Represe tative Installer: LicA Date: Design Engineer: Date: r' n AS-BUILT CHECKLIST LOT NUMBER, STREET NAME Y ASSESSORS MAP & PARCEL NUMBER 1/ LOT LINES &LOCATION OF DWELLINGS (� LOCATIONS &DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES &DWELLING, WELLS a. 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 150' OF SYSTEM / LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE l/ DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX L/ ORIGINAL STAMP & SIGNATURE f/ IMPERVIOUS AREAS - DRIVEWAYS, ETC. v NORTH ARROW LOCATION&ELEVATIONS OF BENCHMARK USED Jun-14-00 10:01 North Andover Com. Dev . 508 688 9542 P .02 1 INSPECTION CHECKLIST FOR SEPTIC SYSTEMS NO Initials Yes A. Bottom of Bed 1. Excavation to proper depth 2. With wrenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation.etc. Comments: B. Retaining Wall 1. Wail height and width as specified 2. Waterproofed -_ 3. Wali minimum0'tO sof plan acil"tty 4. Wall meets spec on Comments: C. Building Sewer 1. Pipe diameter minirnum 4' 2. Schedule 40 pipe 3_ Watertight joints 4. Inlet to tank cemented foot minimum 5. Slope minimum 0.01 or 1/8'per 6. Pipe Properly set on compact 5rrrt base c� 7. Pipe laid an continuous grade in straight time 8. Cleanouts preop all change in a"grunent and grade 9. Manholes at any 9o°change 10. 10'minimum offset to water line Comments: D. Septic Tank -- — i 1. Level 2 1,500 931 minimum 3. Gras baffle present on outlet 4. Manhole to grade ?/ — 5. Manholes over center and each tee 6. 3-20"manholes _ — 7. Net tee minimum 12"under invert S. pullet tee minimum 14"under invert 9. Outlet line cemented 10. Air space 3"above tees 11. 2"—3"drop from inlet to outlet 12. Pipe set --- 13. Comped base wnth 6'of/."crushed stone under tank 14. Tank is watertight Comments: Jun-14-00 10:01 North Andover Com. Dev . 508 688 9542 P .03 Yes NO E. Pump Chamber 1. If separate from tank,compact base with 6"of't."stone underneath 2. Minimum 2"pipe to d-box if gravity system / Q 3. 20"access manhole -�- [3 li . Tank level 5. Watertight `f 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present - 9. Alarm in building on separate circuit 10. Alum functions - - 11. Manual operating switch -�- 12. pump delivers liquid to d-box Comments: F. Distribution Box t/ L D-box level --�� 2. Minimum 0.17'(2")drop from inlet to outlet 3. Minimum 6"sump L/ 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box C� 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double-washed-'/."-- 1 '/z" -pea stone Bucket test done? 2. Minimum 2"of pea stone above distribution lines 3, Minimum 6"stone beneath pipe -��- 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5' from edge of property,if not,then swale. Comments: K Leach Tranches I. Minimum 2 trenches --�� 2. Length of trenches agree with plan. (Max.length 100') 3. Width of trenches agree with plan--Minimum 2';maximum-4'. 4. Vent present if<50 feet or specified , 5. Distance between.trenches minimum 4'and maximums of 6' 6. Minimum distance between trenches .10' �- 7. pipe slope minimum 0.005 or 6"per 100' --.L- 8. Depth of trenches below outlet invert minimum of 6". Jun-14-00 10:02 North Andover Com. Dev . 508 688 9542 P.04 Yes NO 9. Pipes set an stable base. 7�/3 Comments: 1. Leach Field 1. Maximum length of field 100'' 2. Pipe slope minimum 0.005 or 6"per 100' 3_ Separation between pipe W maximum 4. Pipes connected at end S. Separation between ad*,ent fields 10' minimum 6. Pipes set on stable base 7. Maximum 4'separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: I Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48"wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement Comments: K. Final Grade 7 Jl 1. Slope over soil absorption system minimum 0.02 V 2. Ali system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond 10K APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERIINUT DATE: .� -�17- n CLTRRENT E STALLER'S LICENSEM LOCATION:_ er 3 se, LICENSED INSTALLER: `/` v r SIGNATURE: TELEPHONE CHECK ONE: REP. : NEW CONSTRUCTION: L/ IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only S7`.00 Fee Attached? Yes No Foundation As-Built? Yes No T Floor Pians? Yes V/ No Approval ,/�� Date: �© F'11Y 1 7 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at Loor3 rrii zr;e- relative to the application of /J,/, E r dated S-'*-l7-Z00a for plans by and dated <-/3'9 9 with revisions dated ..T-4(-9? I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed—generally first inspection unless there is a retaining wall which should be done fust. Installer must request the inspection but does not have to be present. b) Final Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built or verbal OK from engineer must be submitted to BOH,after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. ;s ?. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Lic used Septic Installer Date: S--12 rr 0�-I ORTH AHr)0VFR/ I i : Town of North Andover, Massachusetts Form No.3 f NORTH BOARD OF HEALTH ?O`tT .o '".tip �sC'(-iii • O T �-1 / �l,n �',S•^•� •'�� DISPOSAL WORKS CONSTRUCTION PERMIT SACHUSE Applicant2L NAME ADD ESS TELEPHONE Site Location Permission is hereby granted to Construct ( or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. i c CHAIRMAN, BOARD OF HEALTH Fee ���� ✓ �- �� D.W.C. No.