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Miscellaneous - 1174 TURNPIKE STREET 4/30/2018 (2)
F - LOT & STREET L' MAP/PARCEL, ` CONSTRUCTION APPROVAL ` HAS PLAN REVIEW FEE BEEN PAID? 5iiD NO PLAN APPROVAL: DATE Z�zz <</ 7 APP. BY �� L DESIGNER: Ci S�1�9A)j&,t) PLAN DATE �f CONDITIONS _ j `�7PJG77VA) FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: e WATER SUPPLY: TOWN WELL G/v&g:- WELL PERMIT `'�`_ DRILLER WELL TESTS: �� �`-.CHEMICAL DATE APPROVED BACTERIA`I DATE APPROVED ----,DATE BACTERIA II APPROVED PLUMBING SIGNOFF WIRING SIGNOFF COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION: NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW CONDITIONS OF APPROVAL (FROM FORM U) ISSUANCE OF DWC PERMITf°'/5 YES NO -DWC PERMIT PAID? j ! '� YES NO DWC PERMIT NO. INSTALLER: <'!, Y« A j` YES NO NEW REPAIR YES _ NO YES NO BEGIN INSPECTION NO: EXCAVATION INSPECTION: NEEDED: PASSED CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: APPROVAL TO BACKFILL: DATE: -O// FINAL GRADING APPROVAL: DATE r FINAL CONSTRUCTION APPROVAL: BY BY DATE: BY v TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Type: Emergency 0 Routine No ❑ -Yes Cessp( .01: No ❑ yes S(,pile Tank: : Date c.'Pumping: Quantiry Pumped . CZE P'' sysler: Pumped `by (Company): Conte -.is transferred to: Appl Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 APPLICATION FOR SITE TESTING/INSPECTION Site Location tx�`1� 3 ic Engineer Test/I nspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. G S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH / / , j / /� a a OL �—�" F ` . 19 APPLICATION FOR SITE TESTING/INSPECTION N— Ap p l i can t �✓ NAME 3 ADDRESS TELEPHONE Site Location U)T- 3 Engineer Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. 6 7c S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Q���SLED i646NC 5 � fi \R4 TE D WPP/ Applican Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 APPLICATION FOR SITE TESTING/INSPECTION NAME ADDRESS IELLPHONE Site Location -�-"-41 l - S, v Engineer Test/Inspection Date and Time 't N Fee ) 2, CHAIRMAN, BOARD OF HEALTH Test No. 61 '73 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. ON I!wl3d '291d OIp4 ':)':)-'ON I!W lad 'S'S ON ISO H_UlV3H 30 421 VOS `NVW211VHD auall pup air(] uoilaadsul/Isal J39UISu3 .� UOlIvool alis N01133dSNl/9NllS31 311S 2103 N011t/313ddV Hl]V3H 30 (MV08 t 'ON w-Ao:J s;lasnyapssEW `aanopud gIJON Jo umOl uroilddV y jd Q31b� , ��. J, / f r S`_ ice� ,f� _ --t' c.�,i �ol.a-�-�-r ; - - - - .. - - - w V �� �� �� �p /�`� �� r �� -�. ` ` i •.� ON ner information is required for every page. Im portant: When filling out forms on the computer, use only the tab key to move your cursor- do not use the return key. �----h ILS RECEIVED, Gcf 212014 TOWN OF NORTH AND? ER Commonwealth of Massachusetts HEALTH DEPpRTM Title 5 official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _1 'Tuan f:n s4-- Property Address Owner's Name _ d o l k A n d Uy e - r Ms i e-i.s " oty/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. A. General Information Inspector. Name of Inspector f 1 Company Name -7 c company Address Cilyrrow n (3-79- :-�-)(-I-FLs�a3 -. Telephone Nu mber B. Certification ,v. 038yT State Zip Code sem' 6 1` - - License Number 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: XPasses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Sigrr urs e Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10, 000 gp.d 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. Title 5Offficial Irxspwocn Farm: Subaurlacu Sewage Dlspwa SWtum• Psgu 1 ci 17 t51rs 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z Property Address j Ow ner � e information is Ownr�s Name required for every _ /✓U fir/0 v C r page. Utp Town State�GS Zip Code �' •�� /5% Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 19 1 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: O 1 n S PC i i G ✓i 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 b 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 structure I 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 • 313 Title6official InspocUaiFam Subsurface Se%sugeDisp,,a System• Puyu 2of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rr f Property Address Caw ner information is Owners Name required for every 19-1,2d- JY State page. City/Town —-^ 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). Thr; 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 mannerwhich 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 t9rts . 3/13 Title 5 offidal Ins pec tion Form Subsurface Sevage Disposal System • Page 3 of 1 7 t&ns • &13 Commonwealth of Massachusetts ° Title 5 Official Insection Subsurface Sewage pi ®�� sposal System Form - Not for Voluntary Assessments n operiy Address cw ner information is Owners Name ' required for every _ Page. Gtv/Tnw �J�� rr�� /� ✓►jG V (( B. Certification (cont.) Zip code of Inspection 2• System will fail unless the Board of Health (and Public Water Supplier, if an determines that the system is functioning in a e manner that protects th safety and environment: public health, ❑ The system has a septic tank and soil absorptions stem 100 feet of a surface water supply or tributary to a surface water su ❑ The system has a septic tank and SAS and the SAS is within a z and supply. pp Y. the SAS is within one 1 ED The system has a septic tank and SAS and the SAS is within 50 feet of of nVate water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fate water more from a private water supply well** Method used to determine distance: eet or ** This system passes if the well water analysis coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is Y performed at a DEP certified laboratory, for fecal to or less than 5 ppm provided that no other failure criteria are tri be attached to this form. 9 equal triggered. Acopy of the analysis n-,�fst 3. Other: D) System Failure Criteria Applicable to All Systems: You mus indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ [t� Backup of sewage into facility or s Clogged SAS or cesspool Yste I component due to overloaded or ❑ Discharge or ponding of effluent to the surface of thero due to an overloaded or clogged SAS or cesspool g and or surface waters ❑ [� Static liquid level in the distribution box above outlet inve or clogged SAS or cesspool rt due to an overloaded ❑ Liquid depth in cesspool is less than 6" below invert or than %1 day flow available volume is less T'Itle 5 offlciE''(4PeCUQ1 F orl,r Setsurf ace Se wage 0,SPOSa SA'Un'' Page 4of 17 MMUM Uy Commonwealth of Massachusetts Title 5 official Inspection luForm ntary sments Subsurface Sewage Disposal System Form -Not for 117H. Cf o Cwner Oyvners Nacre information is f� n (J(� l f �,���I required f or every V Qty/Town _ tate Zip Code Date of Inspection page 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. ❑ L7 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. ❑ 12 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 wateranalysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence nitrate nitrogen Is equal to or less than 5 ppm, of ammonia nitrogen and that no other failure criteria are triggered. A copy of the analysis provided 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 LaLlr,, 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. Tlue 50ffldd Inspucuen Form: Subsurface Sevsge Dlspeeal System- Page 5 o 17 t5ins • 3113 Commonwealth of Massachusetts V E&�� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 17 (t %y -n we st - Prddress f C= Owner Owner's Name information is ! required for every i C SID �( (�� , I �{ 5 ([j -- y page. City(fown 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: Yees/ No lJ-" ❑� Pumping information was provided by the owner, occupant, or Board of Health ❑ / L�' Were any of the system components pumped out in the previous two weeks? Ea ❑ Has the system received normal flows in the previous two week period? ❑ Er-' Have large vol umes 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) L�' ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? C�/ ❑ 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: LS ❑ 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): Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 for example: 110 y cl 0 ( p gpd x # of bedrooms):--�----�+- t5ms • 3113 Title 5Offidal Ins pection Form subsurface Sewage Disposal SAtem• Page 6of 17 Commonwealth of Massachusetts t= Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property A dress Cw ner Cw ner s Name information is COequired for every _ �i�-/i i��/ �V v 1 l3'.5 `'1 01 t_"� page. Qty/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection,, information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes S$ No Last date of occupancy: CLk ((f 114 -- 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: l5irs • 3/13 Title 5 Offidal Ire pectlon Form: SubsUface Sewege Disposal S�etem • Page 7 of 17 Commonwealth of Massachusetts Title 5 official:. Inspection For Subsurtace, Sewage 'Disposal System Form - Not for Voluntary Assessments Cw ner, .Cw ner s Name a -r,1 Information is / n required for every __ (�j " page. Clty/Town State Zip Code Date of Inspection _ D. System Information (cont.) - t5ins - 3113 Last date of occupancy/use: Other (describe below): General Information Pumping Records: \/ e S Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: LLl Date lees ❑ No 1 SCx� gallons tt -- MC'ter cl n T('., c�r Air 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/Altemative 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): Tile SofUciallnspecUonForm SubsurfaceSewagooisposal System• page &.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 �_)so) v,f Property Address I I- . 1 �1 Ow ner Ory ner's Name Information Is /) /_ A•n J`�,�- L required for every / V �i Gf page. . City/Town S State Zip Code Date of Inspection D. System Information (cont.) Approximateage of all components, date installed (if known) and source of information: ) Were sewage odors detected when arriving at the site? ❑ Yes P No Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron40 PVC ❑ other (explain): Distance from private water supply well or suction line: i f + feet Comments (on condition of joints, venting, evidence of leakage, etc.): 1 � �� �� i +� C a I ✓� G !'tncl S h� P Septic Tank (locate on site plan) Depth below grade: 6 j1 Material of construction: ii cone e ❑ metal f eet ❑ 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: t5m- 3/13 T105Of8ciel lmpecdcn Form Subsurface Sewage Disposal SWtam- Pope 9ot 17 Commonwealth of Massachusetts Title 5 official Inspection UForm ntary Sments Subsurface Sewage Disposal System Form - Not for Property Address r Ow ner owner's Name information is N--�4 rlcov r Zip Code Date of Inspection required for every State page oty/Town D. System Information (cont.) Septic Tank (cont.) `>lf�"i •t Distance from top of sludge to bottom of outlet tee or baffle t Scum thickness 7 't 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 were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: ' Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: t5its • 3/13 feel ❑ polyethylene ❑ other (explain): Date Title 6 O Wei Uispection Fomr Subsurface Sewage Dlepoeal SAte m• Page 1 0 ut Commonwealth of (Massachusetts - _- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property ,Address Cw ner Cw ner's Name informCASH information is G required for every MA page. Oty/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No 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 • 3113 fide 50fflcfal Ins pec Uon Form Subsurface Sevage Disposal SAte al. Page 11 of 17 Cw ner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ii 7`t �,'V-1 Property Address Owner's Name Oty/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): y e•S Depth of liquid level above outlet invert <5;+ rin r r C, 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.): l7— bt)7f t.VQ iv, C' ,1)J CVIae. 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): ye S If SAS not located, explain why: lyns- 3113 Tide 5Official liwpecdaiForm: Subsurface Sewage Disposal System- Page 12 d ii Commonwealth of Massachusetts Title 5 Official lnspection. Form' r > Subsurface Sewage Disposal System Form ='Not for VoluntaryAssessments ,"r r "-, i': LNy ' Property Address C- CA F i n owner owner's Name - information Is every. 7--r,,4required for page. Qtyrrown p.w Date of Irispepoon D. System Information (cont.) U. . Type: ❑ leaching pits number: ❑ leaching chambers, number: " ❑ leaching galleries number: leaching trenches number, length: -A'y sm ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure,level of ponding; damp soil, condition of vegetation, etc.): S4e/y1 we5l St l rt G� Cy -)d 16 Cc, P_ 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 tSlrs • 3!13 ❑ Yes ❑ No TldebOtBdal Uspecdon Fortre Subsurface Sev ge Dlsposel System. Page 13 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address -4 aN' of Cw ner ow ner's-Narrie information is -l�l ^Y�oy q � LtM � _� y� required for every N.1L�._. _) page. Cty/Town 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.): UNm- V13 Tltle50fficia Inspec Gun Fornc Subsurface Sevoge Disposal System Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Not:for. Voluntary.. Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 109 rnvpt��z Jt Property+ Address ,�tiQvvcr Citylro14(-uI Owners Name state up Code Date of Inspection Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I rem t5insp.doc • 11/2004 C� L 0 4ioX-39 d euh OJ 8'A f f u 6,-,J c- D�13o� Z Su Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary ry Assessments _ 7�4 Property Address Cwner CC"rU 1 (1 Q t Ow ner s Name information is` required for every 1V-Andc_,uMA. page. Qty/Iown 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 tc 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: tons • Ill ❑ hand -sketch in the area below drawing attached separately Title 501ficial Iris pecliai Form Subsurface Sewage Disposal System page 15 a 17 Ow ner . information is required for every Page. L5ins • 3/13 Commonwealth of Massachusetts Title 5 Official:lns p,ection ,Form Subsurface: Sewage Disposal System Form - Not for Voluntary Assessments �a- R operty Address I ner s Name 0 16w . System Infor Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells on (cont.) State Zip Code Date of Inspection Estimated depth to high ground water: %� /� feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 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: EN �L ------------ Before filing this Inspection Report, please see Report Completeness Checklist on nexta e. P g Me5otficiailnspectlonFornr Subsurface SewageDispaed Stetem• Page 16 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal system Form - Not for Voluntary Assessments Property Address c c- Cw ner pv ner's Nance n ._ information is_�ndr�le�' AAA_, O� N 8 U S required for every Qt Mown State Zip Code Date of hspection page. y E. Report Completeness Checklist inspection Summary: A, B, C, D, or E checked �spection 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 TIUc 5 Of ficial Ins pec tion Form: Subsurface Sevuge Disposal Systern-Page 17 of t51ra • 3r13 DEP has provided a®su�o am so of N pth�r fog at the My be used, buthe t I eoerd of b detdnnine the (ort they � Yt ueir� the form chert With the I�1 Soard of Ngo or ether approviin0 $ ' Pumper Roo" must be SUbthiQq� f., a with 310 CMR 15.351. w' t4 � fi�om the pub date in A. pacility Information _ ►mporont: vftA DECEIVE rI ow 1. System location: use ' , I L/ r n `� eP + . OvT 212014 key to mous Cursor • 40 a TOVVA u►- ►vu i use ft spam /✓G . /A � rjo ✓ e ` EA DEPARTMENT 2. System Owner. -- ►%` oo r-umping Record TiteDtor� ► ...�_ '. Date of Pumping Do z. q y Pte: /S-00 3. Type of system: ❑ C esspool(s) Septic T CJ %ht Tenk CJ ®then (describe): IJ Cram Trap 4. Effluent Tee Fd* present? Q Yes,[ No It yes, a►as it �ned7__ 5. Condition of System: Yes 6. System Pumped 6y. (�t U r `°4"9�y ?• L.OQU0.0 where" contents were dleposcd: S of Roo�p Fir 15tonA.doo 034 VON* t+oty tduriip®t __` SyStwn Purl 116011d , page 1 of .,q b z: Commonv Dal.th of h nspe�c inn rm ►stem Form Commonwealth of Massachusetts l Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form .A. Certification (cont.) ,I/?I TUCNpll " sf /4i,4 (9/ bw S.- cuy/Town Stage zip code Cgro f' r/'All 5-30-0-7 Owner's Name f Date of Impedfon 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 910 CMR 15.303 or in 310 CMR 15.304 exist: Any failure criteria not evaluated are Indicated below. Comments: -r B) System conditionally Passes: ❑ One or more system components as described In the'Condltional Pass' section need to be replaced or repaired, The system, upon completion of the mplaoement or r+epalr, as approved by the Board of Heald, will pass. Answer yes, no or not determined (Y, N, ND) in the 0 for the following statements. ff "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 substaralal kMltratlort.or exfiltratlon or tank fak re 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 1 , struc turaliy sound, not leaking and if a Certificate of Compliance Indicating that the tank Is less than 20,years old Is available. ND Blain: t5k"Alloc • 11/2004 Tide 5 Offidal Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 1 7 q Torp ��Lt SA Nr,jNpoL,<r CAV/Town earal F1'N<<y Owner's Name B) System Conditionally Passes (cont.): MA State '?� -30-07 Date of Inspection C> r?.LlS" Zip Code ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 wlll pass unless Board of Health detenMne$ 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 A wp.d= • 11/2004 We 5 Oltldal Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) /1-7q /Vrwpr/6c si -,I,v 9ovcr cttyiro �4 rol F►'�I�� Owners Name /%4 State $_30-07 Date of Inspection C) Further Evaluation Is Required by the Board of Health (cont): 0/ Z� (/5 - Zip Code 2. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of.a surface water supply or tributary to a surface water supply: ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS Is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance: "" This system passes If the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. l5i W.doc • 1 MAN Title 5 OftW hapocbm Form: Subswface Sewage Disposal System, Page 4 of 16 Commonwealth of Massachusetts Title 5 Official .Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) PMP" Aftm Owners Name 0/8 yS stats Z-20 � ©7 ZipCode Date of Inapedion D) System Failure Criteria Applicable to All Systems: t3i!w@.Ae6.11Rt1s�4 . You must Indicate "Yes" or "No" to each of the following for a! Inspections: Yes No ❑ jj"- 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 dogged 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 ❑ ❑- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(*). 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. ❑ ,f Any pion of a cesspool or privy is within a Zone 1 of a public well. ❑ cr Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Ef Any portion of a cesspool or Povy Is less than 100 feet but greater than 50 feet from a private water supply."l-with no acceptable water quality analysis. (This system passes N the well ii4l er analysis, perrommed at a DEP cerufled 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 pram, provided that no adw failure criteria are triggered. A copy of the* analysis must be attached to this forma Yes No The system. 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. TW I'S QI 14atp n Fomr sews" $Y5WM Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Foran A. Certification (cont.) / -7-/ "%vrN p, x� s I- Property Addoess City/rown State Zip Code y7-30-07 Owner's Name Date of Inspection 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 11 of a public water suppy well If you have answered `yes" to any question in Section E the system Is considered a significant threat, or wwm*ed "yeti' in SoOm D above the largo 1sy0m has failed. The mw 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 corned the appropriate regional office of the bepartrnnent. SbW.doe" 11/2004 Title 5 Of lal InspeOw Form: Subsurface Sewage Disposal System Pdge 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist / / jq Tvr"� 17Ct sk Property Address / ��S jv--! ft"00Vc< ZIA 6) citylfown state zip Cade Carol F�'til�y �'-30~�7 Owner's Name Date of InVectim Check If the following have been done. You must indicate "yes' or "no" as to each of the following: YES NO ❑ ,e' Pumping Information was provided by the owner, occupant, or Board of Health ❑ IT 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? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) g ❑ Was the facility or dwelling Inspected for signs of sewage back up? ki ❑ Was the site Inspected for signs of break out? f ❑ 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 ft faldlity owner (and oceupartts if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of theboil Absorption system (SAS) on the site bas been determined based on: Qf ❑ 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) 1310 CMR 15.302(3)(b)) i5insp doc • 11/2004 Title 5 ONMW Inspection Fow Subsurface Sewage Disposal System Page 7 Of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information Wvel /►�Ifi o/b`lS eA�o f =i',v cy stats _ 3 0-07 Code owW* Nemo Deta of WapeWon Residential Flow Conditions: z Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? ()f yes separate inspection required) Laundry system inspected? Seasonal use? Water meter readings, If available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: CommerclaUlndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/personslsq.ft., etc.): Greece trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, I available: Last date of oxupancy/use: Other (describe): tlik��es • � �I70Q4 .. . Gag" per day (gpd) Date 6(C)o 45a --i Cl Yes fZ No ❑ Yes O No ❑ Yes.X No ❑ Yes .f No N ❑ Yes 0 No CVrr(-4. Date Cl Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No T" ti ;kopeoW Fwms 9upsurkm Wasps Sy rn ...,•.:.:.,,.... ,. Page 8 of 1 Commonwealth Of -Massachusetts Title 5 Offi�ia Inspection. dorm Not;for:VoluntaryAasessments Subsurface Sewage Dispot3al System Foran C ; System Information. (cont.) y I I/ttPmpe4AddM5 1414 s� CrtylTown State Dp Code owners Now Date of bWecdon General Information Pumping Records: Source of information: NO Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: —L How was quantity um determined? G"�{ 04.'V `� P i� 4 cty p ped Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Shared system (yes or no) (if yea, attach, previous inspection records, If any) InMVWIVa/Alterrative technOW APO a.eopy of Me current operation and maintenance contract (to. be obtaiOftm. system owner) TlgM tank. Attach a copy of the DEP approval. Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary. Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) //7-/ /ury ?(t s) Property Address City/rown state Zip Code tarot Fv1lry T-30.,07 owners Name _ I Data of Inspeaion Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, Iuid I vets asS,,ela�Cj, ed to outlet invert, evidence of leakage, etc.): - IOIL44 5"'1 T1V �vf 7'c.c �y/�/rl arc i'v irCowl11(,'v/�. /L'V (f2,16 G141- SAGA 4,- pvwin,,vi 4j 1<.c4jk -(very 2-yr4 Grease Trap (locate on site plan): Depth below grade: rest 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 Cftments (on pumping recommendations, Inlet and 0. Wet 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 d metal [] fiberglass t] polyethylene ❑ other (explain): t �eC • 11/Z004 TW9 s MW Inipvdlon Forth: Subvx4 o Sewaga PWpoaal Sygtam Page 11 of 16 0"vep�n of uquw W"ahova i►rvert - - - Ce eAts (Rote il! box 10Level end:010bull td 1, oAy evidence of solids carryover, any evidence of leaks Into or out of box, etch ° x �'f j-$ � V(.�. /(%i'J j''I'('�►,� 'O JJ ('r�.�V Yl� de-,(,// 1c. fel//yrc r `W ,�I/�S �I fh L���x ; r n Q.ii�� /t�t,� /tGc-�►-> 5 ,Z .. Pump Chamber QocatA elle plan) Pumps In working order , : [3 Yes 8 No Alarms in working order [� Yes (] No f Y , 1 sipdoc 1 U�04 Tltla 1fi�l jri� fprmibwAaoa Seu'apa Dirpo�al System Page 12 of 16 5 L� Commonwealth of.Massachusetts Title 5 Officia11 nspection Form Not,for Votuntary.A*;�tints Su"C* Sewage Disposal :System Form CV`Oys"m Information (cont.) Tv Ivo l Ict s r- PropeRyss —� IV��N�vvr� �vl�} p� Sls` �nro l FI'v, c $ 30 -07 zy� coca Owners Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): =d . Wl Absorption..System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: • Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary.. Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 1 /7tl Tvrevo )CL )- - cityyrro f State Dp code 30 -03 Owner's Name f Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. .s t5insp.doc • 11/2004 A 407,q,/t- 39,2- AA,7�NX — 2.I 'g D�` Id euhf o- A"I f f 1i &,CJ . b -S0,4 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 15 of 16 _7 Town of North.And®ver o� rioRra� Liao .y Office of the Health Department 0 Community Development and Services Division 27 Cbarles Street �giis0 '� q• North Andover, Massachusetts 01845 °Ssacwusj Heidi Griffin Acting Public Health Director Telephone (978) 688-9540 Fax(978)688-9542 TOWN OFNORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE September 23, 2003 This is to certify that the individual subsurface disposal system constructed () or repaired (X) by Tom Sawyer at 1174 Turnpike Street 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. Jonathan arkey. Chairmq6, North Andover Board of Health BOARD OF APPEALS 68M541 B-LTILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 1-7LI 5%f0t:-r AS -BUILT CHECKLIST ✓" LOT NUMBER, STREET NAME 3 2� ASSESSORS MAP & PARCEL NUMBER<� 2 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 j 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 DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK & D -BOX ORIGINAL STAMP & SIGNATURE IL/ AREAS - DRIVEWAYS, ETC. C O&r Cosi Y c5rrr b AT T ►-te el� NORTH ARROW LOCATION & ELEVATIONS OF BENCHMARK USED TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System'( 4onstructcd, ( ) repaired: by 'TB N �d �� •d,�i2. / d ►-��.,'1 located at I 111 rz0 pt kff was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # dated with an approved design flow of _tk &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: L100 ual rj &0r�V��ngineer Representative Final inspection date: -7,-03 s Engineer Repre`s'entative Installer: Lic.#: Date: Design Engineer:)CE—Af Date:. Location: _j�(�j �1`j �J{ (C Gj-"' Owner's Name• � � ►tel l _ �`� Map/Parcel: Trl I o -?A 32 Address: '74- Installer: 74.Installer. Tel i*:—44L ze 2 New (siso) ! Repair Date: Wetlands2ty Zone II_Soil Symbol_Soil IQame Soil Class,_ Deep Observation Hole Logs Elevation Depth Soil Horizon Soil Te=ture Soil Color Soil hlottlinu a /o Gravel, Stones, etc L L v�3l3 icy.► mac. Z 5 y '/c� ec��'• - =-. 7. F-1.4401 V Parent Material_ •" it l.E. Depth to Bedro-kigk�Stytding Water in the Hole: �" Weeping from Pit Face— �E:SHG1r:� " Plt KV 202.2 lZr4K 01L.930 Ids+ G I V a Parent Material_ -+I LA- De Bedrock::::—Standing Depth to Bedroll: Standing Water in the Holr. �Weeping from Pit Date Percolation Tests Obse Dept] Start Time Time Time Time Rate r re.e...... --Yr1 " I . Performed BY; 12I !_-1 WitnessedLAO- l INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes A. Bottom of Bed 1. Excavation to proper depth 2. With trenches, sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation, etc. Comments: B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10' to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8" per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90° change 10. 10' minimum offset to water line Comments: ME Initials D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20" manholes 7. Inlet tee minimum 12" under invert 8. Outlet 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. Compact base with 6" of 3/4" crushed stone under tank E/ 14. Tank is watertight Comments: Initials Yes NO E. Pump Chamber 1. If separate from tank, compact base with 6" of stone underneath 2. Minimum 2" pipe to d -box if gravity system 3. 20" access manhole 4. Tank level 5. Watertight 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. Alar functions 11. Manual operating switch 12. Pump delivers liquid to d -box Comments: F. Distribution Box 1. D -box level 2. Minimum 0. IT' (2") drop from inlet to outlet 3. Minimum 6" sump 4. Outlet pipes show equal distribution 5. Compact base with 6" of stone beneath box 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 -'/4" = 1 %i" - 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: H. Leach Trenches 1. 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 maximum of 6' 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6" per 100' 8. Depth of trenches below outlet invert minimum of 6". Q Yes NO 9. Pipes set on stable base. Comments:. I. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005 or 6" per 100' 3. Separation between pipe 6' maximum 4. Pipes connected at end 5. Separation between adjacent 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 1. Slope over soil absorption system minimum 0.02 2. All 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 { ✓ s a. TOWN, OF NORTH ANDOVER/ p3 4' M ` BOARD OF HEALTH % J Location"7 Permit Food Service $ Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Constructionv/$ Soil Testing $ Design Approval Permit $ ! Dumpster Permit $ /7— Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ offal/Trash Hauler $ Other $ 6594 Health Agent White - Applicant Yellow - Dept. Pink - Treasurer .1K Town of North Andover, Massachusetts Form No. 3 NperM BOARD OF HEALTH "�-%�"'� * DISPOSAL WORKS CONSTRUCTION PERMIT SACHUS�t� Applicant Gam//i���j'.cJGV NAME ADDRESS 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. HAIRMAN, BOARD OF HEALTH ��- D.W.C. No. / �! APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:S = 3 CURRENT INSTALLER'S LICENSE# LOCATION: // 7�1 7`v/^,/ rD Lf Sr. LICENSED INSTALLER: Gr//��hl �U✓ C�� SIGNATURE: TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $175.00 Fee Attached? Yes 'I/ No Foundation As -built? Yes V/ -L No Floor plans on file? Yes No Approval a Iek�' Date: a` .cn�D. S/iOS � 1 � A� APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:S = 3 CURRENT INSTALLER'S LICENSE# LOCATION: // 7�1 7`v/^,/ rD Lf Sr. LICENSED INSTALLER: Gr//��hl �U✓ C�� SIGNATURE: TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $175.00 Fee Attached? Yes 'I/ No Foundation As -built? Yes V/ -L No Floor plans on file? Yes No Approval a Iek�' Date: a` .cn�D. S/iOS F- TO�ffi OF NORTH ANDOVER fi. BOARD OF HEALTH 4 7 Location Permit Food Service Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Construction $ Soil Testing $ Design Approval Permit $ !� Dumpster Pe t/" $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $•� Suntanning Establishment �$ offal/Trash Hauler $ Other - $ 6806 6 Health Agent White - Applicant Yellow - Dept. Pink - Treasurer f NORTN O•.�•o y�.y0 OAL 1 ,SsgCMUSE�� Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant rY/- �'� ©%ti /�� Test No. �D Site Location Reference Plans and Specs. 1_ // ENGINEER DESIGN a DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD OF HEALTH Fee /�� Site System Permit No. ti t a w o� tz obi A y A U a w z 3 E L O z O 3 O •� a � C > V ti CL O o F y c Cti ;n A U 0 O C cw w w o o z o 0 Q. o2�-� j w 4 C Q a CC 0 neo bZ O O 5L ti� Q 8 o a c3� T'xm° as m 'o M m C5. U c U � U 0 3 C) 0 0 _7 M z N x w m yK K z a M rn 0 o 0 O CL 05 x a m b cn w ti n F ? a .2 a C7 mo 0. F v� NORTH OF St�eo Ib gtiO OL O a �" ��SSACHUS�S�� Applicant. NAI Site Location �f Engineer 2/ ' Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH I V• VV APPLICATION FOR SITE TESTING/INSPECTION :� Test/1 nspection Date and Time. CHAT AN, BOARD OF HEALTH Feed='J. Test No. 161a3 S.S. Permit No. D.W.C. No.?K C.C. Date Plbg. Permit No. .> =' Town of'North Andover, Massachusetts Form No. 1 NORTH BOA -'D OF HEALTH APPLICATION FOR SITE TESTING/INSPECTION SACHUS�S�h Applicant NAME ADDRESS/ TELEPHONE Site Location_ i Engineerl/U} Test/Inspection Date and Time ��' / a��l�c� Af) /L j _ A `- 'CHAIR AN, BOARD OF HEALTH \ FeeTest No.��L� r S.S. Permit -No. D.W.C. No. C.C. Date �` Plbg. Permit No. 1 I INi` .�. i 4 i " IJ `Z 5 OC ION: -5 _ S 0 TT ONI J- " I IF WI S CIZ,ta iifvIC �.I !• G 1 �' I iy EX' CD; -.Y Tii NI_ i ;.. 1 I INi` .�. i 0 0 � co .o 0 N h Q1, 1 I ^ � to N � Lo � O O J � 2 � i C� zo �. Li O N � m 1� t J U') Q �.. LIJ O 0 0 � co I W 0 N h V 1 I ^ � to CO Lj Cl- Lo � O O J � 2 � i C� _ Li O N � m 1� t J U') Q �.. LIJ O 0 0 � co I W 0 0 � 1 I � to CO Lj Cl- Lo 2 O J � 2 � ce- wti 0 0 � co I , II i I 0 � 1 I to CO O 2 w wti O N ft-. n 1p I , II i I 0 � 1 to p I w wti O N � m 1� t J U') Q 1- O < Q i BOARD OF HEALTH NORTH ANDOVER, MA 01845�aF 978-688-9540 BOARD OF HEALTH APPLICATION FOR SOIL TESTS AUG 22 2002 DATE . _. %°' 1 MAP &PAR �-- �j CEL. 10� ,� LOCATION OF SOIL TESTS: 11'7 "ru eo pI j—f OWNER: rI K) LE: Y TEL. NO.: ADDRESS: 113 :r �� n{ �r1 �-i�"►2�� ENGINEER: til t 1 I-={ ACV-- TEL. NO.: CERTIFIED SOIL EVALUATOR: 1 11.1. Intended Use of Land: Residential Subdivision Is This: " Repair Testing: �% _ Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No THE FOLLOWING MUST BE INCLUDED WITH THIS FORM Commercial 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of $200.00 per lot for repairs or upgrades. (If time is not critical, fee for repairs is $75.00) GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. Please Do Not Write Below This Line N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: " I HEREBY CERTIFY TO THE TOWN OF NO. ANDOVER BUILDING DEPT. THAT THE FOUNDATION IS LOCATED ON THE LOT AS SHOWN AND THAT IT DOES CONFORM WITH THE TOWN OF NO. ANDOVER ZONING REGULATIONS REGARDING SETBACKS FROM STREETS & LOT LINES." STEPHEN E R.L.S. )"Nil OF NOR F, MAY 2 7` I MAY 23, 2003 DATE Y.•\R14\5830\5830-FNDN-CERT.DWG 5/23/2003 FO UNDA TION PLAN 1174 TURNPIKE STREET IN NO. AND 0 VER, MA DRAWN FOR WILLIAM BARRETT HOMES, INC. DATE: MAY 23, 2003 SCALE: I"=60' 0 30 60 90 MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 1 ��1J7 N/F FERRAGIMO 1 � 178,79 1 N/F THOMAS h co 44-1 C �7 h� — z V) -0 cn o J �, . o o / w `'v / o ./ �' N/F HANSOUR ro / / �4i i LOT 1 mJ 112,000 S. F. . o r ^. / E3 C frl / cj� .� 131.5'_ N/F LIGHTBURN X124.0' .� 4o' 122.7' ` ,d,•�,: 382 � 2 O� 31.73 N/F TRUONG " I HEREBY CERTIFY TO THE TOWN OF NO. ANDOVER BUILDING DEPT. THAT THE FOUNDATION IS LOCATED ON THE LOT AS SHOWN AND THAT IT DOES CONFORM WITH THE TOWN OF NO. ANDOVER ZONING REGULATIONS REGARDING SETBACKS FROM STREETS & LOT LINES." STEPHEN E R.L.S. )"Nil OF NOR F, MAY 2 7` I MAY 23, 2003 DATE Y.•\R14\5830\5830-FNDN-CERT.DWG 5/23/2003 FO UNDA TION PLAN 1174 TURNPIKE STREET IN NO. AND 0 VER, MA DRAWN FOR WILLIAM BARRETT HOMES, INC. DATE: MAY 23, 2003 SCALE: I"=60' 0 30 60 90 MERRIMACK ENGINEERING SERVICES 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 NOWVA` 1-1:9 1N0�!4:4 3�IWOf i aNId ziO �!iacnnG .a r� • � I I I I I I : I I I I �171 I I HEM u D I I I I I 0 I I • I I I ® I I • I I I I I I , I I' I ' � 1 I I I I I ' I I . 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J���NI� ill -r. '�1vQ :A V)5 Wll� Odd 0 e �, Q • w o Q J J O U X N ' _V N QU �� U m -� ►- �+I O ^I Z ._t U 0 r X N � _ L LLJ NUl � N • U O - N - N L to 0 U _ to ' X N A ' 11 U O - iL 0 � x Li n V 1L 1_l_ 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 --,•••*•*•^—""*-*1APPL"ICANT FILLS OUT THIS SECTION* APPLICANT �1 �M�S ! �/l'L�y PHONE LCCATION: Assessor`s Map Number �� PARCEL 3� SUBDIVISION LOT (S) ST. NUMBER / STR.".:T ---r---�---- ^••^•^•"""•"'OFFICIAL USE ONLY"�— RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR CONTS TOWN PLANNER CMENTS FC00 NSPECTOR•HEALTH SEPT C INSPECTOR -HEALTH COMM-': I S DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ DATE APPROVED DATE REJECTED_ '�iCRKS - SEWER/WATER CONNECTIONS DRJVEWAY PERMIT FIRE DEPARTMENT RCEIVED BY BUILDING INSPECTOR DATE Vr Page 1 of l Pamela DelleChiaie From: "Dan Ottenheimer" <info@millriverconsulting.com> To:<pdellechiaie@townofnorthandover.com>;<blagrasse@townofnorthandover.com> Sent: Tuesday, September 09, 2003 6:11 PM Attach: Turnpike Street #1174 Construction Inspection.doc Subject: Turnpike Street #1174 Brian and Pam, Attached please find the construction inspection form for the site visited today at 1174 Turnpike Street. You will note that this is a new form which Brian and I had discussed. I think it will make things simpler and clearer. Brain can fill in the areas which he inspected either on the computer or by hand. On this job Brian, the plan calls for a good amount of fill material at the end of the (each trenches. You may wish to pay attention to that if you do the inspection or I will if I do the inspection. Also, Title 5 requires a minimum of 9" of cover over the septic tank and based. on the grades I saw out there today it was not clear that was going to be able to be provided. Contractor was very nice and agreed to install a manhole to grade for ease of maintenance for the owners. Dan Mill River Consulting Septic System Management Services 5 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 info@millriverconsulting.com 9/10/2003 TOWN OF NORTH ANDOVER SEPTIC SYSTEM CONSTRUCTION NOTES GRAVITY DISTRIBUTION ADDRESS: 1174 Turnpike MAP: LOT: INSTALLER: Tom Sawyer, Arco Excavators DESIGNER: Merrimack Engineering PLAN DATE: March 4, 2003 SEPTIC TANK Date & Initials INSPECTIONS ❑ Bottom of tank hole has 6" stone base 9/9/03Mill River Consulting0 1500 gallon tank has been installed (H-10 or H-20) (monolithic or 2 piece) ❑ Water tightness of tank has been achieved Visual Vacuum Test Water held for 24 hrs 9/9/03Mill River ConsultingEl Inlet tee installed 9/9/03Mill River Consulting0 Outlet tee with gas baffle/effluent filter installed ❑ inch cover to grade installed over outlet of tank 9/9/03Mill River ConsultingO Hydraulic cement around inlet & outlet Comments: Spoke with contractor to assure minimum of 9" cover material provided and access port to within 6" of final grade. Encouraged manhole to grade for ease of access. Page 1 of 3 .W Date & Initials INSPECTIONS 9/9/03Mill River Consulting® Installed on stable stone base n/a ❑ Inlet tee (if pumped or >0.08'/foot) 9/9/03Mill River Consulting❑X Hydraulic cement around inlet & outlets 9/9/03Mill River Consulting0 Observed even distribution ❑ Speed levelers present? (not required) Comments: Discussed flow levelers with contractor. He will install afterwards. SOIL ABSORPTION SYSTEM Date & Initials INSPECTIONS ❑ Bottom of SAS excavated down to soil layer 9/9/03Mill River Consulting0 Title 5 sand installed 9/9/03Mill River Consulting El 3/4-1 W double washed stone installed 9/9/03Mill River ConsultingM 1/8-1/2" (peastone) double washed stone installed 9/9/03Mill River Consulting❑x laterals installed and ends Gappedf connected to header (and vented if impervious material above) size: 4" diam., 50' long 9/9/03Mill River Consulting0 orifices @ 5 & 7 o'clock positions ❑ Elevations of laterals installed as on approved plan Page 2 of 3 -.0 n/a ❑ 40 Mil HDPE barrier installed n/a ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: Contractor did not have survey equipment available. Elevations obtained by designer earlier and will be available on as -built plan. Page 3 of 3 Pamela DelleChiaie From: "Dan Ottenheimer" <info@milldverconsulbng.com> To: "'Pamela DelleChiaie"'<pdellechiaie@townofnorthandover.com> Cc: "'Heidi Griffin"'<hgriffin@townofnorthandover.com>; "'Brian LaGrasse"' <blagrasse@townofnorthandover.com> Sent: Tuesday, September 09, 2003 8: 2 AM Subject: RE: 1174 Turnpike Street - Sy m Final Inspection Request Scheduled for 2:00 on Tuesday 9/9. Dan Mill River Consulting Septic System Management Services 5 Blackburn Center Gloucester, MA 01930-2259 978-282-0014 or 1-800-377-3044 info@milliiverconsulting.com -----Original Message ----- From: Pamela DelleChiaie[mailto:pdellechiaie@townofnorthandover.com] Sent: Monday, September 08, 2003 4:12 PM To: Dan Ottenheimer Cc: Heidi Griffin; Brian LaGrasse Subject: 1174 Turnpike Street - System Final Inspection Request Please call Tom from Arco Excavators to schedule at 978.360.7832. Thanks, Pam Page 1 of 1 9/9/2003 Commonwealth of Massachusetts roftvuw. Q 1 /711 2 � oo�puter. use only the tab 'key Addresq 10 r4we Yaw &— use the return '��o'"" key. h� N Name 2.-�jiS�fXl O Cl��� of NORTH �iV��. Aa►S�4GH�#Sh�S S�s�ie.� l�'��p���g ��co�c# Farmrtf 4 DEP has provided �t� form for use by local Board of Flea deem-P_Wpi 1�saiamit�#�ta#�r�-af�aitt�ortrtt�erappravf autif�r;��,6��'EL� A. ��"�� ���'���� OCT 12 2007 tbfortnd,doo• Q6/03 (�4`Mp r S� TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Stam ZEp Code address of diflierent from bcation} City/ToNrn State /�`(p �^ Zip Code ' 1 s ys V' W' � Telephone Number � ( 0V/ /ter f �-�"(l '�lf .S )(jP �ff Q0a.e+ o _ I. Date of Pumping 3. "Type of system: Q 'Other (describe): v ^ `�0 �� 2. Quantity Primped Date Cesspools) Septic Tank 4. Effluent Tee Filter present? ®Yes No 5. Condition of $velem: C] Tight Tank If Yes, was it cleaned? [I Yes Yes �. Na 6. Syste„�Pumped BY: �rr� ticenae Number �n �s 7. Location where contents w��. d `S 11tm#inSp@Ct mns�t +qkftwm vsPagei -oft